The typical presentation of a thrombosed external hemorrhoid is an acute onset of very severe perianal pain, particularly when walking and sitting. 2. You know that external hemorrhoid is below the dentate line. internal hemorrhoids arise above the dentate line. 3. thrombosed external hemorrhoid requires immediate incision and evacuation of the clot to provide symptomatic relief. Pressure by compression is usually all that is needed to control the bleeding. 4..Sitz baths, applying a topical steroid cream, and increasing fiber intake are the usual treatment for symptomatic external hemorrhoids that are not thrombosed. 5..as a rule alwayes remember that external hemorrhoid s hurts but donot bleeding(opossit internal hemorrhoids) 6.typical picture of pyloric stenosis.,Projectile non-bilious vomiting is seen in virtually all patients. Patients also often develop a hypokalemic, hypochloremic metabolic alkalosis from the persistent vomiting. remeber if they give a child with intermittent spitting up think about pyloric stenosis. 7.abrupt onset of colicky abdominal pain in childeren <2 years ,think about intussusception! what's the etiology? The exact cause is unknown. However, it is associated with Meckel's diverticulum, cystic fibrosis, polyps, and Henoch-Schonlein purpura. remeber A barium enema or air enema is both diagnostic and therapeutic. 8.Remember In any patient with dysphagia that is progressive for only solids, it suggests a growing and obstructive lesion. The history of tobacco and alcohol use, puts person at a much higher risk of carcinoma. The two ways to diagnose this are a barium swallow study, which will show the mucosal mass, or an upper endoscopy study to directly visualize and biopsy the lesion. 9.Remember Esophageal manometry is used to evaluate dysphagia caused by motility disorders. These typically present with dysphagia for solids and liquids and may or may not be progressive. 10.Incarcerated or strangulated hernias in an elderly patient can cause acute abdomen, dehydration, and altered mental status. 11.. Frequent, greasy, malodorous stools are a result of steatorrhea from chronic pancreatitis. This happens from the lack of pancreatic enzymes. Non-enteric coated pancreatic enzyme supplements with concurrent H2 blockers will deliver active enzymes to the proximal small bowel and help reduce malabsorption and steatorrhea. 12.. Acute acalculous cholecystitis is characterized by fever, nausea and vomiting, right upper quadrant abdominal pain, and inspiratory arrest on palpation of the right upper quadrant (Murphy's sign). An elevated leukocyte count is usually present. Gallstones are not present and it is usually associated with trauma, burn, surgery, diabetes mellitus, and bacterial infections of the gallbladder. BUT biliary colic, which is characterized by crampy, right upper quadrant abdominal pain that may radiate to the back and often follows a meal. Nausea and vomiting may be present. Fever, chills, and leukocytosis are notably absent. Gallstones are present on an ultrasound. 13.Acute cholangitis is characterized by fever, right upper quadrant pain, and jaundice (Charcot's triad). 14.The hallmark of mesenteric ischemia is pain out of proportion to physical exam findings. Mesenteric ischemia is especially likely in a patient with known vascular disease and a history of cigarette smoking. The next diagnostic step is a mesenteric angiogram. The superior mesenteric artery is the most often compromised vessel. 15. Patients with ulcerative colitis are at high risk for toxic megacolon, which is also associated with Clostridium difficile colitis 16.. Toxic megacolon presents clinically as abdominal distension and bowel motility disturbances. The next step in evaluation is an abdominal radiograph which will demonstrate a distended large bowel. 17.spontaneous bacterial peritonitis. This diagnosis should be first on your list in any patient with ascites who presents with fevers, abdominal pain, change in mental status, or with other non-specific complaints. These patients need to have a paracentesis. This fluid is then sent to the lab for a cell count, culture, and Gram stain. The diagnosis of SBP can be made by seeing bacteria on a Gram stain, having more than 500 WBC or 250 PMNs in the cell count, or a positive peritoneal fluid culture. Patients with SBP need to be started on a third-generation cephalosporin 18.. Lead levels over 10 mg/dL are considered abnormal. 19.Remeber Fluoxetine is a serotonin reuptake inhibitor that requires 5 weeks to reach a steady state in the body and takes approximately 6-8 weeks to show an adequate response. This should be explained to patients before and during treatment to help them understand the importance of staying on the medication even though they do not feel any effects. 20.congenital diaphragmatic hernia, which is when the abdominal contents herniate into the left hemithorax through a congenital defect in the left hemidiaphragm. This causes displacement of the heart into the right hemithorax and pulmonary hypoplasia. 21 key finding for Esophageal atresia with distal tracheoesophageal fistula usually presents with a history of polyhydramnios, cyanosis with feeding, and increased oropharyngeal secretions. 22.Remember in a traumatic lumbar puncture even though the CSF is initially red, the supernatant of the centrifuged cerebrospinal fluid is clear. This means that the red blood cells have not yet had a chance to lyse and release their intracellular contents into the cerebrospinal fluid. BUT in subarachnoid hemorrhage there would be blood in the CSF, the supernatant of the centrifuged fluid would be xanthochromatic (yellow) due to the lysis of red blood cells and the release of their intracellular contents into the cerebrospinal fluid. 23.The symptoms of crampy abdominal pain and watery, explosive, secretory diarrhea are consistent with enterotoxic E. coli. the cause of traveler's diarrhea ,treatment ciprofloxacin if symptoms persistent. 24.The symptoms of Giardiasis, which usually occur about a week after exposure, include flatus, loose stools, diarrhea, abdominal pain, bloating, and vomiting. The usual scenario for a healthy person that develops this infection is the onset of these symptoms after a camping trip. tx:metronidazole 25.infectious mononucleosis typically presents with a few-week history of fatigue, malaise, and a sore throat. Examination often shows pharyngeal edema, erythema, and palatal petechiae, lymphadenopathy, and splenomegaly. Hepatomegaly may also occur. 26.Hyperthyroidism during pregnancy is treated with propylthiouracil, which crosses the placenta less than other medicines such as methimazole. It should be given in the lowest effective dose and tapered as the patient becomes euthyroid. Untreated severe hyperthyroidism during pregnancy has been associated with spontaneous abortion and premature labor. 27.Remember sudden onset of right upper quadrant pain associated with nausea and vomiting and history right upper quadrant and epigastric pain before, associated with food intake. These symptoms are classical for a perforated peptic ulcer. In a perforated peptic ulcer, a patient can still have right upper quadrant localized tenderness, a thickened gallbladder wall, and pericholecystic fluid from the perforated ulcer. Hence, with any abdominal pain associated with signs, abdominal x-rays both erect and supine are very essential in the initial evaluation to rule out any free air. 28.The first line in treatment of panic disorder is selective serotonin reuptake inhibitors (SSRIs), a group of medications including sertraline, paroxetine, fluoxetine, and citalopram. . 29.Remember Surveillance colonoscopies are generally recommended every 6 months for 2 years beginning after 8 to 10 years duration of ulcerative colitis. 30.The presence of endocervical cells on a Pap test is regarded as evidence of adequate sampling of the transformation zone during cytologic screening of the cervix. When these cells are absent, it indicates that this area may not have been sampled. This is considered a satisfactory, but limited smear. In patients with no known risk factors (i.e., prior abnormal Pap test, multiple sexual partners, smoking) the American College of Obstetricians and Gynecologists recommends that the physician may defer to repeating the Pap test in 12 months even if the sample is not adequ 31.in superior vena cava syndrome (SVCS), which is due to obstruction of the superior vena cava. The vast majority of cases of SVCS are caused by malignancies, with lung cancer being the most common. The most feared complication of SVCS is upper airway obstruction. Radiation therapy is the treatment of choice for most patients with SVCS. 32.Remember in patients with known lung cancer, a biopsy of the mass causing the SVCS is usually not necessary and treatment can commence once the clinical diagnosis is made. In patients without a history of cancer, every effort should be made to obtain a diagnosis before starting treatment, as there are benign causes of SVCS (e.g., thyroid enlargement, thrombosis). 33.Pregnancy is characterized by increased alkaline phosphatase being secreted from the placenta. Alkaline phosphatase is usually secreted by biliary canalicular cells, placenta, bone, and intestinal mucosal cells. Hence, raised alkaline phosphatase is a normal value in growing children and pregnant women. 34.Acneiform eruptions is characterized by papules and pustules resembling acne lesions. The eruptions are distinguished by their sudden onset. Oral medications such as iodides, bromides, testosterone, cyclosporine, antiepileptic medications, lithium, and systemic corticosteroids are common agents that can lead to acneiform eruption. When medium or high doses of corticosteroids are taken for as short a time as 3-5 days, a distinctive eruption may occur, known as steroid acne. It is a sudden out-cropping of inflamed papules, most numerous on the upper trunk and arms, but also seen on the face. The lesions typically present as papules rather than comedones. Tretinoin cream applied once or twice daily may clear the lesions within 1-3 months, despite the continuation of high doses of corticosteroid. 35.The management of hematuria associated with trauma differs in adults and children. In the adult population, imaging is performed only in those patients with gross hematuria or microscopic hematuria plus hypotension. This differs from the pediatric patient. In children, any degree of hematuria (gross or microscopic) should be investigated with imaging studies. One reason for this discrepancy is that large amounts of catecholamines released in injured children may sustain blood pressure in the face of hypovolemia. A CT scan is the most useful imaging modality in this setting. A CT is noninvasive, accurate and fast, and it can help in assessing the size and extent of retroperitoneal hematomas and renal parenchymal trauma. 36. Remeber anterior uveitis is associated with sarcoidosis. Anterior uveitis is usually marked by the abrupt onset of pain and photophobia. Specifically anterior uveitis causes iritis and iridocyclitis. Constriction of the pupil causes increased pain. Slit-lamp examination is diagnostic, showing inflammatory cells in the aqueous humor or deposited along the corneal endothelium. 37.Many diseases are associated with anterior uveitis, including sarcoidosis and the seronegative spondyloarthropathies, including ankylosing spondylitis, psoriasis, inflammatory bowel disease, and Behçet's disease. Infectious disease may also cause uveitis. Some of the associated infections include herpesviruses, tuberculosis, onchocerciasis, and leprosy. In the majority of cases, uveitis is idiopathic. Treatment should include topical corticosteroids to decrease inflammation and mydriatics because dilation of the pupil decreases pain and the formation of synechiae. 38. hyperventilation causes a mild respiratory alkalosis and is experienced as acral and periorbital dysesthesias.(tingling sensation in the fingertips.) 39.Remember treatment of CMV retinitis in HIV if Gancyvlovier dosen't work is FOSCARNET(can cuase renal toxicity). 40.Asperger disorder it's characterized by defecits in interpersonal development,restricted patterns of interest&behaivior,and normal cognitive and speech development. 41.Spondylolysis is a defect seen in the pars interarticularis portion of the lamina.Spondylolysis is believed to be caused by repeated microtrauma, resulting in stress fracture of the pars interarticularis. Heredity also is believed to be a factor. Patients with spina bifida occulta have an increased risk for spondylolysis. Approximately 95% of cases of spondylolysis occur at the L5 level.Athletes who participate in sports, such as soccer, baseball, football, wrestling, gymnastics, and tennis, are more likely to have symptomatic spondylolysis at some point(with hyperextension maneuvers) 42.Patients with suspected spondylolysis should be evaluated initially with plain radiography, consisting of anteroposterior, lateral, and oblique views of the lumbar spine. The lateral views are most sensitive for detection of pars fractures, and the oblique views are most specific. 43..Remember The sudden onset of tachycardia and hypotension in a patient who is being mechanically ventilated with positive pressure, is at increased risk of a bullous rupture from barotrauma, leading to a pneumothorax, 44.young age, occurrence of pain at night, negativity of rheumatoid factor, and especially, bilateral involvement of sacroiliac joints are consistent with ankylosing spondylitis. 45.Ankylosing spondylitis should be suspected in any young person complaining of chronic lower back pain and confirmed by radiographs or CT scans of sacroiliac joints. The disease usually progresses to involve the whole vertebral column, producing ankylosis and respiratory failure secondary to restrictive lung disease. Uveitis and aortic insufficiency are additional manifestations. 46.Still disease is a rare systemic form of arthritis with onset before age 17. It manifests with spiking fever and systemic symptoms that usually antedate arthritis. Associated manifestations include a morbilliform rash, hepatosplenomegaly, serositis, anemia, and leukocytosis. 47.whenever the terms "coin-shaped" or "discoid" are used to describe a patient's skin lesions in a question you should think about nummular dermatitis. 48.Remeber symptoms of congestive heart failure and possible atrial fibrillation, as demonstrated by irregularly irregular heartbeat in question(they never mention stright forward A.F). In addition, are at high risk for the development of an embolic occlusion of the superior mesenteric artery. These patients will present with severe pain out of proportion to their objective physical findings. The diagnosis should be suspected clinically, and immediate superior mesenteric arteriogram should be performed. If evidence of ischemia is confirmed, the patient should proceed to exploratory laparotomy to evaluate for intestinal ischemia and possible gangrenous bowel. 49.BUT Ischemic colitis will usually present as diarrhea, often bloody, in elderly patients with known atherosclerotic heart disease. 50.malignant external otitis, This form is specifically caused by Pseudomonas aeruginosa, and tends to affect elderly diabetics and AIDS patients, causing the findings in the severe and persistent earache. Otoscopic examination demonstrates foul-smelling purulent otorrhea and a red mass lesion of the external ear canal. Biopsy of the mass demonstrates granulation tissue rather than tumor. 51.Headache of sudden onset ("thunderclap" headache), rapid deterioration of mental status and blood in the CSF are virtually diagnostic of ruptured berry aneurysms. Note the characteristic hyperdensity on CT of the suprasellar cistern, indicating blood in the subarachnoid space. Rupture of a berry aneurysm is the most common cause of subarachnoid bleeding.