NOTES FOR STEP 3

Discussion in 'Step 3' started by Guest, Oct 8, 2008.

  1. Guest

    Guest Guest

    NOTES FOR STEP 3

    1. Gastroparesis (DM) Rx = metoclopramide,erythromycin; symptoms: post-prandial fullness,hypoglycemia, sweating, dizziness, constipation

    2. Drugs that lead to hypercalcemia = thiazides,lithium

    3. Calcium greater than 12 or symptoms = NSS IV 3-6 l in 24 h, furosemide if necessary

    4. Hungry bones syndrome = hypocalcemia post opremoval of parathyroid adenoma

    5. Sarcoidosis = increase in vit D levels

    6. Familial hypocalciuric hypercalcemia = low 24 h urine calcium

    7. Chronic thyroiditis (Hashimoto) = antimicrosomalantibodies

    8. Drugs that lead to hypothyroidism = lithium, ASA

    9. Large nodule (cold) in multinodular goiter (hot) =FNA; if follicular elements = excision

    10. Psammoma bodies = papillary carcinoma of thyroid = MC type of thyroid cancer, RF radiation exposure, lymphatic spread

    11. Thyroid cancer types = papillary, follicular (hematogenic spread), anaplastic, medullary (MEN); painful, low uptake, increased ESR

    12. Graves disease Rx = bring the patient to euthyroid stae, then: radioactive iodine, steroids for ophtalmopathy

    13. Plummer disease = long-standing multinodular goiters that become thyrotoxic later

    14. Thyroiditis = low 24 h radioactive iodine uptake

    15. Graves disease Dx = increased thyroid, "hot", proptosis, positive TSH Ig

    16. Nitroblue tetrazolium test = chronic granulomatous disease; tets phagocyte fuction, oxidative burst

    17. Cellular deficiency disease = fatal infections after receiving live viral vaccines (MMR, varicella)

    18. Ab deficiency disease = encapsulated organisms, sino=pulmonary bacterian infections, sepsis

    19. Phagocytic deficiency disease = recurrent abcesses, lymphadenitis, periodontal infections, Gram negatives, catalase positives, e.g. CGD, Chédiak-Higashi

    20. Complement deficiency dis = C2-C4: autoimmune dis; terminal: Neisseria; C3: encapsulated, unusual strains

    21. Severe combined immunodeficiency = first year of life, decrease in T and B cells

    22. Ig A deficiency = MC primary immune deficiency, major anaphylatic reaction to blood products

    23. X-linked hypogammaglobulinemia Rx = IV Ig; defect in tyrosine kinase

    24. X-linked lymphoproliferative disease = catastrophic after EBV infection

    25. Chronic granulomatous disease = decreased intracelular and fungal killing; S. aureus, Aspergillus; Rx: prophylatic antibiotics (TMP/SMX, doxycycline), interferon gamma; vaccinate: Haemophilus, Pneumoccocus, Neisseria, viral vaccines

    26. T-cell deficiency Rx = bone marrow transplant

    27. Transfusion in cellular deficient patient = irradiated, leukodepleted, virus free product

    28. C3 deficiency = increased number of pyogenic infections

    29. Properidin and C5 deficiency = increased Neisseria infections

    30. C1 inhibitor deficiency = hereditary angioedema

    31. Decay accelerating factor deficiency = paroxysmal nocturnal hemoglobinuria

    32. Clomiphene citrate use = ovulation induction (for patients with good estrogen production, such as in OPCD)

    33. Pregnancy = increase in alkaline phosphatase does not indicate disease necessarily, may be normal finding

    34. Primary hypothyroidism = may lead to increase in pituitary, amenorrhea, galactorrhea

    35. Meconium ileus suspicion = barium enema

    36. Cystic fibrosis tests = sweat test, nasal potential testing

    37. Hepatitis B mother = breastfeed is OK!

    38. Graves in pregnancy Rx = propylthiouracil

    39. Cocaine use in pregnancy = placental abruption

    40. Clue cells = bacterial vaginosis; Rx = metronidazole - counsel not to drink alcohol because of disulfiram-like reaction

    41. Pruritic urticarial papules and plaques of pregnancy = third trimester

    42. RF for ectopic pregnancy = age, PID, salpingitis, more than 3 pregnancies

    43. Testicular feminization = dysfunction or absence of testosterone receptors; patient is XY, normal breast development, scant pubic and axilar hair, blind vagina, undescendent testicles, may be felt on the groin.

    44. fever greater than 38 C in less than 4 m.o. = admission, IV antibiotics, full evaluation, multiple cultures

    45. Pyloric stenosis = non-bilious emesis, midepigastric olive: Dx = USG; RF = erythromycin use

    46. MCC of jaundice in pregnancy = viral hepatitis

    47. Symptomatic biliary stones = pregnancy Rx = laparoscopic cholecystectomy

    48. Asymptomatic biliary stones Rx = none

    49. N. gonorrhea = Gram negative diplococci; Rx = ceftriaxone + azithromycin (to cover Chlamydia, which generally is there too); notify publc health authorities

    50. Trichomonas vaginalis = motile flagellated microorganisms in vaginal wet mount
  2. Guest

    Guest Guest

    Notes (51 - 100)

    51. Low grade squamous intraepithelial lesion (cervix) = CIN I; Rx = rescreen in 4-6 months

    52. Abnormal vaginal bleeding in woman older than 35 yo next step = office endometrial pipelle biopsy

    53. Small subchorionic henorrhage Rx = clinical and USG observation

    54. Menorrhagis, anovulatory bleeding = order a TSH!

    55. Group B strep prophylaxis = penicillin or ampicillin to mother during active labor, CBC and blood culture on the newborn

    56. Low plasma bicarbonate causes = diarthea, renal tubular acidosis

    57. Erythema infectiosum = not contagiuos during the rash (slapped face, lacy), only before it

    58. Bleeding in pregnancy = order bood type, Rh, atypical antibodies

    59. Bilious vomiting in infant = think malrotation with volvulus; if no peritoneal signs, flexible sigmoidoscopy is diagnostic and treatment at the
    same time

    60. Bilious vomiting in newborn = remember the 3 Ds: duodenal atresia, double bubble on abd XR, greater incidence in Down's syndrome

    61. Side effects of MgSo4 use for the NB: meconium plug syndrome; in this case, contrast enema is both diagnostic and curative

    62. Polythelia = accessory nipple

    63. Polymastia = extraglandular breast tissue

    64. Hugh grade intraepithelial lesion (cervix) management = colposcopy + endocervical curetage + biopsy

    65. Following a molar pregnancy = contraceptives for 1 year, monitor beta HCG, if it goes up, it could be choriocarcinoma

    66. Fetal alcohol syndrome = cardiac malformation (VSD), CNS abnormalities, face deformities

    67. Tuboovarian abscess Rx = IV atbtcs; surgery only if necessary - it's one of the few cases of abscess that are cured without incision!

    68. Prostate cancer Dx = USG guided needle biopsy with 6-12 specimens

    69. Metastatic prostate cancer Rx = GnRh agonists (flutamide), orchiectomy + chemo

    70. Staging for testicular cancer = serum LDH, AFP, beta HCG, CT chest/abd/pelvis; Rx = radical inguinal orchiectomy + spermatic cord ligation

    71. MC sites of melanoma = trunk for men, legs for women

    72. Basophilic palisiding cells, pearl apperance, upper 1/3 of the face = basal cell ca (the MC skin ca)

    73. Moh's micrographic surgery = for squamous cell ca (lower 1/3 of the face), makes 1-2 mm margins

    74. MCC of encephalitis in adults = HSV; meningeal signs + focal neurological signs, temporal lobe changes on CT; Rx = IV Acyclovir 14-21 days

    75. Listeria monocytogenes meningitis Rx = ampicillin; NB, elderly

    76. Chronic sinusitis = longer than 3 months; clinical Dx, but if something is going to be ordered = CT sinus; Rx = amoxicillin +/- clavulanate +/-
    clindamycin for 21 days, nasal steroid sprays, endoscopic surgery if necessary

    77. Otitis media, ac. sinusitis Rx = TMP/SMX or amoxicillin +/- clavulanate

    78. Otitis externa Rx = topical ofloxacin with steroids; remember to clean the ear before applying the Rx; Pseudomonas, swimmers

    79. Chr carriers of group A strep Rx = clindamycin

    80. Smoker with pneumonia, diarrhea, increased LDH = think Legionella; Dx = urine Ag; Rx = doxycycline

    81. Cystic fibrosis pneumonia Rx = IV ceftazidime + IV levofloxacine = IV aminoglycoside; MCC = Pseudomonas

    82. Aspiration pneumonia Rx = IV ceftriaxone + IV azythromycin + IV clindamycin; chronic, not presentiated, RF positive

    83. Aspiration pneumonitis = acute event, presentiated by somebody, no need for atbtcs

    84. PCP pneumonia Dx = silver stain of sputum, bronchial lavage; Rx = IV TMP/SMX or inhaled pentamidine, add prednisone if: PaO2 less than 70 or A-a gradient more than 35

    85. TB Rx = RIPE for 8 w., then INH + rifampin for 16 w. more

    86. Add vit. B6 for INH

    87. Keep an eye on uric acid for Pyrazinamide

    88. Order ophtalmologic avaliation for Ethambutol

    89. Latent TB Rx = nine months of INH (+ B6)

    90. TB + HIV = use Rifabutin instead of Rifampin because of possible drug interaction

    91. Ac. prostatitis Rx = TMP/SMX or fluoroquinolone for 14 d

    92. Chr prostatitis Rx = fluoroquinolone 1 m. or TMP/SMX 3 m.

    93. Primary/secondary syphilis Rx = Penicillin G 2.4 million U IM; if disease present for more than 1 year = three doses with 1 w. intervals; notify health department

    94. Neurosyphilis Rx = Penicillin G IV for 14 days

    95. DM Dx = random glucose test >200 + symptoms OR twice fasting glucose > 126 OR 75 GTT > 200 at 2 h. OR 50 g GTT > 146 at 2 h

    96. Annual influenza vaccine = patients older than 50 yo, healthcare workers

    97. OCPs = decrease risk for gonococcal PID

    98. Osteoporosis Rx with drugs, not only calcium is indicated when = T-score < 1.5 OR < 2.5 + RF

    99. Dual X-ray absorptiometry (DEXA) T-score = compared to young adults

    100. DEXA z-score = compared to age and race matched population
  3. Guest

    Guest Guest

    Notes (101 - 150)

    101. Elderly + fall = do a home safety evaluation, avoid narcotics

    102. Woman sexually active, younger than 25 yo or with RF = screen for Chlamydia

    103. HTN Dx = 3 separate readings with increased BP

    104. Post exposure TB prophylaxis = 2 drugs chosen according to bug susceptibility

    105. Smallpox Rx = Cidofovir

    106. Anthrax Rx and prophylaxis = ciprofloxacin (adults), penicillin (children)

    107. Household with children = water heater < 120- 130 F

    108. Pneumococcal vaccine = q5 y for >50 yo with chr disease

    109. Td vaccine = q10 y or once at age 50 yo

    110. woman with relative with breast ca = mammogram 10 y before the affected person age + self breast examination

    111. Men with relative with prostate cancer = annual PSA + DRE after 40 yo

    112. Bipolar I = Hx of mania; major depression + or -

    113. Bipolar II = Hx of hypomania + major depression; NO mania

    114. Autism suspicion = order a hearing test before saying it is!

    115. Gingko biloba + warfarin = increased risk of bleeding

    116. 1 yo vaccines = Hib, MMR, varicella, PCV

    117. Adopted foreign child = serology hep B, C, HIV, syphilis, PPD, stool tests

    118. HIV + CD4 , 200 = TMP/SMX prophylatic for PCP pneumonia

    119. Pediculosis, scabies Rx = permethrin lotion; in scabies: treat all household members

    120. Necrotizing infection + DM Rx = X-ray, OR for debridement, amputation if needed

    121. Infection in CRF + indwelling catheter Rx = vancomycin + gentamycin

    122. Tinea versicolor Rx = topical ketoconazole

    123. Waterhouse-Friderichsen syndrome = adrenal infarction after/during meningococcal meningits, decreased cortisol level

    124. Postherpetic neuralgia Rx = amitriptiline

    125. Mononucleosis = leukopenia with atypical lymphocytes, heterophile Abs

    126. Bacteremia in a baby Rx = ampicillin + cefotaxime; covering group B strep, Listeria, E. coli

    127. Hep. B window period = surface Ag and Ab negative (they cancel each other), Dx may be made through core Ag IgM Ab +

    128. Rat bite fever Rx = penicillin G or tetracycline

    129. HUS = ac. renal failure + anemia + thrombocytopenia; E. coli 0157:H7, raw meat

    130. Tinea pedis Rx = topical antifungal for 2-3 w, if not gone = oral griseofulvin 6-8 w

    131. Invasive aspergillosis = multiple bilateral lung nodules with surrounding hemorrhages

    132. Post chemo fever Rx = hospitalize, broad spectrum atbtcs, antifungal if no response

    133. HPV infection Dx when lesions not apparent = apply vinegar to the region

    134. Cat scratch disease Dx = lymph node biopsy; treat only if = bact superinfection (S. aureus), encephalitis

    135. Ac. post-infectious cerebellar ataxia = post varicella infection or vaccine; differential = poisoning

    136. Fever + neutropenia Rx = antipseudomonal third generation cephalosporin OR antipseudomonal penicillin + aminoglycoside

    137. First generation cephalosporin = cefadroxil, cefalexin, cefalotin, cefazolin

    138. Second generation = cefaclor, cefuroxime; antianaerobe: cefotetan, cefoxitin

    139. Thrid generation = cefixime, cefotaxime; antipseudomonal: cefoperazone, ceftazidime

    140. Herpes zoster Rx = acyclovir

    141. Crush injuries Rx = copious alkalinized IV crystaloid (for renal protection)

    142. Exertional heat stroke = may lead to DIC and rhabdomyolysis; Rx = ice water, cold wet sheets + fan

    143. Ecstasy intoxication = may lead to rhabdomyolisis

    144. Ac. ethanol withdrawal Rx = chlordiazepoxide

    145. Edrophonium = acetylcholinesterase inhibitor

    146. Organophosphate poisoning Rx = atropine, pralidomide

    147. Ac. tubular necrosis due to contrast prophylaxis = hidration, acetylcysteine

    148. Avoid/suspend metformin use before tests with, IV contrast (for renal protection)

    149. Opioid intoxication = miosis, resp. depression, coma, hypotension, bradycardia; Rx = naloxone

    150. Severe dehydration in elderly = may lead to ac. suppurative parotitis by S. aureus; Rx = IV hidration, sialogogues, atbtcs; surgical drainage if not better in 12 h
  4. Guest

    Guest Guest

    Notes (151 - 200)

    151. Intoxicated patient = impossible to clear cervical spine because you need to have patient communicating symptoms to do it

    152. Priapism causes = TPN, sickle cell disease, crack/cocaine, trauma, spinal or general anesthesia,trazodone, leukemia

    153. Alcohol withdrawal = happens in hours to 10 days

    154. Urinary retention causes = BPH, prostate ca, prostatitis, urethral stricture, meds, blood clots

    155. Cyanide toxicity (nitroprusside) Rx = sodium thiosulfate

    156. Gallbladder rupture suspicion = exploratory laparotomy

    157. Compartment syndrome signs = most sensitive is loss of DTRs, most ominous is loss of pulse; 6 Ps = pallor, pain, paralysis, paresthesia, pulselessness, poikilothermia

    158. Hyperkalemia + EKG changes Rx = calcium gluconate

    159. Motor vehicle accident with seat belt in place = may cause pancreatic fracture = order a CT scan with IV contrast

    160. Carboxy hemoglobin level > 40% (>15% in pregnancy) Rx = hyperbaric O2 therapy

    161. Methylene chloride (paint remover) intox. = carbon monoxide poisoning; use co-oxymeter

    162. Methemoglobinemia Rx = Methylene blue

    163. IV epinephrine = Rx of pulseless VT or VF (post eletric cardioversion try), not for hypovolemia

    164. PCP intoxication = aggression, ac. psychosis, ataxia, violence, nystagmus, suicide, fever, hypersalivation, hyperacusis

    165. QRS amplitude alternance = cardiac tamponade

    166. ERCP complications = ac. pancreatitis, infected pancreatic pseudocyst formation, cholangitis, perforation

    167. Disrupted/transected urethra suspicion next step = retrograde urethrogram; blood at meatus + high riding prostate

    168. Leaking CSF (ears) = cribiform fracture = blind nasogastric or nasal intubations are contraindicated!

    169. Femoral canal = NAVEL from lat. to medial

    170. Radial head fracture (outstretched hand, Cole's fracture) Rx = sling 2-3 days, early exercises

    171. Wound dehiscence = new onset serous discharge

    172. CXR in pneumothorax = at maximal expiration

    173. Compartment syndrome suspicion = measure compartment pressures, emergent fasciotomy if confirmed

    174. In burn patients, succinylcholine use is contraindicated due to the risk of hyperkalemia

    175. Thioridazine S. E. = prolonged QT

    176. Diuretic for sulfa alergic patients = etacrinic acid

    177. Anabolic steroids S. E. testicular atrophy, liver disease, gynecomastia, impotence

    178. Concussion = head trauma + transient LOC + short amnesia, may have not serious late symptoms up to 6 m. later

    179. Increased ICP first steps in management = intubation + hyperventilation

    180. Lumbar puncture headache = positional, within 24 h.

    181. Anterior spinal arterial occlusion = decreased motor function, decreased sensation, decreased pinprick, preserved proprioception

    182. AST = less specific for liver than ALT; increased in alcoholic liver injury

    183. Ketorolac = NSAID, IV, used in testicular torsion; S.E. = gastric ulceration, GI bleeding

    184. Human bite Rx = ampicillin-sulbactam OR TMP/SMX + clindamycin; if HIV involved = don't worry, it doesn't get transmitted by bite (yet!)

    185. Methanol toxicity = vision changes; order: ABG, electrolytes, osmolality; Rx = IV ethanol, dyalisis

    186. Amytriptiline S.E. = constipation, ac. glaucoma, urinary retention, dry mouth, paralytic ileus; but the worst event in intoxication = cardiac arrhythmias
    187. Electromyography = checks nerve and muscle integrity

    188. Evoked potential studies = monitor transmission of motor impulses in the anterior columns of spinal cord

    189. JC virus + HIV Rx = HAART

    190. JC virus causes = progressive multifocal leukoencephalopathy

    191. Epididimoorchitis Rx = Doxycycline 100 mg PO bid for 10 d + ceftriaxone 250 mg IM

    192. HTN + BPH Rx = terazosin, doxazosin

    193. Increase in AFP = embryonal, yolk sac elements (nonseminomas)

    194. Increase in HCG = seminomas and nonseminomas

    195. Hydrocele = Dx with USG, no Rx required

    196. Metastatic prostate ca Rx = leuprolide, goserelin OR bilateral orchiectomy

    197. Priapism etiology = idiopathic (60%), leukemia, sickle cell dis, pelvic tu and infections

    198. PSA > 4 next step = prostate biopsy

    199. Chancroid = Haemophilus ducreyi, painful, unilateral lymphadenopathy, lesion with purulent base; Rx = ceftriaxone, azithromycin

    200. Granuloma inguinale = C. granulomatis, painless, beefy-red lesion; Rx = TMP/SMX
  5. Guest

    Guest Guest

    Notes (201 - 250)

    201. Lymphogranuloma venereum = Chlamydia trachomatis, herpetiform vesicle with erosion, bilateral suppurative lymphadenopathy; Rx = doxycycline

    202. Syphillis = Treponema pallidum, painless papula with clear, clean base, nontender, nonsuppurative lymphademopathy; Dx = RPR, VDRL, dark field mycroscopy; Rx = penicillin, doxycycline, erythromycin; notify health authorities

    203. Hematospermia with normal PE and labs = observation and reassurance

    204. Tertiary syphilis = not contagious

    205. HAART indications = symptomatic HIV, CD4 < 200, pregnancy

    206. CD4 < 200 = PCP prophylaxis = TMP/SMX, dapsone or atovaquone

    207. CD4 < 50 = MAI prophylaxis = azithromycin weekly

    208. Toxo Ig G + and CD4 < 100 = TMP/SMX OR dapsone + pyrimethamine + leucovorin

    209. TB contact OR PPD > 5 mm + HIV = INH + vit B6 for 9 m.

    210. HIV Dx = vaccines to be given = pneumococcal q 5 y., influenza q 1 y., hepatitis B

    211. Mefloquine S.E. = bradycardia, neuropsychiatric symptoms, prolonged QT

    212. NB of woman with SLE may have = congenital CHB

    213. Chronic fatigue syndrome = fatigue + cognitive changes for 1 y. or more; infectious basis: virus, Chlamydia pneumoniae

    214. Fibromyalgia = pain, tender points (11 of 18 ), sleep changes, psychological distress, allodynia, more than 3 m., realated to SLE, RA

    215. Allodynia = even gentle touch is unpleasant

    216. Avascular necrosis of femoral head causes = pancreatitis, alcoholism, fat embolus, sickle cell anemia, air emboli, steroids; Dx = MRI, SPECT

    217. Idiopathic AVN = Legg-Calve-Perthes disease

    218. AVN Rx = avoidance of activity, taper steroid

    219. Pyogenic granuloma Rx = shave, electrodesiccate base, send it to pathology evaluation

    220. Amelanotic melanoma = It can resemble pyogenic granuloma clinically

    221. Temporomandibular joint disease = orofacial pain, noisy joint, restricted jaw function; Dx = MRI

    222. Complication of hand/wrist trauma = AVN of scaphoid (navicular) bone

    223. Osler-Weber-Wendu = hereditary hemorrhagic telangiectasia = epistaxis, GI bleeding, polycystic kydneys

    224. Von-Hippel-Lindau dis.= cavernous hemangiomas, hemangioblastomas in CNS, retina, renal cell ca

    225. Sturge Weber syndrome = facial port wine stain, seizure, ocular changes

    226. Caplan syndrome = rheumatoid nodules in the lings

    227. Felty syndrome = splenomegaly + neutropenia in severe R.A.

    228. Tuberous sclerosis = ash leaf macules (hypopigmented), calcified intracranial nodules, epilepsy, low inteligence, adenoma sebaceum

    229. Leser-Trelat sign = multiple pruritic seborrheic keratosis associated with internal malignancy

    230. Polymyalgia rheumatica = very high ESR; Rx = low dose corticoids; keep an eye open for possible temporal arteritis

    231. Vitiligo Rx = topical sterois, phototherapy

    232. Porphyria cutanea tarda = blistering in a sun exposed area + milia; Dx = urine prophirin level + hepatitis panel

    233. Dermatitis herpetiformis = chr. pruritic papulovesicular lesions on extensor surfaces, post. hairline; Rx = dapsone

    234. Pemphigus vulgaris Rx = immediate high dose corticosteroids

    235. Hypertensive urgency = the goal is to decrease the diastolic BP to about 100-105 mmHg within a period of 2-6 hours

    236. Avoid nitroprusside infusion for more than 48 h (it may lead to cyanide toxicity)

    237. Hypert. urg. in pregnancy Rx = hydralazine, labetalol

    238. In pheochromocytoma, serotonin syndrome, cocaine use = IV phentolamine

    239. In aortic dissection = nitroprusside + labetalol/metoprolol

    240. Joint replacement in osteoarthritis indications = refractory pain, functional limit, inability for ADLs

    241. Alendronate (Fosamax) S.E. = esophageal irritation, ulceration and it has to be taken with an empty stomach, so always counsel the patient to take it in the morning and sit or stand upright for 30 minutes

    242. Achantosis nigricans = DM, hypothyroidism, Cushing's, Addison's, malignancy

    243. Kaposi's sarcoma = vascular tu, purplish lesions, extravasation of erythrocytes

    244. MCC of alergic contact dermatitis = nickel

    245. Methotrexate, azathioprine, chloroquine, etanercept, infliximab = disease modifying antirheumatic drugs

    246. Lumbar stenosis = pseudoclaudication, worse with hyperextending movements, better with leaning forward, normal ankle-brachial index; Dx = MRI of the lumbar spine

    247. Knee ligament injury Dx = MRI

    248. PNH = GPI anchor prot defic. = hemolytic anemia + pancytopenia + venous thrombosis (e.g. hepatic)

    249. PNH Dx = flow cytometry, HAM test

    250. PNH labs = increased LDH, reticulocyte, decreased or negative haptoglobin, hemosiderinuria, hemoglobinuria
  6. Guest

    Guest Guest

    Notes (251 - 300)

    251. PNH Rx = iron, folic acid, transfusion, corticoids, eculizumab

    252. Erythema nodosum Rx = NSAIDs

    253. Back pain MRI indications = spinal stenosis, osteomyelitis, epidural abscess, post trauma

    254. Down syndrome = should NOt participate in contact sports

    255. Fracture on landing on feet = calcaneum, spine, acetabulum, post. hip dislocation

    256. Melanoma suspicion = excisional biopsy

    257. Osgood-Schlatter dis. = apophysitis of tibial tuberosity; Rx = decrease physical activity

    258. Rotator cuff tear = weakness, instability; Dx = MRI; Rx = arthroscopic repair

    259. Slipped capital femoral epiphysis = Dx = X-ray; Rx = fixation of epiphysis with long screws

    260. Iliotibial band syndr. = pain in lat. aspect of knee

    261. Axillary adenopathy in woman = mammography

    262. Supraclavicular lymph node = lymph node biopsy

    263. Miliaria = heat rash

    264. Erythema multiforme minor = bull's-eye on palms, herpes simplex; Rx = long-term use acyclovir

    265. Pustular psoriasis = sterile, post steroids, fever, malaise, arthralgia, diarrhea; Rx = cyclosporine

    266. Seborrheic keratitis = "stuck=on", waxy grease scale

    267. Dermatomyositis = often is paraneoplasic

    268. Hypercalciuria (renal stones) Rx = hctz orally

    269. Dye S.E. = ac. tubular necrosis = muddy granular casts

    270. ATN = BUN/Cr < 20:1; cisplatin is one of the causes

    271. Ac. interstitial nephritis (drugs) = rash, fever, hematuria, white cell casts, eosinophiluria

    272. Increase in eosinophils = tumors, parasitic infectious, autoimmune diseases

    273. Renal calculi = Abd XR, if - = CT scan of abdomen (shows all types of stones) - actually this information is conflicting between some sources,
    so one should do some research about it

    274. Indinavir (HIV drug) S.E. = renal stone

    275. Struvite stones = Mg ammonium phosphate, pH>7.2, presence of urea splitting bugs (Proteus, Pseudommonas, Klebsiella; Rx = removal

    276. Uric acid stones = radiotranslucent

    277. Asymptomatic bacteriuria in non-pregnant, healthy patient = no Rx is indicated

    278. Doxorubicin (Adriamycin) S.E. = cardiac toxicity, myelosuppression

    279. Vincristine S.E. = motor, sensory and autonomic neuropathy

    280. Bleomycin S.E. = pulmonary fibrosis

    281. Myelosuppressant drugs = methotrexate, vinblastine, doxorubicin

    282. Polycystic kidney dis = colonic diverticular dis (with increased risk for perfuration), it may evolute to end stage renal dis, 10-15% of the patients have intracranial aneurysm

    283. Chrug-Strauss dis = nephritic syndr + eosinophilia + asthma, p-anca +; Rx = steroids, cyclophosphamide, azathioprine

    284. Goodpasture syndr = nephritic syndr + pulmonary hemorrhage; Abs to glomerular basementmembrane

    285. Wegener granulomatosis = nephritis + nasal/sinus problems, c-anca +; Rx = same as Chrug- Strauss

    286. Berger's syndr = IgA nephropathy, no latent period post infection, nephrotic syndr

    287. DMSA renal scan = radionucleotide study for renal function

    288. IV pyelogram = C.I. in renal insufficiency

    289. Kegel exercises = benefits within 6 weeks

    290. Dribbling + dyspareunia + dysuria in woman = urethral diverticulum; Dx = urethroscopy or voiding cystourethrography

    291. Nephrotic syndr = increased susceptibility to bact. infections, hyperlipidemia, mildly hypercoagulable state, hypovolemia

    292. Renal cell ca suspicion = radical nephrectomy; Bx only for metastatic cases (when Sx is not indicated)

    292. Rapidly progressive GN Rx = high dose IV methylprednisolone

    293. Alport syndr = hematuria +/- blindness +/- deafness; type IV collagen of GMB in abnormal

    294. Membranous glomerulonephropathy = MCC of nephrotic syndr in adults; Rx = ACEi

    295. Membranoprolipherative GN = nephrotic sundr; renal dis + decreased complement, realted to hepatitis C virus

    296. Painless hematuria = CT urogram or IVP (check ureteres)
    297. Pyelonephritis suspicion = blood + urine cultures, urinalysis

    298. Immunotherapy = for asthmatics patients with a single allergen

    299. Interstitial fibrosis = decerased FVC, FEV1, RV, TLC, diffusion; increased FEV1/FVC; no response to bronchodilator

    300. Immunisuppressed pat + pulm. aspergilosis Rx = IV amphotericin B
  7. Guest

    Guest Guest

    Notes (301 - 350)

    301. Primary pulm. HTN Rx = inhaled nitrous oxide, Calcium channel blockers

    302. ARDS Rx = limit tidal volume to 6 cc/kg or less

    303. Lung nodule on X-ray = thorax CT scan with contrast

    304. Appropriate tube placement = colorimetric detection of end-tidal carbon dioxide

    305. Sarcoidosis Dx = skin, transbronchial lung biopsy

    306. To decrease aspiration risk during entubation = cricoid pressure

    307. After pulm HTN Dx = vasodilator response testing

    308. Albuterol usage > twice a week = add triamcinolone MDI

    309. Ipratropium bromide = takes about 45 minutes to make effect

    310. Non-massive hemoptysis = CXR, then bronchoscopy, then high resolution CT scan to Dx; not all tests necessary every time, though

    311. Croup (laryngotracheobronchitis) = subglotic swelling, steeple sign on XR, parainfluenza, barking cough; Rx = mist tent, racemic epinephrine, IV corticosteroid, diphenhydramine

    312. TB confirmatory Dx test = sputum acid-fast stain

    313. Ciprofloxacin = does NOT cover streptococcus

    314. Community acquired pneumonia Rx = azithromycin, levofloxacin

    315. Sup. vena cava syndr due to ca Rx = radiation therapy

    316. Penicillin alergy = cephalosporin use is OK if penicillin skin test is -

    317. Heparin = given with warfarin untill 2 days after INR reaches desired level

    318. Foreign body aspiration in children = rigid bronchoscopy, methylprednisolone, cefazolin

    319. Gout Rx = for overproducers = allopurinol; for underexcreters = probenecid

    320. Cauda equina syndr. suspicion = MRI; it's an emergency!

    321. Gian cell arteritis Rx = Prednisone 40-60 md daily for 1-2 m., then taper down; if there is suspicion, treat immediately, even before biopsy, to
    avoid blindness as a complication!

    322. Fight bite bug: Eikenella

    323. Thompson test = pressure on gastrocnemius does not cause foot flexion, + in Achilles tendon rupture

    324. Fibromyalgia symptoms with less than 11 trigger points = myofascial pain syndr.

    325. Gottron's paules = happen in dermatomyositis

    326. Polymyosistis Dx = increased creatinine, aldolase, CPK; EMG; muscle Bx; Rx = high dose corticosteroids

    327. Urobilinogen = increased in hemolysis, hepatocelular dis.; decreased in biliary obstruction

    328. Lithium S.E. = nephrogenic diabetes insipidus, hypothyroidism

    329. Symptomatic hyponatremia Rx = 3% hypertonic saline to increase PNa by 3-5 mEq in 6 h, but no more than 12 mEq per day, because of the
    risk of central pontine myelinolisis

    330. Central pontine myelinolisis = flacid paralysis, dysarthria, dysphagia

    331. Osmotic diuresis = Uosm/Posm>0.7

    332. Diabetes insipidus = Uosm/Posm<0.7

    333. Hypernatremia Rx = correct < 12 mEq/d to prevent cerebral swelling

    334. Symptomatic hypercalcemia or > 13.5 Rx = hydration + furosemide, then biphosphonate or calcitonin; hemodyalisis if necessary

    335. Hypercalcemia has no specific signs and symptoms, only hypocalcemia has them (Chvostek, carpal pedal spasm)!

    336. Intraductal papilloma = bloody nipple discharge

    337. Duct ectasia = fever, greenish cheesy discharge, pain, tenderness

    338. Breast ca = single, hard, immobile, irregular borders, >2cm

    339. Triple Dx = PE + mammogram + FNA citology/Bx

    340. Around 15% of breast cancers have a false negative mammogram

    341. Breast lump in woman younger than 35 yo = if cystic = FNA = if nonbloody liquid = reassurance, if bloody = citology; if not = US and core Bx or excisional biopsy

    342. MC sequelae of meningitis = hearing loss; rememeber to order audiometry in ccs once the meningitis is cured

    343. Meningococcal meningitis prophylaxis = rifanpim or cipro for close contacts

    344. Measles = high fever for 3 days, then Koplik, then 1 day after head-to-toe rash; pneumonia; O.M.; encephalitis (ac.), subac. sclerosing panencephalitis (even after years)

    345. Roseola infantum (exanthema subitum) = high fever for 4 days, stop, then rash on trunk; human herpes virus 6

    346. Erythema infectiosum (fifth disease) = slapped cheek rash; parvovirus B19; when the rash is there, it's not contagious anymore

    347. Varicella Ig = for immunodebilitated, NB, within 4 days of exposure

    348. Scarlet fever = sand paper rash, circumoral pallor, strawberry tongue; Rx = penicillin to prevent RF

    349. Kawasaki syndr Rx = aspirin + IV Ig; f/u with echo

    350. Rocky mountain spotted fever Rx = tetracycline + chloranfenicol OR doxycycline; it may cause DIC, delirium
  8. Guest

    Guest Guest

    Notes (351 - 400)

    351. Epiglottitis Rx = entubate ot tracheostomy, third generation cephalosporin; "thumb sign" on XR, child 2-5 yo, H. influenzae, S. aureus

    352. RSV/bronchiolitis Rx = O2, mist tent, bronchodilators, IV fluids, ribavirin if severe, child <18 mo

    353. Diphteria = grayish pseudomembranous + myocarditis; Rx = atbtc + antitoxin

    354. Pertussis = paroxysmal coughing + whooping inspiratory noise; Rx = atbtc

    355. Post-streptococcal GN = NOT prevented by atbtc

    356. Congenital toxoplasmosis = IC calcifications, chorioretinitis

    357. Congenital varicella-zoster = limb hypoplasia, scarring of the skin

    358. Congenital CMV = deafness, cerebral calcifications, microphtalmia

    359. Conjunctivitis in the first day of life = chemical reaction

    360. Gonorrhea conjunctivitis Rx = erythromycin ointment for 2-5 days

    361. Chlamydial conjunctivitis Rx = topical + oral erythromycin for 5-14 days; the intention is to avoid that it becomes a Chlamydial pneumonia

    362. NB cataracts = TORCH, inherited metabolic dis (e.g. galactosemia)

    363. Orbital cellulitis = ophtalmoplegia, ptosis, severe pain, decreased acuity, it's an emergency!; Rx = blood culture, inpatient IV atbtc

    364. Uveitis in juvenile RA = Dx = slit-lamp exam; Rx = steroid drops

    365. Orchiopexy = correction of cryptorchidism after 1 yo; does NOT affect risk of testicular ca, wich is increased in these cases

    366. PDA = congenital rubella, high altitudes

    367. T4F = VSD + RV hypertrophy + pulm. stenosis + overriding Ao

    368. "Tet" spells = squatting after exertion; increases venous return and peripheric resistance, keeping more blood in lungs and improving oxygenation; very common in T4F, although not patognomonic

    369. Coarctation of Ao = Turner syndr; mid upper back systolic murmur, BP difference between arms and legs

    370. VSD = MC congenital cardiac defect; muscular type is the one that has the greater cahnce of closing by itself before 2 yo, but rarely after 4 yo; fetal alcohol syndr, TORCH, Down syndr

    371. Necrotizing enterocolitis = premature, fever, rectal bleeding, air in bowel wall; Rx = NPO, gastric tube, IV fluids, atbtcs

    372. Cystic fibrosis = meconium ileus, rectal prolapse

    373. Kernicterus = increased unconjugated bilirubin, depoists into the basal ganglia, poor feeding, seizures, flaccidity, opisthotonus, apnea

    374. Breast milk jaundice = peak at 2-3 w; Rx = temporary bottle feeding

    375. Increased unconjugated bilirubin = Criggler- Najar dis., Gilbert dis.

    376. Increased conjugated bilirubin = Rotor, Dubin- Johnson dis.

    377. Sulfa in neonates = displace bilirubin from albumin, leads to kernicterus

    378. Exchange transfusion = unconjugated bilirubin >20 mg/dl + failed phototherapy

    379. MC primary immunodeficiency = Ig A deficiency: respiratory and GI infections; avoid giving Ig (anti IgA antibodies)

    380. Bruton agammaglobulinemia = 6 mo, lung + sinus infections; Streptococcus, Haemophilus

    381. Wiskott-Aldrich defic. + boy, eczema + thrombocytopenia + resp. infections

    382. Chediak-Higashi syndr. = giant granules in neutrophils + oculocutaneous albinism

    383. Complement defic. (C5-9) = recurrent Neisserial infections

    384. Chr. mucocutaneous candidiasis = often associated with hypothyroidism

    385. Osteosarcoma = 10-20 yo, about the knee, "sunburst" on X-ray

    386. Job-Buckley syndr = intense increase in IgE, recurrent Staph infections; fair skin, red hair, eczema

    387. Unicameral bone cyst = expansile, lytic, prox. portion of humerus

    388. Bitot spots(debris in conjunctiva) = vit A deficiency

    389. Vit A toxicity = pseudotu cerebri, bone thickening, teratogenicity

    390. Vit. E defic. = anemia, peripheral neuropathy, ataxia

    391. Give vit. A for = patients with measles

    392. Give vit. E for = Alzheimer's patients

    393. Give vit C for = iron deficiency anemia (increases absorption of Fe; calcium decreases it)

    394. Vit E toxicity = necrotizing enterocolitis in infants

    395. Vit K toxicity = hemolysis (kernicterus)

    396. Vit. B6 defic. and toxicity both manifest as = peripheral neuropathy

    397. Vit. B12 (cobalamin) defic. = megaloblastic anemia + neurologic symptoms

    398. Folic acid defic. = megaloblastic anemia

    399. Bone pain in vit C defic = periosteal hemorrhages

    400. Wernicke/Korsakoff syndr = vit B1 deficiency (thiamine); never give glucose before thiamine for an alcoholic in the ER
  9. drtanvir

    drtanvir Guest

    GIT and hepatobiliary
    Dysphagia: Dysphagia to solids and liquids often indicates a motility problem (i.e., achalasia and esophageal spasm). Dysphagia to only solids indicates mechanical obstruction (i.e., tumor or Schatzki’s ring).
    Achalasia - Dx 1-Barium studies, 2-Esopgaguscopy 3-Manometry. The CONFIRMATION test is Manometry. We also need to do Endoscopy to rule out malignancy.
    Barium swallow: Bird’s beak or steeple sign: Achalasia. Corkscrew-shaped: DES
    NB: In patients with suspected upper esophageal lesion it is always safer to proceed with barrium swallow than with endoscopy.
    Patients with achalasia often lift their arms over their heads or extend their necks to aid in swallowing.
    TREATMENT
    Nitrates and calcium channel antagonists: Relax LES tone, but have only modest efficacy.
    Botulinum toxin injection: Injected into the LES. Performed endoscopically and associated with an 85% initial response, but > 50% of patients require repeated injection within six months. Ideal if the patient is a poor candidate for more invasive treatment.
    Pneumatic dilation: Of those treated, > 75% have a durable response. The perforation rate is 3–5%. Does not compromise surgical therapy.
    Surgery: Laparoscopic Heller myotomy with partial fundoplication (preventing severe reflux that can occur with myotomy). Of all cases, > 85% have a durable response.
    Diffuse Esophageal Spasm – Usually seen in young females. Manifest with chest pain and dysphagia. Etiology in unknown but its related to emotional stress. Unlike Achalasia LES has a normal relaxation response. Esophagogram might show Corkscrew. Tx is with antispasmic drugs, dietry modulation and psychiatric counselling. for USMLE know 1-pathophys, 2-present or absence of perstalsis, 3-LES tone. MERCK:A generalized neurogenic disorder of esophageal motility in which phasic nonpropulsive contractions replace normal peristalsis and, in some cases, lower esophageal sphincter malfunctions occur. Esophageal manometry shows: contractions are usually simultaneous, prolonged or multiphasic, and possibly of very high amplitude.*****Esophagography may not show the corkscrew, so do Manometry, if revealed "repetitive,nonpeistoltis,high amplitude contraction either spontaneoud or after Ergonovin stimulation then its Dx.
    Unlike achalasia, diffuse esophageal spasm and nutcracker esophagus often present with chest pain rather than with dysphagia.
    A sticking sensation in the throat accompanied by heartburn is characteristic of scleroderma. The absence of a peristatltic wave in the lower two thirds of the esophagus and a significant decrease in lower esophegal sphincter tone are also very characteristic.
    Squamous cell carcinoma usually affects the upper and middle parts of the esophagus. It is more common in African American and shows significant association with smoking, alcohol consumption and some dietry factors.
    Adencocarcinoma is more common in Caucassians and usually arise from Barrets esophagus.
    Zenker Diverticulum –
    A 56-year-old man complains of food feeling “stuck†on its way down and vomiting food he ate days ago. Think: Zenker’s diverticulum.
    Zenker is defined as herniation of mucosa through the fibers of cricopharyngeal muscle.
    Pt presents with orophareangeal dysphagia, halitosis, neck mass and are >50yo. UES dysfunction and esophageal dysmotility (motor dysfunction and motility problem) are believed to be the cause. Barium exam helps to delineate the diverticulum, the surgical tx includes excision and frequently cricophareangeal myotomy.. Barieum Esophagograpghy is the confirmatory test od choice, not Esophagoscopy.
    Esophageal cancer: Risk factors include cigarette smoking, alcohol use, obesity, and Barrett’s esophagus. Presents with dysphagia, odynophagia, weight loss, cough, and hoarseness.
    Staging evaluation: Evaluate with endoscopy and biopsy, chest CT, endoscopic ultrasound, and bronchoscopy (to rule out tracheal invasion).
    Pathology: The 1° histologies are squamous cell and adenocarcinoma (increasing in incidence; associated with obesity and GERD).
    TREATMENT
    Localized esophageal cancer: Treat with chemoradiation (5-FU plus cisplatin and external beam radiotherapy) or surgery. Postoperative chemoradiation should be considered for locally advanced cancers.
    Metastatic disease: Few good options are available; drugs include cisplatin, paclitaxel, 5-FU, and gemcitabine.
    PEG tubes are often required to get patients through chemoradiation (as in head and neck cancer).
    Esophageal Rings, Webs, and Strictures
    Lower esophageal (Schatzki) rings: Common (found in 6–14% of upper GI exams); located in the distal esophagus. Often associated with hiatal hernia, congenital defects, or GERD.
    Webs: Less common; located in the proximal esophagus. Congenital.
    Strictures: Result from injury (e.g., reflux, caustic, anastomosis).
    SYMPTOMS/EXAM
    Dysphagia with solids is more severe than that with liquids.
    DIAGNOSIS
    Barium esophagography: May be diagnostic. Normal peristalsis; luminal abnormality is seen.
    Endoscopy: Required to exclude esophageal stricture or tumor.
    TREATMENT
    Esophageal dilation; PPIs to ↓ the recurrence of peptic stricture.

    Esophagitis Infectious
    Most common in immunosuppressed patients (e.g., those with AIDS or malignancies, post-transplant, and patients undergoing chemotherapy) and in the setting of chronic steroid use or recent antibiotic use. Common pathogens include Candida albicans, HSV, and CMV.
    SYMPTOMS/EXAM
    Presents with odynophagia, dysphagia, and chest pain. Oral lesions are not reliable diagnostic indicators.
    C. albicans is the etiologic agent in < 75% of cases and CMV or HSV in < 50%.
    Exam reveals shoddy cervical lymphadenopathy.
    DIAGNOSIS
    In immunocompromised patients, attempt a trial of empiric antifungal therapy (e.g., fluconazole). In immunocompetent hosts, proceed with endoscopy.
    Upper endoscopy with biopsy is the treatment of choice if the empiric trial yields no response. Findings are as follows:
    C. albicans: Linear, adherent plaques that may be yellow or white.
    CMV: Few large, superficial ulcerations.
    HSV: Numerous small, deep ulcerations.
    Idiopathic AIDS ulcers: Low CD4 count; large ulcerations.
    TREATMENT
    Treat or adjust underlying immunosuppression.
    C. albicans: Treatment depends on host immune status.
    Immunocompetent patients: Topical therapy; nystatin swish and swallow five times a day . 7–14 days. Test for HIV.
    Immunocompromised patients: Oral therapy, initially with fluconazole. If the patient is unresponsive, consider increasing fluconazole or giving itraconazole, other azoles, caspofungin, or amphotericin.
    CMV: Ganciclovir 3–6 weeks.
    HSV: Acyclovir or valacyclovir
    Idiopathic ulcers: Trial of prednisone.
    COMPLICATIONS
    Stricture, malnutrition, hemorrhage.
    Esophagitis Pill induced
    Variables include contact time, drug type, and pill characteristics. Most cases arise without preexisting swallowing problems. Pills can remain in a normal esophagus > 5 minutes or for much longer in the presence of stricture or dysmotility. Risk is higher if pills are large, round, lightweight, or extendedrelease
    formulations.
    SYMPTOMS/EXAM
    Presents with odynophagia, dysphagia, and chest pain.
    DIAGNOSIS
    Review medications. Common causative agents include the following:
    NSAIDs: Aspirin, naproxen, ibuprofen, indomethacin.
    Antibiotics: Tetracyclines (especially doxycycline), clindamycin (look for a young patient with acne presenting with odynophagia).
    Antivirals: Foscarnet, AZT, ddC.
    Supplements: Iron and potassium.
    Cardiac: Quinidine, nifedipine, captopril, verapamil.
    Bisphosphonates: Alendronate, pamidronate.
    Antiepileptics: Phenytoin.
    Asthma/COPD medications: Theophylline.
    Upper endoscopy: Evaluate for stricture or mass lesion.
    TREATMENT
    Discontinue the suspected drug. Expect symptom relief within 1–6 weeks.
    Patients should drink eight ounces of water with each pill and remain upright at least 30 minutes afterward.
    Proton pump inhibitors (PPIs) may facilitate healing in the setting of concurrent GERD.

    GERD - In neonates is regurgitation after eating and failure to thrive. The child assumes the position of tilted head and arched back. Dx is 24hr pH monitoring of esophagus. When its unclear whether the pt has nocturnal asthma or GERD, a trial of proton pump inhibitor (Omeprazole) before breakfast is both Dx and therpeutic.
    Esophagoscopy is indicated when a pt fails to respond to antibiotics and or theye are signs of implications (weight loss in cancer).
    Dx Process: once pt presents with cough, and the vigniette says esophagoscopy is normal, the next thing is 24 hour pH monitoring. Then Manometry will confirm dx.
    GERD can happen due to hiatal hernia. Chronic GERD can lead to metaplastic change in lower esophagus called Barret esophagus and is a risk for Adenocarcinoma of esophagus.
    When pt comes in with symptoms of GERD you need to differenciate b.w Barrets,PUD,Gastritis, or tumor. Endoscopy is the most informative procedure for all these. Now if the vingette says "he has no Dysphagia" then you can skip the normal Barium test that precedes endoscopy and go straight to endoscopy. Indications to endoscopy are: 1-Nausea/vomiting, 2-
    weight loss, anemia or melena, 3-Long duration of symptoms (>1-2 yr), 4-Failre to responde to PPI. So here is the order, if there if Dysphagia first do BS, then EC then Manometry. If no dysphagia, first EC and then Manometry, you can skip BS.
    Diagnosis
    For typical symptoms, treat with an empiric trial of PPIs for 4–6 weeks.
    Response to PPIs is diagnostic.
    If the patient is unresponsive to therapy or has alarm symptoms (dysphagia, odynophagia, weight loss, anemia, long-standing symptoms, blood in stool, age > 50), proceed as follows:
    Barium esophagography: Has a limited role, but can identify strictures.
    Upper endoscopy with biopsy: The standard exam in the presence of alarm symptoms (dysphagia, odynophagia, weight loss, bleeding, anemia).
    Normal in > 50% of patients with GERD (most have nonerosive reflux disease), or may reveal endoscopic esophagitis grades 1 (mild) to 4 (severe erosions, strictures, Barrett’s esophagus).
    Strictures can be dilated.
    Ambulatory esophageal pH monitoring: The gold standard, but often unnecessary. Indicated for correlating symptoms with pH parameters when endoscopy is normal and (1) symptoms are unresponsive to medical therapy, (2) antireflux surgery is being considered, or (3) there are atypical symptoms (e.g., chest pain, cough, wheezing).
    Treatment
    Behavioral modification: Elevate the head of the bed six inches; stop tobacco and alcohol use. Advise patients to eat smaller meals, reduce fat intake, lose weight, avoid recumbency after eating, and avoid certain foods (e.g., mint, chocolate, coffee, tea, carbonated drinks, citrus and tomato
    juice). Effective in 25% of cases.
    Antacids (calcium carbonate, aluminum hydroxide): For mild GERD. Fast, but afford only short-term relief.
    H2 receptor antagonists (cimetidine, ranitidine, famotidine, nizatidine): For mild GERD or as an adjunct for nocturnal GERD while the patient is on PPIs. Effective in 50–60% of cases.
    PPIs (omeprazole, lansoprazole, rabeprazole, pantoprazole, esomeprazole):
    The mainstay of therapy for mild to severe GERD. Generally safe and effective, but now associated with pneumonia, atrophic gastritis (hypergastrinemia), enteric infections (C. difficile), and hip fractures. Daily
    dosage is effective in 80–90% of patients. Fewer than 5% of patients are refractory to twice-daily dosage.
    Surgical fundoplication (Nissen or Belsey wrap):
    Often performed laparoscopically. Indicated for patients who cannot tolerate medical therapy or who have persistent regurgitation. Contraindicated in patients with an esophageal motility disorder.
    Outcome: More than 50% of patients require continued acid suppressive medication, and > 20% develop new symptoms (dysphagia, bloating, dyspepsia).
    Endoscopic antireflux procedures: Remain investigational.
    COMPLICATIONS
    Peptic strictures: Affect 8–20% of GERD patients; present with dysphagia.
    Malignancies must be excluded via endoscopy and biopsy; can then be
    treated with endoscopic dilation followed by indefinite PPI therapy.
    Upper GI bleeding: Hematemesis, melena, anemia 2° to ulcerative esophagitis.
    Posterior laryngitis: Chronic hoarseness from vocal cord ulceration and granulomas.
    Asthma: Typically has an adult onset; nonatopic and unresponsive to traditional asthma interventions.
    Cough: Affects 10–40% of GERD patients, most without typical GERD symptoms.
    Noncardiac chest pain: After a full cardiac evaluation, consider an empiric trial of PPIs or ambulatory esophageal pH monitoring.
    Other: Barrett’s esophagus, adenocarcinoma
    Barrett’s Esophagus
    Intestinal metaplasia of the distal esophagus 2° to chronic GERD. Normal esophageal squamous epithelium is replaced by columnar epithelium and goblet cells (“specialized epitheliumâ€Â). Found in some 5–10% of patients with chronic GERD, and incidence ↑ with GERD duration. Most common in
    Caucasian men > 55 years of age; overall incidence is greater in males than in females. The risk of adenocarcinoma is 0.5% per year. Risk factors include male gender, Caucasian ethnicity, and smoking.
    DIAGNOSIS
    Upper endoscopy: Suggestive but not diagnostic, as it is a histologic diagnosis. Salmon-colored islands or “tongues†are seen extending upward from the distal esophagus.
    Biopsy: Diagnostic.
    Shows metaplastic columnar epithelium and goblet cells.
    Specialized intestinal metaplasia on biopsy is associated with an ↑ risk of adenocarcinoma (not squamous).
    TREATMENT
    Indefinite PPI therapy (GERD should be treated prior to surveillance, as inflammation may confound the interpretation of dysplasia).
    Adenocarcinoma surveillance is necessary only if patients are candidates for esophagectomy.
    Upper endoscopy with four-quadrant biopsies every 2 cm of endoscopic lesions.
    Screening (based on criteria from the American Society of Gastrointestinal Endoscopy) is as follows:
    After initial diagnosis, repeat EGD in one year for surveillance with biopsies.
    Proceed according to EGD findings:
    No dysplasia: Repeat survillence EGD and biopsy every 1 – 3 years.
    Low-grade dysplasia: Repeat EGD within six months. If findings are unchanged, extend surveillance to yearly intervals.
    High-grade dysplasia: Management is controversial but includes early esophagectomy or intensive endoscopic surveillance every three months until cancer is diagnosed, followed by esophagectomy.
    Verify with an expert pathologist. Ablative therapies may be attempted (e.g., photodynamic therapy, argon plasma coagulation, endoscopic mucosal resection).
    Boerhaave's Syndrome
    Typical scenario: An alcoholic man presents after severe retching, complaining of retrosternal
    and upper abdominal pain. Think: Boerhaave’s syndrome (full thickness) or Mallory–Weiss syndrome (partial thickness).
    Complete tear of distal esophagus that leads to pneumomediastinum, vs incomplete tear in Malory Weiss and no Pneumomediastinum. Usually presents with acute chest pain following episones of repeated vomiting. Most tears occur in the distal third of the esophagus, which leads to pl effusion.
    Xray shows subcutaneous emphysema.
    Dx barium swallow.The best diagnostic test for esophageal perforation is an esophageogram with water soluble contrast (definite diagnosis in 90% cases). CT scan of the chest is helpful, but may not detect small tears or ruptures. Upper GI endoscopy has no role and should not be used.
    Tx: urgent management is needed b/c of the risk of medistenitits, which carries a mortality rate of more than 40% if not properly diagnosed within first 24 hrs. Antibiotics and thoracotomy and repair of esophagus immediately.
    Mallory Weiss tear
    Classic presentation of hematamessis preceeded by a bout of retching /vomiting only occurs in 30 % of patients. Hiatal hernia is present in 40 – 100% of patients MW tear.
    Endoscopy is gold standard in diagnosing. This procedure typically reveals a single longitudinal tear at the GE junctionj. In patients with MW tear who are not activley bleeding observation and supportive care are typically necessary. PPI are given to all patients to prevent further damage and promote healing.
    *Subcutaneous and mediastinal emphysema are due to a full-thickness tear.
    Dyspepsia
    Typically defined as one or more of the following: postprandial fullness, early satiation, and epigastric burning or pain. Distinct from but can present with GERD (i.e., retrosternal burning). In the United States, the prevalence of dyspepsia is 25%, but only 25% of those affected seek care. Of these, > 60% have nonulcerative dyspepsia and < 1% have gastric cancer.
    SYMPTOMS/EXAM
    May present with upper abdominal pain or discomfort, fullness, bloating, early satiety, belching, nausea, and retching or vomiting.
    DIAGNOSIS/TREATMENT
    Look for alarm features: May include new-onset dyspepsia in patients
    > 50 years of age, unintended weight loss, melena, iron deficiency anemia, persistent vomiting, hematemesis, dysphagia, odynophagia, abdominal mass, a history of PUD, previous gastric surgery, and a family history of gastric cancer.
    If alarm features are present: Perform prompt endoscopy.
    If no alarm features are present: Assess diet and provide education; discontinue suspect medications. Consider a trial of empiric acid suppression; consider testing for and treating H. pylori
    Determine the local prevalence of H. pylori.
    If > 10%: Test for H. pylori by serology, stool antigen, or breath test. If +ive , institute H. pylori eradication therapy. If _, initiate a trial of acid suppression for 4–8 weeks.
    If < 10%: Institute a trial of acid suppression for 4–8 weeks.
    For persistent symptoms:
    If the patient received H. pylori therapy, test for eradication with a stool antigen or breath test, not with serology. If disease is not eradicated, attempt a different regimen. If eradicated, refer to endoscopy.
    If the patient received a trial of PPIs, refer to endoscopy.
    Endoscopy: If unrevealing: Diagnose with nonulcerative dyspepsia and provide reassurance; consider a trial of low-dose TCAs (desipramine 10–25 mg QHS) and possible cognitive-behavioral therapy.
    If revealing: Manage as indicated.
    Endoscopic biopsy, H. pylori stool antigen, and urea breath test can assess active H. pylori
    infection and gauge treatment success. H. pylori serology measures only past exposure
    and cannot be used to confirm eradication.
  10. drtanvir

    drtanvir Guest

    Dysphagia: Dysphagia to solids and liquids often indicates a motility problem (i.e., achalasia and esophageal spasm). Dysphagia to only solids indicates mechanical obstruction (i.e., tumor or Schatzki’s ring).
    Achalasia - Dx 1-Barium studies, 2-Esopgaguscopy 3-Manometry. The CONFIRMATION test is Manometry. We also need to do Endoscopy to rule out malignancy.
    Barium swallow: Bird’s beak or steeple sign: Achalasia. Corkscrew-shaped: DES
    NB: In patients with suspected upper esophageal lesion it is always safer to proceed with barrium swallow than with endoscopy.
    Patients with achalasia often lift their arms over their heads or extend their necks to aid in swallowing.
    TREATMENT
    Nitrates and calcium channel antagonists: Relax LES tone, but have only modest efficacy.
    Botulinum toxin injection: Injected into the LES. Performed endoscopically and associated with an 85% initial response, but > 50% of patients require repeated injection within six months. Ideal if the patient is a poor candidate for more invasive treatment.
    Pneumatic dilation: Of those treated, > 75% have a durable response. The perforation rate is 3–5%. Does not compromise surgical therapy.
    Surgery: Laparoscopic Heller myotomy with partial fundoplication (preventing severe reflux that can occur with myotomy). Of all cases, > 85% have a durable response.
    Diffuse Esophageal Spasm – Usually seen in young females. Manifest with chest pain and dysphagia. Etiology in unknown but its related to emotional stress. Unlike Achalasia LES has a normal relaxation response. Esophagogram might show Corkscrew. Tx is with antispasmic drugs, dietry modulation and psychiatric counselling. for USMLE
    know 1-pathophys, 2-present or absence of perstalsis, 3-LES tone. MERCK:A generalized neurogenic disorder of esophageal motility in which phasic nonpropulsive contractions replace normal peristalsis and, in some cases, lower esophageal sphincter malfunctions occur. Esophageal manometry shows: contractions are usually simultaneous, prolonged or multiphasic, and possibly of very high amplitude.*****Esophagography may not show the corkscrew, so do Manometry, if revealed "repetitive,nonpeistoltis,high amplitude contraction either spontaneoud or after
    Ergonovin stimulation then its Dx.
    Unlike achalasia, diffuse esophageal spasm and nutcracker esophagus often present with chest pain rather than with dysphagia.
    A sticking sensation in the throat accompanied by heartburn is characteristic of scleroderma. The absence of a peristatltic wave in the lower two thirds of the esophagus and a significant decrease in lower esophegal sphincter tone are also very characteristic.
    Squamous cell carcinoma usually affects the upper and middle parts of the esophagus. It is more common in African American and shows significant association with smoking, alcohol consumption and some dietry factors.
    Adencocarcinoma is more common in Caucassians and usually arise from Barrets esophagus.
    Zenker Diverticulum –
    A 56-year-old man complains of food feeling “stuck†on its way down and vomiting food he ate days ago. Think: Zenker’s diverticulum.
    Zenker is defined as herniation of mucosa through the fibers of cricopharyngeal muscle.
    Pt presents with orophareangeal dysphagia, halitosis, neck mass and are >50yo. UES dysfunction and esophageal dysmotility (motor dysfunction and motility problem) are believed to be the cause. Barium exam helps to delineate the diverticulum, the surgical tx includes excision and frequently cricophareangeal myotomy.. Barieum Esophagograpghy is the confirmatory test od choice, not Esophagoscopy.
    Esophageal cancer: Risk factors include cigarette smoking, alcohol use, obesity, and Barrett’s esophagus.
    Presents with dysphagia, odynophagia, weight loss, cough, and hoarseness.
    Staging evaluation: Evaluate with endoscopy and biopsy, chest CT, endoscopic ultrasound, and bronchoscopy (to rule out tracheal invasion).
    Pathology: The 1° histologies are squamous cell and adenocarcinoma (increasing in incidence; associated with obesity and GERD).
    TREATMENT
    Localized esophageal cancer: Treat with chemoradiation (5-FU plus cisplatin and external beam radiotherapy) or surgery. Postoperative chemoradiation should be considered for locally advanced cancers.
    Metastatic disease: Few good options are available; drugs include cisplatin, paclitaxel, 5-FU, and gemcitabine.
    PEG tubes are often required to get patients through chemoradiation (as in head and neck cancer).
    Esophageal Rings, Webs, and Strictures
    Lower esophageal (Schatzki) rings: Common (found in 6–14% of upper GI exams); located in the distal
    esophagus. Often associated with hiatal hernia, congenital defects, or GERD.
    Webs: Less common; located in the proximal esophagus. Congenital.
    Strictures: Result from injury (e.g., reflux, caustic, anastomosis).
    SYMPTOMS/EXAM
    Dysphagia with solids is more severe than that with liquids.
    DIAGNOSIS
    Barium esophagography: May be diagnostic. Normal peristalsis; luminal abnormality is seen.
    Endoscopy: Required to exclude esophageal stricture or tumor.
    TREATMENT
    Esophageal dilation; PPIs to ↓ the recurrence of peptic stricture.
    Esophagitis Infectious
    Most common in immunosuppressed patients (e.g., those with AIDS or malignancies, post-transplant, and patients undergoing chemotherapy) and in the setting of chronic steroid use or recent antibiotic use. Common pathogens include Candida albicans, HSV, and CMV.
    SYMPTOMS/EXAM
    Presents with odynophagia, dysphagia, and chest pain. Oral lesions are not reliable diagnostic indicators.
    C. albicans is the etiologic agent in < 75% of cases and CMV or HSV in < 50%.
    Exam reveals shoddy cervical lymphadenopathy.
    DIAGNOSIS
    In immunocompromised patients, attempt a trial of empiric antifungal therapy (e.g., fluconazole). In
    immunocompetent hosts, proceed with endoscopy.
    Upper endoscopy with biopsy is the treatment of choice if the empiric trial yields no response. Findings are as follows:
    C. albicans: Linear, adherent plaques that may be yellow or white.
    CMV: Few large, superficial ulcerations.
    HSV: Numerous small, deep ulcerations.
    Idiopathic AIDS ulcers: Low CD4 count; large ulcerations.
    TREATMENT
    Treat or adjust underlying immunosuppression.
    C. albicans: Treatment depends on host immune status.
    Immunocompetent patients: Topical therapy; nystatin swish and swallow five times a day . 7–14 days. Test for HIV.
    Immunocompromised patients: Oral therapy, initially with fluconazole. If the patient is unresponsive, consider increasing fluconazole or giving itraconazole, other azoles, caspofungin, or amphotericin.
    CMV: Ganciclovir 3–6 weeks.
    HSV: Acyclovir or valacyclovir
    Idiopathic ulcers: Trial of prednisone.
    COMPLICATIONS
    Stricture, malnutrition, hemorrhage.
    Esophagitis Pill induced
    Variables include contact time, drug type, and pill characteristics. Most cases arise without preexisting swallowing problems. Pills can remain in a normal esophagus > 5 minutes or for much longer in the presence of stricture or dysmotility. Risk is higher if pills are large, round, lightweight, or extendedrelease
    formulations.
    SYMPTOMS/EXAM
    Presents with odynophagia, dysphagia, and chest pain.
    DIAGNOSIS
    Review medications. Common causative agents include the following:
    NSAIDs: Aspirin, naproxen, ibuprofen, indomethacin.
    Antibiotics: Tetracyclines (especially doxycycline), clindamycin (look for a young patient with acne presenting with odynophagia).
    Antivirals: Foscarnet, AZT, ddC.
    Supplements: Iron and potassium.
    Cardiac: Quinidine, nifedipine, captopril, verapamil.
    Bisphosphonates: Alendronate, pamidronate.
    Antiepileptics: Phenytoin.
    Asthma/COPD medications: Theophylline.
    Upper endoscopy: Evaluate for stricture or mass lesion.
    TREATMENT
    Discontinue the suspected drug. Expect symptom relief within 1–6 weeks.
    Patients should drink eight ounces of water with each pill and remain upright at least 30 minutes afterward.
    Proton pump inhibitors (PPIs) may facilitate healing in the setting of concurrent GERD.
    GERD - In neonates is regurgitation after eating and failure to thrive. The child assumes the position of tilted head and arched back. Dx is 24hr pH monitoring of esophagus. When its unclear whether the pt has nocturnal asthma or GERD, a trial of proton pump inhibitor (Omeprazole) before breakfast is both Dx and therpeutic. Esophagoscopy is indicated when a pt fails to respond to antibiotics and or theye are signs of implications (weight loss in cancer).
    Dx Process: once pt presents with cough, and the vigniette says esophagoscopy is normal, the next thing is 24 hour pH monitoring. Then Manometry will confirm dx.
    GERD can happen due to hiatal hernia. Chronic GERD can lead to metaplastic change in lower esophagus called Barret esophagus and is a risk for Adenocarcinoma of esophagus.
    When pt comes in with symptoms of GERD you need to differenciate b.w Barrets,PUD,Gastritis, or tumor.
    Endoscopy is the most informative procedure for all these. Now if the vingette says "he has no Dysphagia" then you can skip the normal Barium test that precedes endoscopy and go straight to endoscopy. Indications to endoscopy are:
    1-Nausea/vomiting, 2- weight loss, anemia or melena, 3-Long duration of symptoms (>1-2 yr), 4-Failre to responde to PPI. So here is the order, if there if Dysphagia first do BS, then EC then Manometry. If no dysphagia, first EC and then Manometry, you can skip BS.
    Diagnosis
    For typical symptoms, treat with an empiric trial of PPIs for 4–6 weeks.
    Response to PPIs is diagnostic.
    If the patient is unresponsive to therapy or has alarm symptoms (dysphagia, odynophagia, weight loss, anemia, long-standing symptoms, blood in stool, age > 50), proceed as follows:
    Barium esophagography: Has a limited role, but can identify strictures.
    Upper endoscopy with biopsy: The standard exam in the presence of alarm symptoms (dysphagia, odynophagia, weight loss, bleeding, anemia).
    Normal in > 50% of patients with GERD (most have nonerosive reflux disease), or may reveal endoscopic
    esophagitis grades 1 (mild) to 4 (severe erosions, strictures, Barrett’s esophagus).
    Strictures can be dilated.
    Ambulatory esophageal pH monitoring: The gold standard, but often unnecessary. Indicated for correlating
    symptoms with pH parameters when endoscopy is normal and (1) symptoms are unresponsive to medical therapy,
    (2) antireflux surgery is being considered, or (3) there are atypical symptoms (e.g., chest pain, cough, wheezing).
    Treatment
    Behavioral modification: Elevate the head of the bed six inches; stop tobacco and alcohol use. Advise patients to
    eat smaller meals, reduce fat intake, lose weight, avoid recumbency after eating, and avoid certain foods (e.g., mint,
    chocolate, coffee, tea, carbonated drinks, citrus and tomato
    juice). Effective in 25% of cases.
    Antacids (calcium carbonate, aluminum hydroxide): For mild GERD. Fast, but afford only short-term relief.
    H2 receptor antagonists (cimetidine, ranitidine, famotidine, nizatidine): For mild GERD or as an adjunct for
    nocturnal GERD while the patient is on PPIs. Effective in 50–60% of cases.
    PPIs (omeprazole, lansoprazole, rabeprazole, pantoprazole, esomeprazole):
    The mainstay of therapy for mild to severe GERD. Generally safe and effective, but now associated with
    pneumonia, atrophic gastritis (hypergastrinemia), enteric infections (C. difficile), and hip fractures. Daily
    dosage is effective in 80–90% of patients. Fewer than 5% of patients are refractory to twice-daily dosage.
    Surgical fundoplication (Nissen or Belsey wrap):
    Often performed laparoscopically. Indicated for patients who cannot tolerate medical therapy or who have persistent
    regurgitation. Contraindicated in patients with an esophageal motility disorder.
    Outcome: More than 50% of patients require continued acid suppressive medication, and > 20% develop new
    symptoms (dysphagia, bloating, dyspepsia).
    Endoscopic antireflux procedures: Remain investigational.
    COMPLICATIONS
    Peptic strictures: Affect 8–20% of GERD patients; present with dysphagia.
    Malignancies must be excluded via endoscopy and biopsy; can then be
    treated with endoscopic dilation followed by indefinite PPI therapy.
    Upper GI bleeding: Hematemesis, melena, anemia 2° to ulcerative esophagitis.
    Posterior laryngitis: Chronic hoarseness from vocal cord ulceration and granulomas.
    Asthma: Typically has an adult onset; nonatopic and unresponsive to traditional asthma interventions.
    Cough: Affects 10–40% of GERD patients, most without typical GERD symptoms.
    Noncardiac chest pain: After a full cardiac evaluation, consider an empiric trial of PPIs or ambulatory esophageal
    pH monitoring.
    Other: Barrett’s esophagus, adenocarcinoma
    Barrett’s Esophagus
    Intestinal metaplasia of the distal esophagus 2° to chronic GERD. Normal esophageal squamous epithelium is
    replaced by columnar epithelium and goblet cells (“specialized epitheliumâ€Â). Found in some 5–10% of patients with
    chronic GERD, and incidence ↑ with GERD duration. Most common in
    Caucasian men > 55 years of age; overall incidence is greater in males than in females. The risk of adenocarcinoma
    is 0.5% per year. Risk factors include male gender, Caucasian ethnicity, and smoking.
    DIAGNOSIS
    Upper endoscopy: Suggestive but not diagnostic, as it is a histologic diagnosis. Salmon-colored islands or
    “tongues†are seen extending upward from the distal esophagus.
    Biopsy: Diagnostic.
    Shows metaplastic columnar epithelium and goblet cells.
    Specialized intestinal metaplasia on biopsy is associated with an ↑ risk of adenocarcinoma (not squamous).
    TREATMENT
    Indefinite PPI therapy (GERD should be treated prior to surveillance, as inflammation may confound the
    interpretation of dysplasia).
    Adenocarcinoma surveillance is necessary only if patients are candidates for esophagectomy.
    Upper endoscopy with four-quadrant biopsies every 2 cm of endoscopic lesions.
    Screening (based on criteria from the American Society of Gastrointestinal Endoscopy) is as follows:
    After initial diagnosis, repeat EGD in oneyear for surveillance with biopsies.
    Proceed according to EGD findings:
    No dysplasia: Repeat survillence EGD and biopsy every 1 – 3 years.
    Low-grade dysplasia: Repeat EGD within six months. If findings are unchanged, extend surveillance to yearly intervals.
    High-grade dysplasia: Management is controversial but includes early esophagectomy or intensive endoscopic
    surveillance every three months until cancer is diagnosed, followed by esophagectomy.
    Verify with an expert pathologist. Ablative therapies may be attempted (e.g., photodynamic therapy, argon plasma coagulation, endoscopic mucosal resection).
    Boerhaave's Syndrome
    Typical scenario: An alcoholic man presents after severe retching, complaining of retrosternal
    and upper abdominal pain. Think: Boerhaave’s syndrome (full thickness) or Mallory–Weiss syndrome (partial thickness).
    Complete tear of distal esophagus that leads to pneumomediastinum, vs incomplete tear in Malory Weiss and no Pneumomediastinum. Usually presents with acute chest pain following episones of repeated vomiting. Most tears occur in the distal third of the esophagus, which leads to pl effusion.
    Xray shows subcutaneous emphysema.
    Dx barium swallow.The best diagnostic test for esophageal perforation is an esophageogram with water soluble contrast (definite diagnosis in 90% cases). CT scan of the chest is helpful, but may not detect small tears or ruptures.
    Upper GI endoscopy has no role and should not be used.
    Tx: urgent management is needed b/c of the risk of medistenitits, which carries a mortality rate of more than 40% if not properly diagnosed within first 24 hrs. Antibiotics and thoracotomy and repair of esophagus immediately.
    Mallory Weiss tear
    Classic presentation of hematamessis preceeded by a bout of retching /vomiting only occurs in 30 % of patients.
    Hiatal hernia is present in 40 – 100% of patients MW tear.
    Endoscopy is gold standard in diagnosing. This procedure typically reveals a single longitudinal tear at the GE junctionj. In patients with MW tear who are not activley bleeding observation and supportive care are typically necessary. PPI are given to all patients to prevent further damage and promote healing.
    *Subcutaneous and mediastinal emphysema are due to a full-thickness tear.
    Dyspepsia
    Typically defined as one or more of the following: postprandial fullness, early satiation, and epigastric burning or pain. Distinct from but can present with GERD (i.e., retrosternal burning). In the United States, the prevalence of dyspepsia is 25%, but only 25% of those affected seek care. Of these, > 60% have nonulcerative dyspepsia and < 1% have gastric cancer.
    SYMPTOMS/EXAM
    May present with upper abdominal pain or discomfort, fullness, bloating, early satiety, belching, nausea, and retching or vomiting.
    DIAGNOSIS/TREATMENT
    Look for alarm features: May include new-onset dyspepsia in patients
    > 50 years of age, unintended weight loss, melena, iron deficiency anemia, persistent vomiting, hematemesis, dysphagia, odynophagia, abdominal mass, a history of PUD, previous gastric surgery, and a family history of gastric cancer.
    If alarm features are present: Perform prompt endoscopy.
    If no alarm features are present: Assess diet and provide education; discontinue suspect medications. Consider a trial of empiric acid suppression; consider testing for and treating H. pylori
    Determine the local prevalence of H. pylori.
    If > 10%: Test for H. pylori by serology, stool antigen, or breath test. If +ive , institute H. pylori eradication therapy. If _, initiate a trial of acid suppression for 4–8 weeks.
    If < 10%: Institute a trial of acid suppression for 4–8 weeks.
    For persistent symptoms:
    If the patient received H. pylori therapy, test for eradication with a stool antigen or breath test, not with serology. If disease is not eradicated, attempt a different regimen. If eradicated, refer to endoscopy.
    If the patient received a trial of PPIs, refer to endoscopy.
    Endoscopy: If unrevealing: Diagnose with nonulcerative dyspepsia and provide reassurance; consider a trial of low-dose TCAs (desipramine 10–25 mg QHS) and possible cognitive-behavioral therapy.
    If revealing: Manage as indicated.
    Endoscopic biopsy, H. pylori stool antigen, and urea breath test can assess active H. pyloriinfection and gauge treatment success. H. pylori serology measures only past exposure and cannot be used to confirm eradication.
  11. Guest

    Guest Guest

    Notes (401 - 450)

    401. Manganese toxicity = "manganese madness"in miners of ore

    402. Chromium deficiency = impaired glucose tolerance

    403. Removal of the ileum, tapeworm Diphylobothrium latum = B12 defic.

    404. MCC of vit. B12 defic. = pernicious anemia

    405. Pernitious anemia association = vitiligo, hypothyroidism, hypoadrenalism

    406. Liver failure + increase in PT Rx = fresh frozen plasma

    407. Rubella vaccine = NOT for immunocompromised patients (except for HIV), if given to a woman and she gets pregnant in the first three months after, abortion is NOT indicated, chances are nothing bad will happen to the fetus

    408. Mean = average value

    409. Median = middle value

    410. Mode = MC value

    411. Brain death with confounding medical dis. = needs additional confirmatory test

    412. Tardive dyskinesia Rx = switch anitipsychotic to clozapine

    413. Ac. dystonia, parkinsonism as S.E. Rx = diphenhydramine, trihexyphenidyl, benztropine

    414. Akathisia Rx = betablockers

    415. Neuroleptic malignant syndrome, malignant hyperthermia Rx = dantrolene

    416. Thioridazine S.E. = retinal pigment deposits

    417. Chlorpromazine S.E. = jaundice, photosensitivity

    418. P. aeruginosa bacteremia Rx = tobramycin or amikacin + piperacillin OR ceftazidime OR cefepime

    419. Ecthyma gangrenosum Rx = IV atbtc (not debridement)

    420. Cryptococcal meningitis Dx = + india ink preparation; Rx = amphotericin B + flucytosine 10-14 d, then fluconasole prophylaxis forever (for HIV); may require repeated lumbar punctures to decrease the pressure

    421. Phenytoin toxicity = nystagmus on far lateral gaze, neurotoxicity; remember that it decreases the OCP levels in the blood

    422. Catheter-related syst. infection = removal + vancomycin + gentamycin

    423. Vertebral osteomyelitis Dx = MRI is the most accurate, bone Bx is the gold standard

    424. Meningococcal meningitis prophylaxis = oral rifampin OR S.D. oral ciprofloxacin OR S.D. IM veftriaxone

    425. IV pentamidine S.E. = metabolic disturbances, such as hypoglycemia (always check in case of seizure)

    426. Herpes zoster Rx = acyclovir within 48 h of onset of rash

    427. Candida ophtalmitis with vitreal involvement Rx = vitrectomy + systemic antifungal

    428. Hypothermia or shock post blood transfusion = think hypocalcemia!

    429. HIV prophylaxis post exposure = zidovudine + lamivudine for 4 w

    430. Lungs + sinuses infections post bone marrow transplant = invasive aspergillosis

    431. Rhinocerebral mucormicosis Rx = surgical debridement + IV amphotericin B

    432. MCC of FUO = infection (30-40%)

    433. Progressive multifocal leucoencephalopathy (JC) = multiple focal neuro symptoms in HIV patient

    434. Shoulder dystocia Rx = stop pushing, suprapubic pressure, McRobert's maneuver

    435. McRobert's maneuver = two assistants flexing thighs back against abd.

    436. Zavanelli maneuver = replace fetal head back into the pelvis, but then you have only 7 minutes to perform the c-section

    437. ARDS = clear lungs + diffuse bilat. infiltrates on CXR; Rx = PEEP around 9, high O2 concentration, low tidal volume (<6 ml/kg)

    438. Neonatal polycythemia Rx = hydration + partial exchange transfusion

    439. Mendelson's syndrome = aspiration pneumonitis

    440. Ac. tubular necrosis = after prerenal azotemia; muddy brown casts in urinalysis; increased BUN and creatinine, anion gap acidosis

    441. Hemosiderin laden macrophages = Wegener's, Goodpasture's

    442. Heparin induced thrombocytopenia Rx = suspend it, lepirudin or argatroban; prevention = use low molecular heparin instead, or limit the use to a maximum of 5 days

    443. Ascities fluid analysis = serum-ascitic fluid albumin gradient (SAAG) - if <1.1 g/dl = cirrhosis, CHF; if >1.1 = ca, pancreatitis

    444. Ac. compartment syndr. complication = rhabdomyolisis that may lead to ARF; Dx = pressure > 30 mmHg; Rx = emergent fasciotomy

    445. Mental status change in the elderly = meds, infection, metabolic, thyroid dis.

    446. Metastasis prostate ca Rx = leuprolide (LHRH agonist) + flutamide (antiandrogen)

    447. Octreotide = somatostin analog, for bleeding esophageal varices

    448. Active lower GI bledding = STAT colonoscopy or radionuclide scan

    449. Ac. hemolytic transfusion reaction Rx = stop it and hydrate!

    450. Metronidazole = contraindicated for breastfeeding women
  12. Guest

    Guest Guest

    Notes (451 - 500)

    451. Postpartum endometritis Rx = clindamycin + gentamicin

    452. Infant botulism Rx = supportive care, human derived botulin antitoxin; expect 1-3 m of hospitalization and full recovery

    453. Febrile transfusion reaction avoidance = washed cells

    454. Pre-angiography = discontinue metformin to avoid renal complications and acidosis

    455. Hypocalcemia = hyperactive DTRs

    456. Hypermagnesemia = loss of DTRs

    457. Condyloma acuminata = vaginal delivery is OK!

    458. Transurethral resection of the prostate S.E. = hyponatremia = twitching, seizures

    459. Stress ulcer prevention = oral PPI suspension

    460. Erb's palsy association = diaphragmatic paralysis

    461. Torsades de points with instability = unsynchronized cardioversion, then, IV magnesium sulfate, then temporary transvenous overdrive
    pacemaker (in this orden, according to necessity)

    462. MCC of CAH = 21-hydrolase enzyme defic. (increased 17-alpha-hydroxyprogesterone)

    463. 11-hydroxilase defic. = HTN, hypernatremia, hypokalemia, due to the increase in 11- deoxycorticosterone, which is a mineralocorticoid

    464. Classic dashboard injury (car accident) = post. cruciate ligament lesion

    465. Mechanical valves INR goal = 2.5-3.5

    466. Cimetidine, trimethoprim S.E. = decrease clearance of creatinine

    467. ITP in adults Rx = corticosteroids, then IV Ig, then splenectomy (rarely needed)

    468. Hyperhomocysteinemia Rx = folic acid

    469. Borderline personality dis. Rx = dialectical behaviour therapy

    470. RSV Dx = detection of RSV Ag in nasal/pulm secretions by ELISA

    471. Sudden hyperglycemia + total parenteral nutrition = sepsis

    472. Hashimoto's thyroiditis association = thyroid lymphoma

    473. Chr. recurrent pancreatitis complication = isolated gastric varices

    474. Doxorubicin use = serial radionuclide ventriculography or MUGA is used to evaluate cardiotoxicity

    475. Hospice care = life expectancy < 6 m

    476. DM screening = 45 yo, q3y if no risk factor

    477. Chlordiazepoxide = Rx of alcohol withdrawal

    478. Ceftriaxone S.E. = increase in both types of bilirubin

    479. CIN 1 = repeat pap smear in 6 m

    480. Wernicke's encephalopathy = confusion + ataxia + nystagmus (ophtalmoplegia)

    481. Korsakoff's psychosis = may happen as a consequence of giving glucose before thiamine; confabulation (creating a story to fill the gap in
    memory); mamilory bodies changes

    482. Multiple sclerosis suspicion = MRI brain and spine; Rx (acutely) = steroids; to prevent relapsing = interferon OR glatiramer (remember they are both teratogenic); repeat MRI in 3 months

    483. Increased bleeding time Rx = IV desmopressin (e.g. renal failure)

    484. Isotretinoin, minocycline S.E. = pseudotu cerebri

    485. MC scaphoid fracture complication = nonunion

    486. Orthostatic hypotension = decrease by 20 mmHg in syst BP OR 10 mmHg in dyast BP

    487. Thiazides, amiodarone, sulfa S.E. = photosensitivity

    488. Increase in fibrinogen happens with use of = lovastatin, atorvastatin, pravastatin, simvastatin

    489. Ac. Ao dissection HTN Rx = IV betablockers + nitroprussiate

    490. Dipyridamole, adenosyne = C.I. in asthma or COPD

    491. Antenatal corticosteroid therapy = 24-34 w = IM bethametasone, dexamethasone

    492. 50 mg oral glucose challenge >140 = do a 100 mg OGTT with 3 h measurement

    493. Glucose in pregnancy goals = fasting 60-90, postprandial < 120

    494. TMP-SMX = NOT in first and third trimester

    495. Pyelonephritis + pregnancy Rx = IV ceftriaxone OR ampicillin + gentamycin

    496. Condyloma acuminata in mucosa or pregnancy Rx = trichloroacetic acid

    497. Severe PID Rx = IV cefoxitin/ceftriaxone + IV doxycycline

    498. Next day pill = levonorgestrel (up to 120 h after)

    499. Cystic fibrosis infertility = 95% for men, 20% for women

    500. Hyperthyroidism + pregnancy Dx = free T4, total T4, TSH
  13. Guest

    Guest Guest

    Notes (501 - 550)

    501. Pap smear screening = 3 y after first intercourse or 18 yo

    502. Hypothyroidism in pregnincy = dose of Lthyroxine needs to be increased (increased thyroglobulin)

    503. Pessaries (+ vaginal estrogen) = structures to support the vagina walls

    504. ASCUS Dx next step = HPV DNA testing, then colposcopy if necessary

    505. RA with poor response to methotrexate = infliximab OR etanercept; do a PPD first!

    506. PCP intoxication Rx (if patient not extremely agitated) = low-sensory enviroment; haloperidol, diazepam if necessary

    507. Metoclopramide S.E. = extrapyramidal symptoms

    508. Influenza Rx = zanamivir, rimantadine or amantadine within first 30-48 h of symptoms

    509. Sup. vena cava syndr = CT of neck + chest w/ contrast

    510. MCC of Guillain-Barre syndr = C. jejunii infection; Rx = IV Ig or plasmapheresis, respiratory support if necessary, keep an eye on the patient, with bedside pulmonary function tests!

    511. Ac. stress disorder = < 4 w post event

    512. Post-traumatic stress disorder = > 4w post event, even years

    513. Hyperviscosity syndr = Waldenstrom's macroglobulinemia (increased Ig M), multiple myeloma

    514. PE suspicion = V/Q scan, then venous USG, then CT angiogram of the chest (in this order, if necessary)

    515. Chlamydia infection + HLA-B27+ = Reiter's syndr; Rx = atbtc, exercise, sulfasalazine, methotrexate

    516. Ethylene glycol = severe anion gap acidosis, Kussmaul's respiration

    517. Ethylene glycol, methanol intox. Rx = fomepizole infusion (ADH competitive inhibitor)

    518. Klinefelter's syndr = risk factor for male breast cancer

    519. Doxycycline S.E. = photosensitivity

    520. Isotretinoin S.E. = hypertriglyceridemia, may lead to pancreatitis

    521. Pulm. contusion Rx = admission for 24-48 h, pulm. toilet, O2, pain control, fluid management

    522. Renal cell ca = renal mass + polycythemia + flank pain + smoking

    523. Amiodarone S.E. = thyroid dysfunction, corneal deposits, skin discoloration, pulm. fibrosis, liver toxicity

    524. Metformin S.E. = metabolic acidosis, weight loss

    525. Glyburide = metabolized by kydneys; glitazones = metabolized by liver

    526. indirect inguinal hernia Rx = elective repair ASAP

    527. TSS Rx = clindamycin +/- naficillin + IV fluids (up to 20 L!)

    528. Metformin C.I. = CHF, alcoholism, renal failure

    529. Glitazones C.I. = CHF NYHA classes III, IV

    530. C. difficile infection is caused by = clindamycin, ampicillin, amoxacillin, cephalosporins

    531. After 2 cystitis in 6 months = prophylaxis for 6- 12 m

    532. Decreased TSH, but normal T3, T4 = repeat TSH after 6-8 w

    533. Anorexia nervosa with <75% of ideal weight = hospitalization

    534. Early childhood respiratory disease with apnea = RSV bronchiolitis

    535. Heat stroke Rx = augmentation of evaporative cooling

    536. Isolated increase in alkaline phosphatase = liver tb, liver lymphoma (prolipherative processes)

    537. Epididimitis association = hydrocele

    538. Rabies prophylaxis in pat. prevoiusly vaccinated = only vaccine, no Ig

    539. Hemochromatosis = liver dysfunction, arthropathy, central hypogonadism, skin pigmentation, DM; Dx = serum iron studies

    540. Hormone replacement therapy S.E. = increase in triglycerides

    541. Primary HIV-associated thrombocytopenia Rx = zidovudine

    542. HAART for HIV for 6 m = decrease viral load to < 50 copies/ml is expected

    543. Perimenopause = period between 2-8 y preceding menopause to 1 y after

    544. Dysfunctional bleeding during perimenopause = vaginal USG or endometrium biopsy

    545. Meniere disease = periodic vertigo + unilat. hearing loss + tinnitus; associated with syphillis

    546. H. pilory erradication test after Rx = urea breath test or fecal Ag test after 4-12 w

    547. Variceal hemorrhage re-bleeding = endoscopy + band ligation or sclerotherapy

    548. Non-gonococcal urethritis Rx = azithromycin (SD) OR doxycycline; if no response = metronidazole + erythromycin OR high dose erythromycin

    549. Reiter's syndr = conjunctivitis + urethritis + spondiloarthropathy

    550. Patellar tendon tear = inability to mantain extension of knee; Rx = early surgical repair
  14. Guest

    Guest Guest

    Notes (550 - 600)

    551. Epistaxis Rx = topical vasoconstrictor + anesthetic + chemical or electro cauterization; if it fails = bacitracin covered ant nasal tampon

    552. Central midbrain lesion = abnormal CN III function

    553. Multiple myeloma Dx = serum prot. electrophoresis, bone marrow Bx (>20% plasma cells), skeletal suvey, whole body XR

    554. Cleft lip surgical correction = 10 pounds, 10 weeks, 10 g of Hb

    555. Marfan's syndr = corrective Sx when Ao root = 45 mm

    556. Asymptomatic alfa 1 antitrypsin defic. = spirometry q3 m

    557. Opioid withdrawal + HTN Rx = clonidine

    558. Meningoencefalitis + pneumonia + splenomegaly = Chlamydia psittaci pneumonia (birds contact); Rx = doxycycline 100 mg q12h for 21 days

    559. Lyme dis. with Bell's palsy = order CSF analysis!

    560. Asymptomatic increase in TSH = order anti- TPO!

    561. Any bite Rx = ampicillin-sulbactam

    562. Exposure to active TB = immediate PPD, if - repeat in 3 m

    563. Early stress fracture Dx = MRI, triple phase bone scans with tecnitium; Rx = rest for 4-6 w, pain control, gradual return to activity

    564. Spinal epidural abscess Dx = gadoliniumenhanced MRI or CT with myelography; Rx = early surgical decompression + drainage in the first 24 h

    565. Lactose intolerance = yogurt is recommended

    566. Ureteral stones < 5 mm = usually pass by themselves; if not = shockwave lithotripsy

    567. Ureteral stones > 8-10 mm = flexible ureteroscopy + laser lithotripsy

    568. Cervical cerclage = done at 13-17 w, removed at 36 w

    569. Scrotal trauma with abnormal PE = surgical exploration

    570. Risk factor for prostate cancer = start screening (PSA + DRE) at 45 yo

    571. Alopecia areata Rx = topical or intralesional corticosteroids

    572. Hypokalemia + paralytic ileus = correct hypokalemia immediately!

    573. Marfan's syndr = dural ectasia (MC), ectopia lentis, Ao dilatation, MVP

    574. Pineal tu = Parinaud's syndr = loss of pupillary reaction, vertical gaze, optokinetic nystagmus, ataxia, can secrete HCG

    575. MC symptom of sickle cell dis = dactylitis; second = splenic sequestration

    576. Cough due to forced expiration = asthma

    577. Common migraine = no aura; classic migraine = aura +

    578. Chlamydia in pregnancy Rx = erythromycin

    579. DM retinal, vitreous hemorrhages Rx = laser photocoagulation

    580. Sydehams chorea Rx = oral penicillin 10 d, then prophylaxis

    581. HAART Rx for asymptomatic HIV = CD4 < 350, viral load > 55000, check q 3 m

    582. Paget's dis of the bone Rx = biphosphonates (alendronate)

    583. First generation relative with colon ca = start screening at 40 yo

    584. Asymptomatic bacterial vaginosis in pregnancy = NO Rx!; if high risk for preterm labor or symptomatic = oral metronidazole or clyndamycin

    585. Anaphylaxis with pulm/cardiovascular symptoms = epinephrine IV

    586. Hemochromatosis Rx = therapeutic phlebotomy

    587. Penicillamine = promotes excretion of copper

    588. Post communicating art aneurysm = CN III palsy

    589. Inoperable head and neck ca = chemo + radiotherapy

    590. P. carinii pneumnia Dx = fiberoptic bronchoscopy with bronchoalveolar lavage; Rx if mod/severe = admission + IV TMP/SMX, add corticosteroids if A-a gradient >35 or pO2 <70

    591. Carbon monoxide poisoning Dx = co-oxymeter

    592. Chr mesenteric ischemia Dx = mesenteric duplex USG

    593. Atopic dermatitis Rx = topical steroids, tacrolimus, pimecrolimus

    594. Pyloric stenosis Dx = USG; associated with erythromycin use

    595. Pertussis prophylaxis = erythromycin

    596. Air in the distal colon = partial (not total!) obstruction

    597. Increased insulin and increased C-peptide = insulinoma, sulfonylurea use

    598. Medullary thyroid ca = screen for pheochromocytoma

    599. HTN in ac. ischemic stroke = treat only if syst > 220, dyast > 120

    600. Rhabdomyolisis causes = cocaine, acohol, trauma, exertion. hypothermia, hypothyroidism
  15. Guest

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    Notes (601 - 650)

    601. Drugs that cause pancreatitis = diuretics, valproic acid, metronidazole, tetracycline

    602. Peripheral vasc dis Rx = cilostazol (platelet inhibitor and art vasodilator)

    603. Rocky mountain spotted fever Rx = doxycycline

    604. New onset of severe seborrheic dermatitis = order an HIV test!

    605. Necrotizing fasciitis due to group A strep Rx = surgical debridement + IV clyndamycin

    606. Pill-induced thyrotoxicosis = undetectable thyroglobulin

    607. Graves dis. Rx = bring the patient to a normal thyroid state with beta=blockers, PTU, methimazole, then radiodine ablation + glucocorticoids (for ophtalmopathy)

    608. Thyroid storm Rx = PTU or methimazole + glucocorticoids

    609. Cushing's triad (increased ICP) = bradycardia, HTN, respiratory depression

    610. Postherpetic neuralgia Rx = desimipramine, amitriptyline, capsaicin, gabapentin, topical long acting oxycodone

    611. Diabetic neuropathy Dx = nerve conduction studies

    612. Amaurosis fugax = carotid doppler evaluation

    613. TCA induced VT Rx = lidocaine

    614. Watching out for scleroderma renal involvement = monthly BP measurement

    615. Constructional, dressing apraxia = nondominant parietal lobe lesion

    616. Aphasia = dominant temporal lobe lesion

    617. Porphyria cutanea tarda = painless blisters + hyperthricosis + hyperpigmentation, associated with hepatitis C

    618. Lyme arthritis Dx = synovial fluid ELISA or western blott; Rx = 30 d of amoxicillin or ceftriaxone or doxycycline or erythromycin; 90% of cure in 1 y

    619. Pheochromocytoma Rx = alpha blockade 10-14 d pre-op + CT/MRI

    620. Neonate opiate withdrawal Rx = paregoric or tincture of opium

    621. Amyotrophic lateral sclerosis Rx = riluzole

    622. Neurogenic syncope = vasovagal, common faint

    623. Autonomic neuropathy = leads to postural hypotension

    624. Restless legs syndr Rx = pramipexole, ropinirole (dopamine agonists)

    625. Pick's dis = slowly progressive frontal and/or temporal lobe dementia = not only cognitive, but behavioral changes

    626. Varicocele complication = testicular atrophy

    627. Obesity surgery indication = BMI > 40 kg/m2

    628. Ao stenosis association = angiodysplasia in colon

    629. CO poisoning = several people in the same household with throbbing headache, nausea, malaise, dizziness

    630. Ovaries = 2-3 cm in young women, non palpable after menopause

    631. Venous sinus thrombosis Rx = heparin, even with hemorrhagic infarction

    632. Ac. variceal bleeding = give fluoroquine 7-10 d for infection prophylaxis, it improves the outcome

    633. Infant botulism symptoms = decreased gag reflex, constipation, lethargy, poor sucking

    634. Ac. gout Dx = arthrocentesis; Rx = ibuprofen, indomethacin, colchicine, glucocorticoids

    635. Giardia = no eosinophilia

    636. Down syndr screening = AFP, HCG, unconjugated estriol, dimeric inhibin-A

    637. Severe pneumonia Rx = hospitalization + ceftriaxone + azithromycin

    638. Delayed puberty = no increase in testicle size by 14 yo, diameter < 2.5 cm; Dx = bone age determination (XR)

    639. HTN + scleroderma renal crisis Rx = ACEi

    640. Scombroid = fish bad conservation; 10-30 minutes after ingestion, patient has histamine realted symptoms; self-limited

    641. Ac. dystonic reaction (e.g. metoclopramide) Rx = IV diphenhidramine

    642. Urine toxicology = urine immunoassay screen (results in 1 hour)

    643. Achalasia = dysphagia for both solids and liquids

    644. Fasting blood glucose 100-126 = increased risk for CAD; metformin may be given, specially if metabolic syndr present

    645. Sjogren's syndr Dx = minor salivary glan Bx is gold standard

    646. Celiac dis. Dx = anti-endomisial, anti-tissue transglutaminase Ab levels

    647. SAH = xantochromia in CSF is found only after 4 h of symptoms

    648. COPD prognosis = FEV1

    649. Cosyntropin stimulation test indication = adrenal failure

    650. RA = clinical Dx; if RF - order anti-CCP Ab; if erosive joint dis = treat with methotrexate and other DMARDs
  16. Guest

    Guest Guest

    651. Mother with DM type I = 3% risk, father = 6% risk the child will have it too

    652. Transverse myelitis = rapidly progressive weakness post URI + sensory loss + urinary retention

    653. Nonbacterial prostatitis Rx = sitz baths + NSAIDs

    654. Mesenteric ischemia = metabolic acidosis

    655. HIV teratogenic drugs = efavirenz, delavirdine

    656. Dextrose + insulin = decrease tryglycerides

    657. Extrapyramidal symptoms + dementia = subcortical dementia

    658. Carpal tunnel syndr initial Rx = continuous wrist splint

    659. Cutaneous cryptococcosis suspicion = bx of skin lesions

    670. Trichomoniasis in breastfeeding mother = no breastfeeding for 24 h after SD of metronidazole, discard pumped milk

    671. Erysipela = group A strep

    672. Papillary thyrois ca Rx = near total thyroidectomy; no need to stage before it

    673. Onychomicosis Rx = oral terbinafine or itraconazole

    674. Disseminated gonococcal infection Dx = cultures = joint fluid, mucosal surfaces

    675. Lead blood level > 44 = chelation therapy; intoxication = > 10

    676. Vit B12 replacement = check K closely for 48 h (it may decrease quickly)

    677. Dumping syndr Rx = high prot, low carbohydrate diet

    678. Initial screening for infertility = semen analysis

    679. Excess iodine contrast S.E. = thyrotoxicosis

    680. CD4 < 200 = TMP/SMX (P. carinii)

    681. CD4 <50 = azithromycin or chlarithromycin (MAC)

    682. INR > 20 = FFP, IV vit K; between 5 and 20 = oral vit K; <5 = hold coumadin until desired level

    683. Ac. retroviral syndr = thrombocytopenia, leukopenia

    684. Lactose intolerance Dx = lactose breath hydrogen test

    685. Drugs that have anemia as S.E. = phenytoin, methotrexate, trimethoprim; Rx = folinic ac (leucovorin)

    686. Rosacea Rx = topical metronidazole; remember this disease may have ocular symptoms, and can't be treated as acne

    687. Carbamazepine S.E. : neutropenia, SIADH, glaucoma, constipation

    688. Eryhtema chr. migrans + tick bite = treat it with doxycycline right away (28 d), don't wait for serology

    689. Gonorrhea Rx in cephalosporin allergy = ofloxacin, ciprofloxacin (+azithromycin)

    690. BPPV Rx = canalith repositioning procedure

    691. HIV lipodystrophy = HAART S.E., increase tryglycerides; Rx = gemfibrozil

    692. Pernicious anemia Dx = anti-intrinsic factor Ab testing (not Schilling test!)

    693. Psoriatic arthritis, nail dis Rx = methotrexate

    694. Chr. liver dis = give hepatitis A vaccine

    695. Bacterial conjunctivitis Rx = erythromycin ointment, sulfa drops

    696. Bile-salt induced diarrhea = post cholecystectomy, short bowel syndr; Rx = cholestyramine

    697. Disease transmitted only by mothers in a family = mitochondrial heritance

    698. Adult Still's dis = RA variant; fever + salmoncolored maculopapular rash; Rx = NSAIDs; monitor liver function!

    699. Amiodarone in anticoagulated patients = doctor should decrease the warfarin dose in 25%

    700. Back pain for more than 6 w = order ESR; if > 20, order imaging studies
  17. Guest

    Guest Guest

    Notes (701 - 750)

    701. Tinea versicolor Rx = topical terbinafine

    702. Bacterial overgrowth Dx = quantitative jejunal cultures

    703. Ultrarapid acting insulin = lispro, aspart

    704. Hydrocortisone = low-potency steroid

    705. Betamethasone = high-potency steroid

    706. Barret's esophagus without dyspalsia = endoscopy + Bx q 1-3 y

    707. Premenstrual syndr Rx = SSRIs; no improvement = alprazolam

    708. Retrosternal goiter with compressive symptoms = surgery

    709. Drugs that decrease sexual drive = bupropion, mirtazapine

    710. Valproic acid S.E. = urinary frequency and incontinence

    711. Renal art. stenosis Dx = MR angiography

    712. Primary pulm. HTN Rx = anticoagulation (INR = 2) + oral vasodilator

    713. CoAo Dx = MRI of chest

    714. Undescended tests = wait until 6 mo

    715. Initial smoking cessation aid = high dose nicotine patch (but patient needs to be commited, because smoking using the patch may lead to coronary spasm and even MI!); bupropion later

    716. Initial sleep apnea investigation = medical workup (investigate hypothyroidism too)

    717. Rare event study = meta-analysis (incerase sample size, therefore increase power); limitation = heterogeneous studies put together

    718. Mass in the hepatic duct Rx = ERCP + stent placement; if it fails = percutaneous transhepatic cholangiography + stent

    719. Borderline personality = splitting, e.g. primitive idealization; Rx = dialectical behavour therapy

    720. Falling on an outstretched hand = scaphoid fracture; Dx = CT scan of the hand, bone scan; complication = nonunion

    721. Epidural spinal cord compression (metastasis) = thoracic radicular pain, neuro symptoms; Rx = high dose corticosteroids, MRI, radiation

    722. Hemochromatosis Rx = phlebotomy

    723. Penicillamine = promotes copper excretion (Wilson's dis)

    724. Extremely ominous sign of preeclampsia/eclampsia = retinal hemorrhages

    725. Ac. adrenal insuf. Rx = dexamethasone + cosyntropin stimulation test

    726. Symptomatic rectocele Rx = surgery or pessary + estrogen cream

    727. HIV and RPR + = CSF examination; if nl = benzathine penicillin weekly x 3, warn about possible Jarisch-Herxheimer reaction

    728. Painless low GI bleeding = colonoscopy or radionuclide scan with technitium-99

    729. IgM HIV Ab assay = low sensitivity, do NOT use!

    730. Indeterminate HIV ELISA = order HIV RNA PCR assay or p24 Ag

    731. HIV with or without Rx = monitor CD4 count and HIV load q 3-4 m

    732. Survival analysis = accounts for number of events AND timing of events

    733. Blepharospasm = focal dystonia; Rx = botulin toxin injection

    724. Prerenal azotemia = decrease fractional excretion of sodium

    725. Drug-induced allergic interstitial nephritis = happens after 3-5 d of causal agent; eosinophils in urine

    726. Most benefitial step to decrease osteoporosis risk = quit smoking

    727. Ankylosing spodilitis suspition = X-ray sacroiliac joint, repeat q 3 m + ESR

    728. Chr. Foley catheter + candida on urine culture = no Rx if asymptomatic

    729. Viral meningitis in chidren = enterovirus, arbovirus; in adults = HSV

    730. Drugs with thrombocytopenia as S.E. = clopidogrel, heparin

    731. Ideal blood culture = 1 h before fever

    732. Chr. non-remiting cluster headache Rx = verapimil, lithium; ac. crisis = 100% oxygen inhalation

    733. Condyloma acuminata in pregnancy = do NOT use podophilin, use trichloroacetic acid instead

    734. Chr. hepatitis C Rx = interferon alpha-2b (+/- ribavirin)

    735. Hormone replacement therapy cessation = do not do it abruptly, taper it down instead!

    736. Confidence interval includes 1.0 = not sattistically significant

    737. Latent TB infection = PPD + and CXR WNL; Rx = isoniazid + B6 for 6-12 m

    738. ARDS causes = sepsis, pneumonia, severe trauma, burns, drowning, pancreatitis; clear lungs on PE + diffuse, bilat infiltrates on CXR; Rx = PEEP around 9 cmH2O, high O2 concentration, low tidal volume (6 ml/kg)

    739. Emergency contraception after 120 h = copper IUD

    740. DM + C-section prep = normal insulin the night before; insulin drip + D5 1/2 NS + KCl during the day, keep glucose <160

    741. Single most important predictor for CV risk = DM

    742. Diet for diarrhea = normal, age appropriate with low fat and low sugar

    743. Sedative and hypnotic drugs for the elderly = increased risk for falls, so risk x benefits have to be carefully evaluated

    744. BZD withdrawal = tremolousness, seizure, psychosis, increased HR, BP, body temperature, anxiety, restlessness, confusion, disorientation; Rx = IV lorazepam, diazepam

    745. Anemia of chr. dis. = RA, SLE, vasculitis; if severe, with normal erythropoietin levels = red cell transfusion

    746. Sjogren's syndr Dx = anti-Ro, anti-L2 in salivary gland; gold standard = labial minor salivary gland Bx = focal collections of lymphocytes; associated with non-Hodgkin's lymphoma (B-cell lymphoma)

    747. MEN 1 = hyperparathyroidism, pancreatic tu, pituitary tu

    748. MEN 2A = medullary thyroid ca, pheochromocytoma, hyperparathyroidism

    749. MEN 2B = medullary thyroid ca, pheochromocytoma, mucosal neuromas, marfanoid habitus

    750. Vertebrae osteomyelitis and diabetic foot = most accurate test = MRI; gold standadrd = bone Bx; culture = deep curetage tissue
  18. Guest

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    Notes (751 - 800)

    751. Addison's dis = decreased Na, increased K, hyperchloremic metabolic acidosis; Dx = ACTH stimulation test, early mornong cortisol

    752. IV pentamidine S.E. = increased or decreased K, decreased Ca, hyper or hypoglycemia

    753. Obesity surgery indications = BMI > 40, coexisting diseases, decreased quality of life

    754. Erb's palsy prognosis = 80% chance near full recovery in 1 y

    755. NF 1 = cafe-au-lait spots, cutaneous neurofibromas, axillary freckling, unilat. acoustic neuroma

    756. NF 2 = hypopigmented spots, family history of bilat. deafness (bilat. acoustic neuromas)

    757. Tuberous sclerosis = congenital ash-leaf spots, glial prolipheration, organ hamartomas/cysts

    758. Sturge-Weber syndr = facial port-wine stain, leptomeningeal angiomatosis

    759. Osler-Rendu-Weber syndr = vascular lesions of the CNS, multiple telangiectasias

    760. Diaper rash Rx = topical zinc oxyde paste, petrolatun, keep area dry; if it fails = low-potency corticosteroids ointment, but keep an eye open for fungal infections!

    761. Situations with increased amylase = pancreatitis, ac. parotiditis, intestinal dis., renal failure, cholecystitis, fallopian tube dis.

    762. Mild ac. pancreatitis Rx = IV fluids + pain control + NPO + NG tube aspiration; atbtcs if severe necrotizing pancreatitis, fever, evidence of infection (imipenem, third gen. cephalosporin, piperacillin, fluoroquinolone, metronidazole); if it fails = CTguided aspiration of tissue, culture and sensitivity

    763. Infant, children with TB meningitis Rx = 12 m of anti-TB drugs + corticosteroids; if resistant = 18- 24 m

    764. LDL goal is < 100 in = coronary dis. peripheral and cerebral vascular dis., DM

    765. Hypophosphatemia = respiratory weakness, hemolysis, decreased release of O2 from Hb

    766. Postpartum endometritis + breastfeeding Rx = clindamycin + gentamycin; main risk factor = Csection

    767. Sarcoidosis = hypercalciuria, hypercalcemia, thrombocytopenia, increased serum ACE, hypergammaglobulinemia

    768. Herpes gestationis = paules, plaques, vesicles around umbilicus; Rx = topical steroids, oral antihistamins (it has nothing to do with the virus)

    769. Inflammatory myositis Rx = high-dose glucocorticoids (prednisone 1 mg/kg), immunosuppressants

    770. Depot medroxyprogesterone indicated as contraceptive = menorrhagia, PID, fibrosis, heavy smoking; decrease the incidence of endometrial ca

    771. Shuffling gait = decreased speed and amplitude of leg movements; Parkinson's

    772. Spastic paraparesis = patient drags legs forward, no bending of the knees

    773. Cerebellar ataxia = "drunken sailor", zigzag, jergy gait

    774. Senile gait = "walking on ice"

    775. Neonatal polycythemia = Htc > 65%, apnea, hypoglycemia, increased bilirubin, cardiac and respiratory compromise; Rx = adequate hydration + partial exchange transfusion

    776. C. botulinum soil spores = California, Pennsylvania, Utah

    777. Neuropathic ca pain Rx = sharp = carbamazepine; dull = desipramine

    778. Organophosphate poisoning Rx = atropine + pralidoxime

    779. Meralgia paresthetica = entrapment of lat. femoral cutaneous nerve

    780. Higher specificity = higher PPV; higher sensitivity = higher NPV

    781. Emphysematous pyelonephritis (DM) Rx = IV atbtcs + immediate nephrectomy

    782. Pregnancy + epilepsy with no seizures for 2-5 y = try to taper down and withdrawal the drug

    783. No adequate response to osteoporosis Rx = investigate multiple myeloma!

    784. Pseudomembranous colitis = repeat immunoassay if - but strong suspition, repeat Rx with metronidazole if no response on first try

    785. Diabetic mononeuropathy prognosis = very good, improvement in a few weeks

    786. Metoclopramide = many S.E., tachyphylaxis

    787. Single small pedunculated polyp = colonoscopy q 3 y

    788. Seizures post stroke Rx = phenytoin, carbamazepine

    789. Glucocorticoids for < 3 weeks = no need to taper it down

    790. Increased anion gap metabolic acidosis = renal failure, ketoacidosis, lactic acidosis, metformin, intoxications = aspirin, ethylene glycol, methanol

    791. CCS - Rupture of AAA case = order monitors, oxygen, IV access BEFORE PE

    792. CCS - DKA = order calcium, phosphate, amylase, lipase, serum osmolality, ketones

    793. CCS - COPD with pneumonia = monitor peak flow and FEV1

    794. CCS - Anaphylaxis case = give epinephrine BEFORE PE

    795. CCS - Paracentesis needed = order analysis of the fluid = ceel count, diff., prot, glucose, cytology; depending on the case = Gran stain, culture, AFB staining, amylase, bilirubin

    796. CCS - Domestic abuse = urine toxicology, skeletal survey, support group, social worker

    797. CCS - SLE = ESR, serum ANA, UA, CXR, total complement, anti-ds DNA, DEXA, prednisone, NSAIDs, rheumato consult, nephro consult,
    sunblock use

    798. CCS - Croup = cool mist tent, decadron, racemic epinephrine, observe for 4 h

    799. CCS - Turner's syndr = GH, oxandrolone, estrogen + progestin, vit. D

    800. CCS - When ordering corticosteroids in high doses or prolonged use intended = H2 blockers, vit. D, calcium, DEXA scan, exercise, sometimes even viphosphonate

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