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    part 2 my notes!

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    170.Risk factors for (DVT) are pregnancy, trauma, prolonged immobilization, orthopedic and certain neurosurgical procedures are associated with the greatest short-term risk. with the risks of the fracture and the surgery being additive, some estimates place risk of DVT at greater than 80%.
    The risk of pulmonary embolism is also high and significant, but not nearly as much as DVT. These estimates range from 2-27%.171.Remember when ever you use niacin you should monitor liver function and plasma glucose carefully.
    when do you use niacin?when patient cannot tolerate statins and also it's the best choice for rising HDL
    172.remember an angiogram is not necessary in the management of ischemic mucosal colitis. Ischemic colitis is diagnosed by colonoscopy. Patchy depigmented areas confirm mucosal ischemia, which is managed by intravenous fluids and bowel rest.
    173.Abdominal pain in an elderly patient associated with bloody diarrhea and hypotension should arouse the suspicion of ischemic bowel.. A classical appearance on the flexible sigmoidoscopy of green mucosa and isolated depigmented patches are suggestive of ischemic colitis. These patients should initially be adequately hydrated and put on bowel rest. 174. Remember white cells generally indicate active inflammation. The presence of leukocytes in a stool sample would be highly suggestive of IBD.175.The treatment of unstable atrial fibrillation (atrial fibrillation associated with hypotension, myocardial ischemia, congestive failure, etc.) is immediate synchronous cardioversion, in an attempt to immediately restore sinus rhythm.176.Churg-Strauss vasculitis: Prednisone should be started at a moderate dose, along with a bisphosphonate to prevent osteoporotic fractures,in initial therapy no cyclophosphamid,...177.Remember Major depression need not present as classic dysphoria or sadness.It may present as irritability particularly in children and adolescent.178.know pictures of fundoscopy ( glaucoma, DM, and cmv)
    skin (herpes zoster)
    ecg (1st degree block) preop.179.IN DM with sports this is what we do… check ketone.. if positive ,, he cant participate until ketones are gone… in DM insulin is decreased with snacks during break….check glucose before and after sports is also a recoomendation180.black male with HTN + DM .what HTsive med do u give?
    …..Ace inhibitor….*htn plus diabetes
    181.“BILATERAL”renal a. stenosis with HTN, what med do you use to tx HTN…
    Answer is calcium channel blocker…. If it was unilateral stenosis then ACE inhibitors182.A male pt with thumb base pain what is dxa.
    De querene tensovitis is the answer… treatment is nsaid and intrathecal steroids.183.a pregnant rh- do not know father what is next? test rh titer now184.primigravida 28 weeks, rh negative ,husband positive anti ***** antibody positive what next
    1)give anti rhd
    2.dont give anti rhd
    3.do amniocentesis, answer,,,, DON’T DO ANYTHING…185.During a flu. Season, a pt who did got get flu. Shot and had a flu.s/s for 4 days came in for treatment. You provide for him:
    1. amantadine 2. zanamivir 3. only symptomatic support including (Tyleno)Symptomatic treatment ( amantadine or zanamivir is given within 72 hours of influnza… ZANAMIVIR is the best treatment it covers both A and B)186.Know exact inetrvals for pap smear (cervical cancer screening), breast cancer screeing, prostate cancer screening and colorectal cancer.This is very important topic many Q in this topic
    187.How do you treat Cocaine abuser with 210/115 BP?
    Cocaine induced HTN - treated with Benzo, Nitroglycerin or Nitroprusside drip and Phentolamine 1 mg IV
    No beta blockers like propranolol
    188. Remember Bilious vomiting in an infant means that there is a malrotation with volvulus until proven otherwise. The radiographic findings of the cecum in the left upper quadrant confirms this clinical diagnosis. An upper gastrointestinal series would likely show a bird-beak deformity of the midgut where there is volvulus of the gut around a mesenteric "Ladd" band.
    189.Remember about 20% of malrotation with volvulus is associated with duodenal atresia, annular pancreas, or a duodenal diaphragm. About 33% of cases present in the first week of life and 85% present in the first year of life. The hallmark of malrotation is ischemia of the midgut as the superior mesenteric vein and the superior mesenteric artery are occluded by the twisting mesentery. Immediate surgery is necessary to prevent death or the loss of much of the bowel.190.Intussusception typically presents in infants from 4 months to 2 years of age, with alternating lethargy and irritability, colicky abdominal pain, and currant jelly stools. In addition, there is usually a right lower quadrant mass on abdominal x-ray.191. The presence of tamponade is suggested by the presence of diminished heart sounds and pulsus alternans (a beat to beat variability in the QRS amplitude) on EKG.192.It 's useful to note that the shock typically associated with sepsis, anaphylaxis, and neurogenic shock is associated with vasodilation, and hence, with warm extremities.193.complication of polycytemia vera:1.Hyperuricemia due to increased rbc turnover is common in patients with polycythemia vera, and these patients are at increased risk of gout.
    2.Both arterial and venous thrombosis are common in polycythemia vera. The Hct is directly related to the risk of thrombosis. This association between Hct and risk of thrombosis forms the basis for the treatment recommendation to keep the Hct less than 46%. The platelets are derived from the neoplastic clone and may not function normally3.Approximately 15-20% of patients with Polycythemia vera eventually develop myeloid metaplasia. Myeloid metaplasia is characterized by gradual replacement of the marrow space with fibrosis, and movement of hematopoiesis into the spleen and liver. The spleen and liver become massively enlarged, and the patient becomes progressively pancytopenic

    194. Polycythemia vera :Neoplastic hematopoietic stem cell,CBC in Polycythemia vera: Hct and often WBC and platelets are increased ,reatment: Phlebotomy or hydroxyurea or 32P to keep Hct below 46% ,Decreased or low normal erhtropoitine195. Secondary Polycythemia: disorder Due to tissue hypoxia causing an appropriate increase in Epo production, or to renal or hepatic disease causing an inappropriate increase in Epo production ,Only Hct is increased ,Treatment is usually not required,Normal or increased erhtropoithine196.Hyperuricemia: An elevated uric acid level can result from gout, renal failure or an increased production of uric acid secondary to high rates of cell turn over such as in patients with hematologic malignancies. it may also be seen during treatment of these malignancies with chemotherapy when the rapid destruction of cells releases large amounts of uric acid into the blood, so called "tumor lysis."
    197.Whenever u see an HIV positive patient on pentamidine with seizure think ((pentamidine induced hypoglycemia..and check bld glc!!))198. Efavirenz contraindicated in pregnancy199.Hypocalcemia, hypomagnesemia, hyperphosphatemia. Renal impairment progressing to renal failure. side effect of foscarnet also remember other drugs like Other drugs that affect the kidneys like amphotericin B and pentamidine should be avoided.

    200.). The CT scan can be normal in 5% of patients with a subarachnoid hemorrhage within the first 12 hours of headache onset. Between 24 and 72 hours from onset of headache, up to 25% of CT scans can be normal. Therefore, if one suspects a subarachnoid hemorrhage from the patient's history, it is imperative to perform a lumbar puncture to evaluate the CSF for xanthochromia and red blood cells. Xanthochromia is not seen in a traumatic tap and may be more specific than RBC analysis.
    201.the age of 18 months, most children will have developed a specific set of skills which can be divided into: social, self-help, gross motor, fine motor, and language. Social skills at this age include greeting people by saying "hi" or something similar, giving hugs and kisses, and playing patty-cake. Self-help involves drinking from a cup and feeding self with a spoon. Gross motor skills include walking without help and beginning to run. Fine motor skills would include scribbling with a crayon and stacking 2 blocks. Language skills should encompass talking in single words, asking for food or drink with words, and following simple instructions.
    202.Histoplasma capsulatum is a dimorphic fungus ,it is endemic to the Ohio, Missouri, and Mississippi River valleys ,
    T lymphocytes are crucial in limiting the extent of infection. Susceptibility to dissemination is increased markedly with impaired cellular host defenses.
    A thorough social and occupational history is essential in the initial evaluation. Travel or residence in an endemic area or activities involving bats or birds, whether recent or remote, should aid in the differential. Determine if the patient has a drug history or comorbid condition that is contributing to an immunocompromised state.203.temporomandibular joint (TMJ) disorder, which is a very common disorder that can usually be detected by palpating the area just in front of the tragus. Joint clicking may be found when the patient opens and closes his mouth. Symptoms of TMJ include orofacial pain, a noisy joint, and restricted jaw function.204.remember treatment for preventing recurrence of HBV after liver transplant is HBV Ig + Lamivudine205.Hairy-cell leukemia: B-cell leukemia
    -tartrate resistant acid phosphatase
    -give cladribine for treatmen.206. Rx acute attacks of migrains : Rizatriptan 207.Rx acute attack of migrains lasts for longer than 48 hours or r frequently recurrent : ergotamine208.Rx rhabdomyolysis : osmotic diuresis + bicarbonate 209.Low Ca, high P, high PTH=secondary hyperPTH due to renal failure
    -lung cancer: high PTH-related peptide, high Ca, low P
    -primary hyper PTH: high Ca, low P, high PTH
    -multiple mieloma: high Ca, low to normal PTH
    210.HIV patient pneumonia-MC is still pneumococcus
    In PCPpneumonia=>no pleural effusions
    In PCPpneumonia=>no pleural effusions
    211.A new born with central cynosis ,apex palpated on the rt and scaphoid abdomen,neonatologist suspects diaphragmatic hernia? whats the next step to do?
    do orogastric suction and can operate after 2/3 days because the lungs are hypoplastic and u allow them to be mature
    212.42 yo M, repeated LL clots ? Dx? (factor V laiden deficiency)213.. M with superficial varicose veins, discoloration of LL ? cause? (increased hydrostatic pressure in the v/s)214.M fall off a ladder & hit with the ladder, 3-4 Ds later comes with abd pain, tense & tender, abd XR shows fluid under both side diaphragm ? Dx ?( splenic rupture)215.9 mo, said to be fell off couch, have different color bruises all over, withdrawn, can’t sit or stand without support, <5th % ? what next? (skeletal survey)216.. The treatment of choice for lithium levels greater than 4.0 mEq/L is hemodialysis.217.In the 2001 update of their screening recommendations, the U.S. Preventive Services Task Force strongly recommended routine screening for chlamydia in all sexually active women aged 25 and younger, as well as in asymptomatic women older than 25 who are at high risk.218.intermittent claudication, which is a sign of peripheral vascular disease. Patients often complain of pain during exertion that is relieved by rest. Noninvasive evaluation is usually recommended initially and consists of determining the ratio of ankle to brachial arterial pressures. The ankle/brachial artery ratio is determined by measuring and comparing the 2 blood pressures. If the ratio is less than 1 (greater than or equal to 1 is considered normal), peripheral artery disease is present219. Remember Vancomycin is used in febrile and neutropenic patients in addition to ceftazidime when the patient has an indwelling central vascular catheter220. Chest pain, fever, tachycardia, subcutaneous emphysema, dysphagia, and dyspnea are suggestive of an esophageal perforation. An esophageal perforation may result from endoscopic procedures, external trauma, esophageal disease, and spontaneous perforation from violent bouts of emesis. Prompt recognition of an esophageal perforation is necessary to prevent delayed complications. Whenever a perforation is suspected, a contrast study should be performed with water-soluble contrast material. If this study does not demonstrate the perforation, it should be repeated with barium. Barium is more accurate for a delineating esophageal leakage. Contrast studies not only help in diagnosing esophageal rupture but also document the level of injury, which has important implications for treatment.
    221.Topical steroid and phototherapy are the two main therapeutic modalities in treating vitiligo. 222.the presence of a central venous catheter for 6 days in an intensive care unit (ICU) dictates strong consideration of catheter-associated sepsis, for which staphylococci are the most common cause. The absence of inflammatory changes at the site of catheter insertion is not uncommon in the presence of catheter-associated bacteremia. Because methicillin-resistant strains of staphylococci are common in many ICUs, vancomycin must be a component of the antibiotic regimen to cover these pathogens. Genta-micin is used to cover the less frequent possibility of gram-negative catheter-associated sepsis and is indicated because the patient is in septic shock. 223.The diagnosis of common variable immunodeficiency (CVI) should be suspected in any patient with abnormally recurrent or severe bacterial infections of the upper or lower respiratory tract. Early diagnosis of CVI is important because immunoglobulin replacement therapy can prevent recurrent infections and associated chronic tissue damage. It is important to consider other conditions that may predispose a patient to recurrent respiratory tract infections, such as allergies and anatomic abnormalities, when evaluating a patient for suspected humoral immunosuppression. The laboratory tests for CVI consist of measuring serum immunoglobulin levels, including subclasses of IgG. In addition to quantitative measurements of serum immunoglobulins, it is important to evaluate the patient’s ability to produce specific IgG antibodies to protein and polysaccharide antigens. The decision to treat patients with immunoglobulin replacement therapy is based on the frequency and severity of recurrent infections and a demonstrated failure to mount functional antibody responses, rather than on the absolute level of serum IgG. 224. Adrenoleukodystrophy:
    1.X linked ds
    2.cha by visual loaa,spasticity,mental retardation.
    3.there is failure of meta of long chain fatty acid.
    Rx-Dietary restriction of long chain fatty acid225.Remember The psychiatric manifestations of hypothyroidism include fatigue, depression, lethargy, psychomotor retardation, poor concentration, and forgetfulness.226.Remember Spironolactone has an anti-aldosterone effect and therefore predisposes a patient to hyperkalemia. (Remember that hyperkalemia is an important stimulus for the secretion of aldosterone.) 227.Remember Acetaminophen can predispose susceptible patients to renal failure through tubular injury (acetaminophen is a metabolite of phenacetin, a known tubular toxin.228.Remember MRI with gadolinium is considered the most sensitive test for detecting microadenoma. The test can reveal microadenomas in 20% of normal women.229.Achalasia is a neurogenic esophageal disorder thought to be caused by a malfunction of the myenteric plexus of the esophagus. The result is denervation of the distal esophageal muscle with resulting impaired esophageal peristalsis. The characteristic findings on esophageal manometry are diminished or absent peristalsis in the body of the esophagus and a high resting lower esophageal pressure230.remember 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 lamp231.Remember Evaluating the optic discs for hyperemia is typically reserved for suspected methanol toxicity, since methanol is metabolized to formic acid, which can cause irritation of the optic nerve232.Remember whenever they asked about vulvar heart disease ,look at BP ,if it's wide,you should consider AR!233.Mitral stenosis presents with a diastolic rumbling murmur heard at the apex of the heart
    AR:blowing diastolic murmur heard loudest at the left sternal border234.Acute cholecystitis is the result of cystic duct obstruction, and this would be best demonstrated by a HIDA scan. 235.Remember skin tags, more formally known as acrochordons236.Remember silent hematuria can be due to renal, ureteral, or bladder cancer, and these malignant processes must be effectively ruled out. Intravenous pyelogram (IVP) will visualize kidney and ureteral tumors, but is not reliable enough to rule out bladder cancer. Direct visualization of the bladder mucosa by cystoscopy is the only way to rule out bladder cancer. Thus, both procedures are needed.237.Remember There is no need for prophylaxis for IE when the cardiac lesion is due to prior coronary artery surgery, mitral valve prolapse without regurgitation, prior rheumatic fever or Kawasaki disease without valvulopathy, presence of a pacemaker, isolated secundum atrial septal defect, surgically repaired septal defect or patent ductus arteriosus, or physiologic heart murmurs. 238.remember some procedures require no prophylaxis for endocarditis regardless of the type of cardiac lesion. These include dental procedures that do not induce bleeding, endotracheal intubation, tympanotomy tube insertion, cesarean section, uncomplicated uterine procedures in the absence of infection, and cardiac catheterization. 239.Remember Increasing anemia in a previously well-maintained immunosuppressed patient is suggestive of parvovirus B19 infection, especially with an associated reticulocytopenia. Occasionally giant pronormoblasts may be seen on the peripheral blood smear. A bone marrow examination may confirm the absence of erythroid progenitor cells and exclude other pathology, but is not required to diagnose parvovirus B19 infection. The diagnosis should be confirmed by the detection of parvovirus B19 antigen or significant levels of parvovirus B19 DNA in serum by (PCR). 240.Remember paitent with kawasaki have conjunctival involvment but in scarlet fever no conjunctival !!241.HHv6:Roseola
    HHV7itrias rosea
    HHv8:kaposi sarcoma242.Erythema multiforme,exfoliative dermatitis& the *******-Johnson syndrome r potentially life-threatening drug reactions of sulfa agent.243.Remember The risk of contracting meningococcal disease among household members and childcare and nursery school contacts is considered high enough to warrant chemoprophylaxis. Rifampin, ceftriaxone, and ciprofloxacin r the 3 recommended agents used as chemoprophylaxis for invasive meningococcal disease.244.inhalant intoxication is characterized by euphoria,belligerence,apathy,impaired judgment,dizziness,nystagmus,incoordination,slurre d speech,unsteady gait,lethargy,depressed reflexes,psychomotor retardation,tremor,muscle weakness,diplopia.Stupor,coma may occur.245.Good q:A 48 yo woman has a 3yr history of gradually progressive writhing movements of her extremities,emotional lability,aggressive outbursts& memory impairment.Mental status exam reveals a withdrawn& irritable woman who speaks only in monosyllables.Which of the following is the most appropriate pharmacologic intervention?
    A:benztropine
    B:carbamazepine
    C:chlorpromazine
    D:haloperidol
    E:lorazepamD:haloperidol
    Case of Huntington dementia246.A preterm infant required positive pressure ventilation for 3mo,and developed bronchopulmonary dysplasia.After discharge from the hospital,the child was noted to have intermittent episodes of acute respiratory distress& wheezing unresponsive to bronchodilator therapy.The most appropriate diagnostic test in this case is:
    a:Cxray
    b:a serum theophyline level
    c:an ABG determination
    d:an echocardiogram
    e:bronchoscopy
    A. e:bronchoscopy
    It’s the diagnostic test of choice,characteristic findings on bronchoscopy in this infant include narrowing of the airway by abnormal growth of tissue,tracheomalacia or bronchomalacia or both247.Remember Steroids, especially intraarticular steroids,r very effective when NSAIDs and Colchicine (which are the treatment of choice for acute gout)r contraindicated.In this pt,CRF is a relative contraindication to NSAID & rofecoxib use.So,intraarticular steroids would likely give him relief from his pain by decreasing inflammation and provide treatment with few systemic effects.248.Neuromelanin are found in substantia nigra & locus ceruleus and they disappear in Parkinson's dz.249.which type of brain tumor can be spread by CSF ?medulloblastoma250.Remember germinoma, as common in pineal gland area, give Parinaud's. Brain stem glioma give (usually benign pilocytic astrocytoma) may give locked-in syn.
    251.which lesion can be induced by aneurysm of Posterior communicating artery of Circle of Willis ?
    which lesion can be induced by aneurysm of Anterior communicating artery of Circle of Willis ?
    1.3rd nerve palsy
    2.bitemporal lower quandrantinopia
    252.)CHF due to aortic regurgitation=>give diuretics, ACE inhibitors, digoxin, NOT Beta-blockers-which prolong the diastole=>increased regurgitation253.Malaria-P.vivax-fever every 48h
    P.ovale-fever every 72h
    P. falciparum=>no periodicity
    -starts with intens chills, then the hot phase, then 2-6h later-vomitting, low BP, tahicardia
    -anemia, splenomegaly
    -hystory of past similar complaints when in Africa254.Babesiosis-RBC cell parasite
    -from ticks
    -varies frrom asymptomatic to severe anemia, jaundice and renal failure
    -seen in splenectomised patients or with HbSS diseases255.)TB can appear in HIV patients even with CD4>200/ul
    -no need of hystory of close contacts256.Case of SYSTEMIC MASTOCYTOSIS
    which there's proliferation of mast cells in the skin,liver,spleen,BM&lymph nodes.
    It can occur at any age,no FH+,and atopy is not increased in these pts.
    the cutaneous lesions of urticaria pigmentosa respond to trauma with urtication and erythema(Darier's sign)
    diagnosis with clinical findings&Ph.E,and lab findings:A 24 hr urine collection for histamine,histamine and PGD2 metabolites is the most common noninvasive procedure.confirmtion of diagnosis with tissue diagnosis.
    Rx:symptom/sign directed approach:H1&H2 antihistamines257.an associated hypogammaglobulinemia is an underlying cause for infection &
    ,serum beta2-microglobulin is the single most powerful predictor of survival and can substitute for staging:
    SEEN IN MM258.Remember Pts with DM&CRF and multiple organ failure can develop acalculous cholecystitis.Acalculous cholecystitis is characterized by the absence of gallstones and sometimes even biliary sludge.These pts may not present with classical signs of cholecystitis, because of associated diabetes mellitus and multiple organ failure.US may fail to show evidence of gallstones or obvious signs of cholecystitis.A CT scan of the abdomen and pelvis will reveal a thickened gallbladder wall, pericholecystic fluid, gas within the gallbladder wall, and evidence of surrounding inflammation.259.Afetr abdom. aortic aneurysm repair and blood in the stool=>suspect ischemic colitis=> do sigmoidoscopy/colonoscopy to assess coloniv viability, if CT scan is inconclusive, BUT NOT Barium enema=>can cause perforation260.In SLE=> non-erosive arthritis
    In RA=erosive arthritis:indication for starting Methotrexate 261.Patient of IPPV who deteriorates=>do CXR to rule out barotrauma262.Kallmann's syndrome-46,XX
    -anosmia
    -hypogonadotropic hypogonadism
    -absent pubic, axillary hair
    -absent breasts
    -amenorrhea263.Acute liver failure-appears within 8 weeks from the start of the injury
    Fulminant hepatitis=acute liver failure+hepatic encephalopathy264.factor XI deficiency
    it's largely confined to Ashkenazi-Jewish populations.Spontaneous bleeding may occur in homozygotes:epistaxis,menorrhagia or bleeding after dental procedures or surgery.Hemarthroses as in hemophilia A or B r unusual265.ts with factor XIII defeciency usually bleed in the neonatal period from their umbilical stump or circumcision266.Remember i t’s recommended that during nursing home outbreaks of influenza,both amantadine& immunization should be given to those who haven’t received annual immunization267.remember whenever you suspect venous sinus thrombosis.MRV is the best noninvasive test to confirm this diagnosis.Pregnancy& postpartum state r RFs for it.268.In neurofibromatosis type 2, when suspect acoustic neuroma=> first do MRI with gadolinium=best test, then surgery to remove the tumor269.Solitary brain metastasis=>surgical resection, followed by whole brain irradiation
    Multiple brain metastasis=>palliative brain irradiation270.)Eaton-Lamber Syndrome=>auto-antib. against gated Ca channels
    -small-celllung cancer
    -treat by plasmapheresis+immunossupressive therapy
    271.To diagnose lutheal phase defect=>endometrial biopsy which shows loss of endometrial maturation by more than 2 days as compared to normal272.Remember Juvenile angiofibroma is a highly vascular fibrous tumor that classically affects adolescent males and appears to be related to androgenic stimulation. It manifests with recurrent epistaxis. 273.Mutation of an X-linked gene coding for a tyrosine kinase is the underlying molecular mechanism leading to X-linked agammaglobulinemia of Bruton, a syndrome characterized by inability of pre-B cell precursors to mature into B-lymphocytes. Humoral immune deficiency thus manifests274. Mutations of the autosomal gene encoding adenosine deaminase represent the most common cause of the recessive form of severe combined immunodeficiency disease (SCID), encompassing a heterogeneous group of conditions characterized by deficiency of both T- and B-cell mechanisms. SCID may be autosomal dominant, autosomal recessive, or X-linked. Mutations of the X-linked gene coding for a cytokine receptor subunit represent the most common cause of the autosomal dominant form of SCI.275.Remember Children with hypospadias are prone to urinary tract infections and other urinary tract anomalies.don't forget U/A and Sono
    276.Remember One of the most important reasons for steatorrhea in newborns is bile acid deficiency. Bile acids are very important in normal absorption of fat, which constitutes a major portion of an infant's calories intake. Unfortunately, the bile acid pool in neonates is very small when compared with that in adults. In addition, neonates often lose an excessive amount of bile acids in their stools. This results in physiologic steatorrhea because of poor absorption of fat. Preterm infants, have an even smaller bile acid pool and are more likely to have steatorrhea because of poor fat absorption. This will result in poor weight gain. The solution to this problem is to substitute medium-chain triglycerides (MCTs) in the formula for long-chain triglycerides (LCTs), because, unlike LCTs, MCTs do not require bile acids for absorption.277. Inhalant abuse such as model glue, correction fluid, spray paint, and gasoline, to achieve an altered mental state. It is a common health problem in adolescence. The effect of inhaling a large quantity of hydrocarbons has been described as "quick drunk" because it resembles alcoholic intoxication. Initially, euphoria develops; then, lightheadedness and agitation. Disorientation, ataxia, and dizziness might develop with increasing intoxication. In extreme cases, generalized weakness, hallucinations, and nystagmus can occur. Abusers often show deterioration in school performance, disturbance of family relationships, and increased risk-taking behaviors.278.Remember Encephalopathy is the major chronic morbidity following chronic inhalant abuse. and also keep in mind that a good history is essential because there is no drug screen test that can detect inhalant hydrocarbons. 279.Atrial myxoma=>systemic signs, dyspnea, like mitral stenosis, but no opening snap, murmur changes with position=>high risk of embolization28o.A 2 month old infant can lift its head to 45 degrees, eyes follow to the midline, vocalizes, smiles and has a state of half-waking consciousness281.The ability to lift the head to 90 degrees, eyes crossing the midline, laughing and slight awareness of the caregiver are characteristic childhood development landmarks of a 4 month old infant.282. 6-month old infant can roll over, grasp a rattle, turn to voice, feed self and separate the world into a "parent" and "not parent" world. 283.Remember The combination of female sex and breech presentation results in developmental dysplasia of the hip in 1 in 35 such births.284.Remember PCP is a hallucinogen that causes CNS stimulation (hypertension, tachycardia, brisk reflexes, hyperthermia). Other hallucinogens such as LSD and mescaline cause dilated pupils but PCP has an effect of constricting pupils. Seizures and coma are more common with PCP and intracranial hemorrhages have been reported.285.Marijuana ingestion or inhalation(toxication) causes relatively benign symptoms that include euphoria, hunger, tachycardia and injected conjunctivae. Pupils usually remain normal.286.Screening for prostate cancer:
    ->40 years=yearly rectal exam
    ->50 years=PSA=rectal exam
    -if abnormal=>transrectal US, then niddle biopsy, then bone scan for staging287.Intelectualization=transforming an unpleasant event into a purely intellectual problem
    Rationalization=offering rational explanations in an attempt to justify undesirable attitudes, impulses, beliefs-ex. a guy is rejected from getting jobs at various interviews says that he saved money because the commute was paid by his interogators...288.Internuclear ophtalmoplegia=demyelinization of medial longit. fasciculus
    -sign of MS289.Cervical spondylosis-chronic neck pain, limited rotation and lateral bending of head
    -sensory deficit due to osteophyte-induced radiculopathy290.Constitutional delay of growth is suggested by a child who is growing at a normal or mildly decreased rate. The patient is delayed in pubertal development, and the bone age significantly lags behind the chronologic age. 291.Familial short stature is characterized by a child with short parents, by a bone age consistent with the chronologic age, and by a growth curve that follows the normal pattern even though it is significantly below the 3rd percentile. 292.Malrotation is usually caused by the presence of a volvulus, which presents with sudden onset of bilious vomiting, abdominal distention, rectal hemorrhage, peritonitis, and shock. It is a surgical emergency.293 . Pyloric stenosis :It is caused by hypertrophy and hyperplasia of the antrum of the stomach, resulting in obstruction. 294.The most common cause of urethral obstruction in males is posterior urethral valves. It typically results in urinary obstruction and vesicoureteral reflux.it will cause bedwetting day and night,FTT, enlarge bladder!Voiding cystourethrogram is the definitive diagnostic test.295. Marfan syndrome is an autosomal-dominant disorder The genetic defect results in abnormal synthesis and secretion of fibrillin, Patients with Marfan syndrome often have involvement in the skeletal, ocular, and cardiovascular systems. Most of the morbidity and mortality with this disease are related to the cardiovascular manifestations; patients develop aortic root dilatation. This may be associated with aortic insufficiency and aortic arch dissection. They may also have mitral valve prolapse . Aortic root, aortic valve, and mitral valve replacement may be needed during the lifetime of the patient. Patients with Marfan syndrome may frequently complain of chest pain; these patients must be viewed as having aortic dissection until proven otherwise. In this population, a spontaneous pneumothorax is another potential cause of chest pain. 296. beta-blockers clearly slow the progression of aortic root dilatation in those with mild aortic root dilatation in Marfan syndrom.. Exercise should be limited to aerobic activities. Patients must avoid contact sports that cause acceleration-deceleration injury and isometric maneuvers that tend to increase central blood pressure. Aerobic activity is encouraged, but those with established aortic root dilatation should have adequate heart rate control with beta-blockers.
    297.)Brown recluse spider-deep bite, ulcer with a necrotic center and erythematous halo, treat by local excision
    Black widow spider=>abdominal rigidity, muscle cramps, nausea, vomitting, no local ulcer
    -treat by Ca gluconate, muscle relaxants298.Pneumonia post bone marrow transplant=>think CMV
    -not immediate, comes in about 2 weeks to 2 years post-transplant299.Asymptomatic Paget disease=>no treatment
    -symptomatic (lytic lesions or skullinvolvement)=>biphosphonates=CHOICE300.If isolated proteinuria detected=>repeat distick testing at least twice more; then if still (-)=>reassurance; if (+)=>check 24h urinary proteins, BUN, Cr301.Venous ulcers=>medial aspect of foot
    Arterial ulcers=>lateral........................302.Dissemi nated gonococcal infection-rash, tenosynovitis, polyarthralgia (migratory)
    -mediated by immune complexes from gonococcemia303.Foreign body aspiration=sudden onset of resp. distress, afebrile, interstitial retractions
    -do direct laryngoscopy+rigid brochoscopy
    -one lung is hyperinflated, the other is hypoinflated304.Remember throwing a ball overhead is most consistent with the motor development of a 24-month-old child305. Building a tower is a good way to assess a child's motor function.3 cubs 15
    4 cubs 18
    7 cubs 24306.Osteoid osteoma is a small benign tumor of the bone that frequently affects the tibia. The tumor is usually unilateral and manifests with nocturnal pain, which awakens the child and is promptly relieved by aspirin or NSAIDs307.Stress fractures affect small bones that normally have a thin cortical bone. When subjected to repeated mechanical stress, such as marching, skiing, ballet dancing, etc., the bone accumulates microfractures that eventually result in chronic pain and swelling. Metatarsal bones are the most frequently affected. 308.Osteosarcoma is a malignant bone tumor affecting children and adolescents. Unilateral bone pain in the segment involved (usually proximal tibia or distal femur) or pathologic fracture is the usual mode of presentation309.Remember In children, the most common cause of stridor is laryngomalacia.310.Renovascular disease is the most frequent cause of hypertension in young children. Ailments such as polycystic kidney disease, congenital vascular disease, tumors and infections can all lead to hypertension, and a urologic evaluation is imperative.
    311.ALwayes remember For patients with persistent asthma symptoms, inhaled corticosteroid is the treatment of choice312.In acute CHF, treatment should begin immediately. IV furosemide is the drug of choice because its onset is very rapid. It can provide quick symptomatic relief and improve respiratory distress. Angiotensin-converting enzyme inhibitors are used for the long-term management of patients with CH.313.Measles is associated with subacute sclerosing panencephalitis, a chronic encephalitis of the central nervous system manifested by progressively bizarre behavior and decline in cognitive function. 314.Bell palsy, a postinfectious allergic or immune demyelinating facial neuritis. Epstein-Barr virus is the preceding infection in approximately 20% of cases.However, herpes simplex virus, Lyme disease caused by Borrelia burgdorferi and mumps have been associated with Bell palsy too.315.microhematuria after trivial trauma in children may be a sign of a congenital anomaly that makes the urinary tract unusually vulnerable. The warning should be heeded, and an anomaly sought. The first, noninvasive test should be the sonogram. 316.Neurofibromatosis is a multisystem genetic disorder. The features of this condition are more than six café-au-lait spots, two or more neurofibromas, axillary freckling, optic gliomas, iris hamartomas (Lisch nodules), and osseous lesions. There is almost always a first-degree relative with neurofibromatosis.317.An infant with HLH(hypoplastic left heart) syndrome has a hyperdynamic precordium because the enlarged right ventricle is contracting against systemic pressure. The infant also has a loud, or even palpable, second heart sound (S2) because the pulmonary artery acts as the aorta by pumping blood to the systemic circulation through the ductus arteriosus. The high end-systolic pressure markedly enhances S2. The flow from the right ventricle to the pulmonary artery is not turbulent; therefore, there is usually no significant murmur heard on auscultation. When the ductus closes, or when the pulmonary vasculature resistance falls, the flow to 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. Administration of room air or even hypobaric oxygen (FiO2 less than 21%) and the use of muscle relaxants can prevent hyperventilation and subsequent pulmonary vasodilation, thus reversing systemic hypoperfusion and metabolic acidosis. 318. Osteoid osteoma usually affects patients between the ages of 5 and 24 years. This lesion can occur in almost any bone, although it is most common in the lower extremities. Osteoid osteoma also may occur in the posterior elements of the spine. Patients usually present with pain, which is characteristically worse at night and relieved with aspirin. the pain is now managed with naproxen or ibuprofen. The process may cause growth disturbances, such as leg length discrepancy or bowing of an extremity, or scoliosis. Radiographs usually show a sclerotic lesion and sometimes a localized lytic defect or nidus (<1 cm in diameter) within the sclerotic bone. The nidus is best demonstrated with CT.319.Ewing sarcoma is a malignant tumor of bone arising in medullary tissue. It most often occurs in cylindrical bones. Prominent symptoms include pain, fever, and leukocytosis. Radiographs have a typical "onion skin appearance."
    320.Attention deficit/hyperactivity disorder (ADHD) is characterized by impulsivity, hyperactivity, and inattention lasting at least 6 months. To make the diagnosis, the disorder must have started before age 7, and six signs each of inattention and impulsivity/hyperactivity need to be present in both home and school.321.the presence of IgG against hepatitis A could mean a previous infection and is not diagnostic of a current infection. there is no chronic hep A.322.CMV infection : Heterophile Ab test is negative 323.-Cyclophosphamide: ovarian fibrosis in 1/5 femals. Also bladder problems 324.Reloxafine: drug use for osteoprosis, inc HDL, dec LDL, doesn’t tx hot flash
    325.Remember CLL : stage I (lymphocytosis & lymphadenopathy) req no tx 326.Membranous nephropathy : . Among infections, cuases #1 is Hep B #2 syphilis
    327.Remember whenever you see MI in yuong age think :-Familial hypercholesterolemia Fam hx, xanthoma, AD mutation in LDL receptor gene .327.Autoimmune Hep : liver biopsy shows lymphocytic portal inflammation w/ early bridging necrosis. Type I (classic) assoc. w/ antinuclear & antismooth Ab. Type II (common in W European descent) has Ab to circulating liver-kidney microsomes 328.Wiskott Aldrich synd: XR immunodef triad of thrombocytopenia, eczema, recurrent infection. T & B cell defect. Inc risk of ALL & lymphoma. Tx is splenectomy, continued antibiotics, IVIG, bone marrow transplant 329.Poststreptococcal glomerulonephritis is the most common cause of acute glomerulonephritis in children. Itusually follows a streptococcal pharyngitis by 1-2 weeks and a streptococcal skin infection by 2-3 weeks Laboratory values are usually significant for markedly decreased complement levels (C3 and C4), hypo- or hypernatremia, and a blood urea nitrogen elevated disproportionately to the creatinine. In order to diagnose poststreptococcal glomerulonephritis with certainty, there needs to be evidence of a preceding streptococcal infection such as an elevated ASO or streptozyme.
    33o.Total anomalous pulmonary venous return is characterized by the pulmonary veins forming a confluence behind the left atrium, and draining into the right atrium. Complete mixing takes place in the right atrium, with a right-to-left shunt through the foramen ovale to the left side of the heart. Often, no murmur is heard on cardiac examination, although a short systolic murmur is sometimes heard. ECG often reveals right atrial enlargement and right ventricular hypertrophy. The 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. Definitive treatment is surgical anastomosis of the pulmonary vein to the left atrium. don't forget figure 8 or snow man!331.Hypoplastic left heart syndrome is characterized by underdevelopment of the left ventricle and the ascending aorta. Typically, there is obstruction at the mitral valve, causing all pulmonary venous blood to shunt through either an ASD or a patent ductus arteriosus (PDA) into the right atrium. Total systemic blood flow is channelled through the ductus arteriosus from the pulmonary artery. As the ductus closes, these infants present with shock because systemic blood flow is significantly reduced.
    these paitents have ,HEPAtO SPLENEMEGALLY,CARDIOMEGALLY,DYSPENEA,CYANOSIS332.P DA causes symptoms of pulmonary congestion, dyspnea, widened pulse pressure, and bounding arterial pulsation because aortic blood flow is shunted from left to right.333.PS causes a harsh systolic murmur easily audible over the upper left sternal border. There is a significant right-to-left shunt because the large VSD allows unrestricted flow from the right ventricle to the left ventricle, causing cyanosis.334.In which disease polymerisation of microtubules in leukocytes is the primary defect and what are its effects?Cheideck-Higashi
    Phagolysosome defect leads to infection with Staph, 335.Acid base disorder seen in a case of cardiorespiratory arrest?
    first, resp acidosis becos of arrest of resp
    after a time later, metabolic acidosis as tissue hypoxia going on336.Gaucher's: glucocerebroside
    Tay-Sachs': ganglioside
    Niemann-Pick's: sphingomyelin337.actinic keratoses (AK), which are common lesions seen on sun-exposed skin. AKs are a cutaneous dysplasia of epidermis that may undergo malignant transformation. They typically occur in middle-aged and elderly adults. AKs can be macules or papules, and often have a hyperkeratotic, adherent scale. The "cutaneous horn" is caused by an abnormal growth pattern of the cells within the AK, that resembles an animal horn. The treatment includes cryosurgery, surgical excision, pathologic evaluation, and topical therapy.338.keratoacanthoma is a rapidly growing nodule that has keratinous debris in the center. It is related to squamous-cell carcinoma.339.Because of its toxicity, especially in elderly patients and patients with liver and renal dysfunction, colchicine is not used frequently to treat acute gout.340.High levels of cisapride (or astemizole, among other drugs) can cause prolonged QT intervals, torsades de pointes, ventricular tachycardia, and death. cisapride levels can be especially high when their metabolism is inhibited by ritonavir.341.The patient with trichomoniasis often has a purulent vaginal discharge and some vaginal and cervical erythema (strawberry cervix). Wet smear is the most useful test and is approximately 80% sensitive for Trichomonas342.Bacterial vaginosis presents as a gray, homogeneous, foul-smelling vaginal discharge with a pH exceeding 4.5, an amine odor when sodium or potassium hydroxide is added to the discharge, and clue cells in the exudate (vaginal epithelial cells coated with bacteria343.remember Patients with suspected sexually transmitted diseases are good candidates for HIV serologic screening, but HIV infection does not appear to increase the risk of vulvovaginal candidiasis, trichomoniasis, or bacterial vaginosis.344. Escherichia coli (EHEC): Bloody diarrhea, abdominal cramping, and absence of fever are common, and the disease tends to occur in previously healthy people who consumed underheated ground beef345.From most transmissible to least transmissible, the pathogens are: hepatitis B (e antigen-positive)—about 30% to 40% of needlesticks; hepatitis C—about 3%; HIV—about 0.25%; and hepatitis A—almost never (transmission can occur during the initial viremic phase of infection only). 346..Remember Cryptococcal meningitis can occur in immunologically normal patients with no underlying disease. 347.Patients with moderately advanced to advanced immunosuppression from HIV may develop a syndrome of fever, mild hepatitis, and elevated angioma-like skin lesions cause by Bartonella henselae.The skin lesions can resemble Kaposi’s sarcoma, but the biopsy specimen shows characteristic findings of Bartonella infection, including Warthin-Starry–stained organisms.348.The evaluation of health-care workers at the time of exposure to blood should include an HIV antibody test (ELISA) and testing for protection against hepatitis B.349.Remember In 60% of patients with cervical intraepithelial neoplasm (CIN) the lesion resolves spontaneously; only 1% of patients have lesions that progress to cancer. The remaining patients have a chronic infection. HPV infection leading to CIN is acquired by sexual intercourse, although the male partner is usually not aware of a penile lesion, and HPV can be transmitted to new sexual partners.350.Alwayes remember Some patients with rapidly progressive meningococcemia and meningococcal meningitis may have a normal cerebrospinal fluid examination on first presentation. !!!then suspect clinically start ceftriaxone and don't care the CSF!!!351.what is the pathophys of idiopathic pulm fibrosis?its the immune complex mediated activation of alverolar macrophages .....probably related to locally generated immune comples, alveolar macrogphages become activated and the produce several mediatores that recruite and induce fibroblast proliferationand ca .
    clues which are imp are chest auscultation reveals coarse dry crackes and on chest x ray retucilar or reticulonodular disease..ct ground glass apperarance....pft's restrictive pattern 352.hypersen pneumonitis is type III hypersentsitivity 352.Remember Like their younger counterparts, patients older than 60 years who are not immunosuppressed contract pneumonia caused by the usual pathogens, such as Streptococcus pneumoniae and Haemophilus influenzae. More important, advanced age is associated with infections due to Staphylococcus aureus and enteric gram-negative bacilli. Empiric antibiotic coverage for pneumonia among persons in this age group should include agents active against these pathogens.
    353.Remeber Sarcoptes scabiei: The most effective way to confirm the diagnosis is to place a drop of mineral oil on a suspected area, and unroof the burrow hole with a needle or scalpel and examine the scrapings under the microscope. The patient should be treated with permethrin cream and close contacts should be treated, even if asymptomatic.
    after DIAgnosis establish now you can treat and ......but not before scraping the lesions and evaluating them under the microscope.IT IS NOT A CLINICAL DIAGNOSIS!354.2 situation that you can see WBC cast:
    pyelonephritus and alergic interstial nephritus355.by which mechanism cyclosperin cuase HTN?and what's the treatment of HTN in this situation?
    renal vasoconstriction& sodium retention.RX--ca+ blockers356.giving ACE and NSAID with each other can cuase decrease in GFR and RF,by which mechanism??angiotensin II causes constriction at efferent arteriole.
    ACEI causes dilatation of that arteriole.
    so that renal blood flow is increased. But GFR and Filtration fraction are decreased as there is decreased filtration pressure.renal PG dilate afferent arterial tone.
    NSAID causes afferent arteriolar constriction.
    so that decreased Renal bld flow and GFR => renal shut down 357.pathogenes of Alport syndrome: collegen type IV for GBM358.which diuretic cuase dissolved uric acid stones?uric acid is less soluble than its urate salt,and decreasing the urinary PH increase concentration of the uric acid form,becuase ACTAZOLAMID increase urinary PH ,it can be used to dissolved uric acid stone.359.what's Tx(treatment) of Goodpasture's syndrome?
    tx wegner granolomatosis?plasmapharesis - gotta get rid of antiglomerular basement membrane antibodies, steroids+cyclophosphamid for Wegners granulomatosis
    360.)Impaired consciousness, even following a first seizure=>do CT scan without contrast361.Guillain-Barre syndrome is an acquired demyelinating neuropathy that usually follows a viral respiratory infection or immunizations. It is characterized by ascending weakness. Sensation is intact. A main diagnostic clue is absent deep tendon reflexes
    -not EEG361.Alwayes Remember Heart size is usually normal early in the course of common congenital heart diseases. This is true of coarctation of the aorta, aortic stenosis, pulmonic stenosis, tetralogy of Fallot, and tricuspid atresia. In transposition of the great vessels, however, a roentgenogram will show a large, egg-shaped heart with a narrow supra-cardiac stalk
    362.Pneumonia that does not respond to beta-lactamines=>suspect Legionella
    -diagnose by urinary Legionella antigen (ELISA)363.Remember most common cause of hematuria in children is infection, which should be ruled out by culture unless the history strongly suggests another cause. Other causes include post-streptococcal glomerulonephritis, neoplasms, stones364.Remember A hydrocele of the tunica vaginalis testis occurs frequently at birth but usually resolves in a few weeks or months. No treatment is indicated during the first year of life unless there is a clinically evident hernia. A simple scrotal hydrocele without communication with the peritoneal cavity and no associated hernia should be excised if it has not spontaneously resolved by the age of 12 months. 365.The current mainstay of treatment for metastatic prostate cancer is androgen deprivation therapy using a leuteinizing hormone-releasing hormone (LHRH) agonist such as leuprolide or goserelin or by performing a bilateral orchiectomy. 366.Remember hep B with membranous and hep c with membrano proliferative 367.Neurological Features of Sjogren’s Syndrome:
    Small vessel strokes
    Encephalitis
    Dementia
    Peripheral neuropathy – may be sensory, motor or mixed
    Seizures
    Aseptic meningitis 368.alwyes remember one of the important neurologic manifestaion of Vasculitis is peripheral neuropathy,especially in CSS!
    369.asthma+eosinophilia +peripheral neuropaythy DX??
    CSS(UW).369.Differentiating Parkinson’s disease and essential tremor Age – Parkinson’s tends to come on later in life Location – Essential tremor is more generalised and symmetrical. It often affects the head and voice. First degree relatives – More commonly affected in essential tremor
    Associated neurological signs – rigidity, bradykinesia in Parkinson’s, usually none in essential tremor. Response – Parkinson’s will respond to L-Dopa, anticholinergics and dopamine agonists. Essential tremor is often responsive to alcohol, benzodiazepines and beta-blockers
    Writing – Parkinson’s sufferers often demonstrate micrographia, while essential tremor often involves tremulous writing. 370.which malignancy you can see in wiskott aldrich syndrme?NHL371 .what is the cuase of death in NF1 in future?
    Sarcoma372.remember recent trials have indicated that a combination of unfractionated heparin plus a platelet glycoprotein IIb/IIIa inhibitor is superior to heparin alone in reducing morbidity and mortality in patients with acute coronary syndromes.373.The asymptomatic patient with Descending thoracic aortic aneurysms is treated medically until the size of the aneurysm is 5 to 6 cm or symptoms present. Medical management includes aggressive blood pressure control,(B blocker and nitroproside), serial imaging for evaluation of size (diameter), and close follow up for symptom onset.374.Remember there is a increase incidence of CAD in premenopuse women with SLE!(due to imune complex)
    also chronic use of corticosteroid can cuase hyperglycemia and hyperlipedemia!375.S. epidermidis, is the single most common cause of catheter-acquired sepsis and the most usual coagulase-negative staphylococcus,cover it with Vancomycin376.Rifampin is an inducer of cytochrome P-450 enzyme systems and causes to decrease the plasma concentrations of protease inhibitors in HIV paitent!!BE CAREFUL!!377. MCcune albright sd recocius puberty, aromatase enz def, cystis in bone
    + cafe auliat spots 378.Remember The diagnosis of pesudo tumor cerebri can be made only after intracranial causes for increased intracranial pressure have been excluded by MRI (tumor, venous sinus thrombosis, ventricular outflow obstructive lesions) and a lumbar puncture documents an elevated opening cerebrospinal fluid pressure.379.Remember Carbidopa is combined with levodopa to minimize peripheral side effects of levodopa, with nausea being the most common side effect.380.Toxoplasmosis is the most common cause of intracranial mass lesions in patients with AIDS. It typically develops subacutel

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    Cyrus, you have the best review notes i've read for Step 2. Thanks for posting them!

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