1.The typical presentation of a thrombosed external hemorrhoid is an acute onset of very severe perianal pain, particularly when walking and sitting. 2. You know that external hemorrhoid is below the dentate line. internal hemorrhoids arise above the dentate line. 3. thrombosed external hemorrhoid requires immediate incision and evacuation of the clot to provide symptomatic relief. Pressure by compression is usually all that is needed to control the bleeding. 4..Sitz baths, applying a topical steroid cream, and increasing fiber intake are the usual treatment for symptomatic external hemorrhoids that are not thrombosed. 5..as a rule alwayes remember that external hemorrhoid s hurts but donot bleeding(opossit internal hemorrhoids) 6.typical picture of pyloric stenosis.,Projectile non-bilious vomiting is seen in virtually all patients. Patients also often develop a hypokalemic, hypochloremic metabolic alkalosis from the persistent vomiting. remeber if they give a child with intermittent spitting up think about pyloric stenosis. 7.abrupt onset of colicky abdominal pain in childeren <2 years ,think about intussusception! what's the etiology? The exact cause is unknown. However, it is associated with Meckel's diverticulum, cystic fibrosis, polyps, and Henoch-Schonlein purpura. remeber A barium enema or air enema is both diagnostic and therapeutic. 8.Remember In any patient with dysphagia that is progressive for only solids, it suggests a growing and obstructive lesion. The history of tobacco and alcohol use, puts person at a much higher risk of carcinoma. The two ways to diagnose this are a barium swallow study, which will show the mucosal mass, or an upper endoscopy study to directly visualize and biopsy the lesion. 9.Remember Esophageal manometry is used to evaluate dysphagia caused by motility disorders. These typically present with dysphagia for solids and liquids and may or may not be progressive. 10.Incarcerated or strangulated hernias in an elderly patient can cause acute abdomen, dehydration, and altered mental status. 11.. Frequent, greasy, malodorous stools are a result of steatorrhea from chronic pancreatitis. This happens from the lack of pancreatic enzymes. Non-enteric coated pancreatic enzyme supplements with concurrent H2 blockers will deliver active enzymes to the proximal small bowel and help reduce malabsorption and steatorrhea. 12.. Acute acalculous cholecystitis is characterized by fever, nausea and vomiting, right upper quadrant abdominal pain, and inspiratory arrest on palpation of the right upper quadrant (Murphy's sign). An elevated leukocyte count is usually present. Gallstones are not present and it is usually associated with trauma, burn, surgery, diabetes mellitus, and bacterial infections of the gallbladder. BUT biliary colic, which is characterized by crampy, right upper quadrant abdominal pain that may radiate to the back and often follows a meal. Nausea and vomiting may be present. Fever, chills, and leukocytosis are notably absent. Gallstones are present on an ultrasound. 13.Acute cholangitis is characterized by fever, right upper quadrant pain, and jaundice (Charcot's triad). 14.The hallmark of mesenteric ischemia is pain out of proportion to physical exam findings. Mesenteric ischemia is especially likely in a patient with known vascular disease and a history of cigarette smoking. The next diagnostic step is a mesenteric angiogram. The superior mesenteric artery is the most often compromised vessel. 15. Patients with ulcerative colitis are at high risk for toxic megacolon, which is also associated with Clostridium difficile colitis 16.. Toxic megacolon presents clinically as abdominal distension and bowel motility disturbances. The next step in evaluation is an abdominal radiograph which will demonstrate a distended large bowel. 17.spontaneous bacterial peritonitis. This diagnosis should be first on your list in any patient with ascites who presents with fevers, abdominal pain, change in mental status, or with other non-specific complaints. These patients need to have a paracentesis. This fluid is then sent to the lab for a cell count, culture, and Gram stain. The diagnosis of SBP can be made by seeing bacteria on a Gram stain, having more than 500 WBC or 250 PMNs in the cell count, or a positive peritoneal fluid culture. Patients with SBP need to be started on a third-generation cephalosporin 18.. Lead levels over 10 mg/dL are considered abnormal. 19.Remeber Fluoxetine is a serotonin reuptake inhibitor that requires 5 weeks to reach a steady state in the body and takes approximately 6-8 weeks to show an adequate response. This should be explained to patients before and during treatment to help them understand the importance of staying on the medication even though they do not feel any effects. 20.congenital diaphragmatic hernia, which is when the abdominal contents herniate into the left hemithorax through a congenital defect in the left hemidiaphragm. This causes displacement of the heart into the right hemithorax and pulmonary hypoplasia. 21 key finding for Esophageal atresia with distal tracheoesophageal fistula usually presents with a history of polyhydramnios, cyanosis with feeding, and increased oropharyngeal secretions. 22.Remember in a traumatic lumbar puncture even though the CSF is initially red, the supernatant of the centrifuged cerebrospinal fluid is clear. This means that the red blood cells have not yet had a chance to lyse and release their intracellular contents into the cerebrospinal fluid. BUT in subarachnoid hemorrhage there would be blood in the CSF, the supernatant of the centrifuged fluid would be xanthochromatic (yellow) due to the lysis of red blood cells and the release of their intracellular contents into the cerebrospinal fluid. 23.The symptoms of crampy abdominal pain and watery, explosive, secretory diarrhea are consistent with enterotoxic E. coli. the cause of traveler's diarrhea ,treatment ciprofloxacin if symptoms persistent. 24.The symptoms of Giardiasis, which usually occur about a week after exposure, include flatus, loose stools, diarrhea, abdominal pain, bloating, and vomiting. The usual scenario for a healthy person that develops this infection is the onset of these symptoms after a camping trip. tx:metronidazole 25.infectious mononucleosis typically presents with a few-week history of fatigue, malaise, and a sore throat. Examination often shows pharyngeal edema, erythema, and palatal petechiae, lymphadenopathy, and splenomegaly. Hepatomegaly may also occur. 26.Hyperthyroidism during pregnancy is treated with propylthiouracil, which crosses the placenta less than other medicines such as methimazole. It should be given in the lowest effective dose and tapered as the patient becomes euthyroid. Untreated severe hyperthyroidism during pregnancy has been associated with spontaneous abortion and premature labor. 27.Remember sudden onset of right upper quadrant pain associated with nausea and vomiting and history right upper quadrant and epigastric pain before, associated with food intake. These symptoms are classical for a perforated peptic ulcer. In a perforated peptic ulcer, a patient can still have right upper quadrant localized tenderness, a thickened gallbladder wall, and pericholecystic fluid from the perforated ulcer. Hence, with any abdominal pain associated with signs, abdominal x-rays both erect and supine are very essential in the initial evaluation to rule out any free air. 28.The first line in treatment of panic disorder is selective serotonin reuptake inhibitors (SSRIs), a group of medications including sertraline, paroxetine, fluoxetine, and citalopram. . 29.Remember Surveillance colonoscopies are generally recommended every 6 months for 2 years beginning after 8 to 10 years duration of ulcerative colitis. 30.The presence of endocervical cells on a Pap test is regarded as evidence of adequate sampling of the transformation zone during cytologic screening of the cervix. When these cells are absent, it indicates that this area may not have been sampled. This is considered a satisfactory, but limited smear. In patients with no known risk factors (i.e., prior abnormal Pap test, multiple sexual partners, smoking) the American College of Obstetricians and Gynecologists recommends that the physician may defer to repeating the Pap test in 12 months even if the sample is not adequ 31.in superior vena cava syndrome (SVCS), which is due to obstruction of the superior vena cava. The vast majority of cases of SVCS are caused by malignancies, with lung cancer being the most common. The most feared complication of SVCS is upper airway obstruction. Radiation therapy is the treatment of choice for most patients with SVCS. 32.Remember in patients with known lung cancer, a biopsy of the mass causing the SVCS is usually not necessary and treatment can commence once the clinical diagnosis is made. In patients without a history of cancer, every effort should be made to obtain a diagnosis before starting treatment, as there are benign causes of SVCS (e.g., thyroid enlargement, thrombosis). 33.Pregnancy is characterized by increased alkaline phosphatase being secreted from the placenta. Alkaline phosphatase is usually secreted by biliary canalicular cells, placenta, bone, and intestinal mucosal cells. Hence, raised alkaline phosphatase is a normal value in growing children and pregnant women. 34.Acneiform eruptions is characterized by papules and pustules resembling acne lesions. The eruptions are distinguished by their sudden onset. Oral medications such as iodides, bromides, testosterone, cyclosporine, antiepileptic medications, lithium, and systemic corticosteroids are common agents that can lead to acneiform eruption. When medium or high doses of corticosteroids are taken for as short a time as 3-5 days, a distinctive eruption may occur, known as steroid acne. It is a sudden out-cropping of inflamed papules, most numerous on the upper trunk and arms, but also seen on the face. The lesions typically present as papules rather than comedones. Tretinoin cream applied once or twice daily may clear the lesions within 1-3 months, despite the continuation of high doses of corticosteroid. 35.The management of hematuria associated with trauma differs in adults and children. In the adult population, imaging is performed only in those patients with gross hematuria or microscopic hematuria plus hypotension. This differs from the pediatric patient. In children, any degree of hematuria (gross or microscopic) should be investigated with imaging studies. One reason for this discrepancy is that large amounts of catecholamines released in injured children may sustain blood pressure in the face of hypovolemia. A CT scan is the most useful imaging modality in this setting. A CT is noninvasive, accurate and fast, and it can help in assessing the size and extent of retroperitoneal hematomas and renal parenchymal trauma. 36. Remeber anterior uveitis is associated with sarcoidosis. Anterior uveitis is usually marked by the abrupt onset of pain and photophobia. Specifically anterior uveitis causes iritis and iridocyclitis. Constriction of the pupil causes increased pain. Slit-lamp examination is diagnostic, showing inflammatory cells in the aqueous humor or deposited along the corneal endothelium. 37.Many diseases are associated with anterior uveitis, including sarcoidosis and the seronegative spondyloarthropathies, including ankylosing spondylitis, psoriasis, inflammatory bowel disease, and BehÃ§et's disease. Infectious disease may also cause uveitis. Some of the associated infections include herpesviruses, tuberculosis, onchocerciasis, and leprosy. In the majority of cases, uveitis is idiopathic. Treatment should include topical corticosteroids to decrease inflammation and mydriatics because dilation of the pupil decreases pain and the formation of synechiae. 38. hyperventilation causes a mild respiratory alkalosis and is experienced as acral and periorbital dysesthesias.(tingling sensation in the fingertips.) 39.Remember treatment of CMV retinitis in HIV if Gancyvlovier dosen't work is FOSCARNET(can cuase renal toxicity). 40.Asperger disorder it's characterized by defecits in interpersonal development,restricted patterns of interest&behaivior,and normal cognitive and speech development. 41.Spondylolysis is a defect seen in the pars interarticularis portion of the lamina.Spondylolysis is believed to be caused by repeated microtrauma, resulting in stress fracture of the pars interarticularis. Heredity also is believed to be a factor. Patients with spina bifida occulta have an increased risk for spondylolysis. Approximately 95% of cases of spondylolysis occur at the L5 level.Athletes who participate in sports, such as soccer, baseball, football, wrestling, gymnastics, and tennis, are more likely to have symptomatic spondylolysis at some point(with hyperextension maneuvers) 42.Patients with suspected spondylolysis should be evaluated initially with plain radiography, consisting of anteroposterior, lateral, and oblique views of the lumbar spine. The lateral views are most sensitive for detection of pars fractures, and the oblique views are most specific. 43..Remember The sudden onset of tachycardia and hypotension in a patient who is being mechanically ventilated with positive pressure, is at increased risk of a bullous rupture from barotrauma, leading to a pneumothorax, 44.young age, occurrence of pain at night, negativity of rheumatoid factor, and especially, bilateral involvement of sacroiliac joints are consistent with ankylosing spondylitis. 45.Ankylosing spondylitis should be suspected in any young person complaining of chronic lower back pain and confirmed by radiographs or CT scans of sacroiliac joints. The disease usually progresses to involve the whole vertebral column, producing ankylosis and respiratory failure secondary to restrictive lung disease. Uveitis and aortic insufficiency are additional manifestations. 46.Still disease is a rare systemic form of arthritis with onset before age 17. It manifests with spiking fever and systemic symptoms that usually antedate arthritis. Associated manifestations include a morbilliform rash, hepatosplenomegaly, serositis, anemia, and leukocytosis. 47.whenever the terms "coin-shaped" or "discoid" are used to describe a patient's skin lesions in a question you should think about nummular dermatitis. 48.Remeber symptoms of congestive heart failure and possible atrial fibrillation, as demonstrated by irregularly irregular heartbeat in question(they never mention stright forward A.F). In addition, are at high risk for the development of an embolic occlusion of the superior mesenteric artery. These patients will present with severe pain out of proportion to their objective physical findings. The diagnosis should be suspected clinically, and immediate superior mesenteric arteriogram should be performed. If evidence of ischemia is confirmed, the patient should proceed to exploratory laparotomy to evaluate for intestinal ischemia and possible gangrenous bowel. 49.BUT Ischemic colitis will usually present as diarrhea, often bloody, in elderly patients with known atherosclerotic heart disease. 50.malignant external otitis, This form is specifically caused by Pseudomonas aeruginosa, and tends to affect elderly diabetics and AIDS patients, causing the findings in the severe and persistent earache. Otoscopic examination demonstrates foul-smelling purulent otorrhea and a red mass lesion of the external ear canal. Biopsy of the mass demonstrates granulation tissue rather than tumor. 51.Headache of sudden onset ("thunderclap" headache), rapid deterioration of mental status and blood in the CSF are virtually diagnostic of ruptured berry aneurysms. Note the characteristic hyperdensity on CT of the suprasellar cistern, indicating blood in the subarachnoid space. Rupture of a berry aneurysm is the most common cause of subarachnoid bleeding. 52.PBC is due to an autoimmune destruction of intrahepatic bile ductules, and the diagnosis is made by liver biopsy. The serology that should be checked is the antimitochondrial antibody. Primary biliary cirrhosis is often seen in individuals with other autoimmune diseases, such as SjÃ¶gren syndrome, pernicious anemia, and Hashimoto thyroiditis. 53.Myasthenia gravis is an autoimmune disease in which antibodies directed against the acetylcholine receptor of the muscle side of the neuromuscular junction block the ability of the receptor to bind to acetylcholine. Remember insulin resistance is also produced by a similar mechanism, i.e. antibodies to insulin receptors block the receptors' ability to bind to insulin 54.The first step in the approach to a patient with a community-acquired pneumonia is to categorize condition according to the American Thoracic Society guidelines (1993), which are based on severity of illness, age, comorbidities, and the need for hospitalization. the criteria for hospitalization (one of the following is needed: respiratory rate > 30 breaths/min, room air PaO2< 60 mm Hg, O2 saturation less than 90% on room air, or bilateral or multiple lobes involved), and older than 60 years. 55.normal value for the anion gap is 12 Â± 4 mEq/L. Causes of increased anion gap include conditions that produce ketoacidosis (diabetes mellitus, alcoholism, starvation), renal failure with retained sulfate and phosphate, drugs or metabolites (salicylate or ethylene glycol poisoning), alkalosis with increased negative charge of protein anions, and dehydration (hemoconcentration). 56.Remember Subcutaneous unfractionated heparin is used for prevention of DVT in immobile patients or in hospitalized patients unable to ambulate. However, after orthopedic surgery, especially after joint procedures, its efficacy is very poor, given the increased venous stasis ,you should use warfarin. 57.Remember Both chronic laxative use and chronic diuretic use can produce hypokalemia. Severe hypokalemia, with plasma potassium <3 mEq/L, can markedly affect skeletal, smooth, and cardiac muscles. Skeletal muscle effects can include weakness, cramping, fasciculations, paralysis (with risk of respiratory failure), tetany, and rhabdomyolysis. Smooth muscle effects include hypotension and paralytic ileus. Cardiac muscle effects include premature ventricular and atrial contractions, tachyarrhythmias, and AV block. Additional ECG changes can include ST segment depression, increased U wave amplitude, and T wave amplitude less than U wave. 58.Basal cell carcinoma affects sun-exposed areas, particularly the mid and upper face, in patients lacking protective pigmentation. One of its morphologic forms is that of a raised, waxy, pale lesion that grows very slowly and doesn't metastasize to lymph nodes. 59.Key for Keratoacanthoma : grows very rapidly in a matter of weeks and has a scaly, rough appearance, with a core of keratin. If untreated, it eventually sloughs off. 60.Squamous cell carcinoma is usually an ulcer, rather than a nodule. In the face, it favors the lower lip. If present for several years, lymph node metastasis can sometimes occur. 61.euthyroid sick syndrome, which occurs in many seriously ill patients who do not have clinical hypothyroidism. especially in ICU 61. The TSH level is usually most helpful in distinguishing euthyroid sick syndrome from true hypothyroidism, as it often above 30 mU/mL in true hypothyroidism and may be below normal, normal, or minimally elevated in euthyroid sick syndrome. Disproportionately decreased T3 is also typical of euthyroid sick syndrome, and T4 may be normal or decreased. 62.Remember hepatorenal syndrome occurs during the end stages of cirrhosis and is characterized by diminished urine output and low urinary sodium. In the setting of end-stage liver disease, renal vasoconstriction occurs, and the distal convoluted tubule responds by conserving sodium. Unless the renal function is allowed to deteriorate further, liver transplantation will reverse this vasoconstriction and kidney function will return to normal. then when ever you have cirrhosis with reanal faiuler the most appropriate treatment is LIVER TRANSPALNTION! 63.In beta thalassemia, a reduced production of beta chains occurs with normal amounts of alpha production 64.A shock-like pain upon percussion on the volar aspect of the wrist (Tinel sign) is a characteristic sign of Carpal tunnel syndrome ,,is most often idiopathic, but may represent a manifestation of underlying disorders such as rheumatoid arthritis, sarcoidosis, amyloidosis, acromegaly, and leukemia. 65.Fibrositis , also known as fibromyalgia, refers to a poorly understood syndrome of widespread musculoskeletal pain associated with tenderness in multiple trigger points. Fatigue, headache, and numbness are also common. Women between 20 and 50 years of age are most commonly affected. Neck, shoulders, low back and hips are usually involved. 66.Reflex sympathetic dystrophy describes a syndrome of pain and swelling of one extremity (most commonly a hand), associated with skin atrophy. It is thought to be secondary to vasomotor instability. Sometimes, it follows injuries to the shoulder (shoulder-hand variant). 67.Femoral pseudoaneurysms represent an important vascular complication of cardiac catheterization. The combination of a pulsatile mass, femoral bruit, and compromised distal pulses make this diagnosis likely. The diagnosis can be confirmed by ultrasound of the groin.(it was exam question of one of my friend). 68.Cholesterol emboli syndrome is also an important complication to recognize in the post-catheterization patient. It usually presents, however, with skin findings in the distal extremities of livedo reticularis, ischemic ulcerations, cyanosis, gangrene, or subcutaneous nodules. 69.Remember Another important complication of cardiac catheterization via the femoral artery is a retroperitoneal bleed . This complication presents, however, as either new back pain, an unexplained drop in the hematocrit, or purpura over the flanks. 70.what is piriformis syndrome?? As you may recall from your anatomy, the piriformis is the small muscle that crosses the greater sciatic foramen, cutting it into two spaces as the muscle passes from the edge of the sacrum to the greater trochanter. The sciatic nerve comes out of the greater sciatic foramen below the piriformis, and is liable to compression by the muscle. Symptoms are as described above; bicycle riding and running may also set off the symptoms, which may take the form of chronic nagging ache, pain, tingling, or numbness. Treatment is usually to teach the patient to avoid maneuvers that set off the symptoms. Some patients have been helped by corticosteroid injection near the site where the piriformis muscle crosses the sciatic nerve; this therapy is thought to work by reducing the fat around the muscle and thereby increasing the available space in the area. 71.in Adison disease Laboratory findings include hyponatremia (due to aldosterone deficiency), hyperkalemia, and normocytic anemia with eosinophilia and lymphocytosis. The diagnosis is made with the ACTH stimulation test. Cortisol and aldosterone levels do not increase when the ACTH is given. The treatment is glucocorticoid and mineralocorticoid replacement. 72.HIV encephalitis, clinically known as AIDS dementia complex, . The pathologic substrate is a subacute inflammatory infiltration of the brain caused by direct spread of HIV to the CNS. 73. The diagnosis of HIV encephalitis (or AIDS dementia complex) must be reached by exclusion of other infective and neoplastic conditions associated with AIDS. AIDS dementia complex is characterized by cognitive impairment, incontinence, impairment of motor skills, and confusion. MRI studies and CSF analysis are useful in excluding other CNS diseases . 74.HIV myelopathy manifests mainly with spastic paraparesis. It is a complication similar in pathologic substrate to vitamin B12 deficiency, i.e., vacuolar degeneration of the posterior and lateral columns of the spinal cord. 75.Progressive multifocal leukoencephalopathy consists of multifocal areas of myelin destruction. These changes would be visible on MRI. This complication is due to JC virus, a papovavirus that causes asymptomatic infections in immunocompetent individuals. 76.Patients with longstanding extensive ulcerative colitis for at least 10 years' duration are at increased colon cancer risk. Appropriate surveillance involves annual or biannual colonoscopy with multiple biopsies at regular intervals, even of normal appearing mucosa, to check for dysplasia 77.Individuals with herpes zoster are contagious and can spread the VZV virus. 78.Decreased esophageal peristalsis and decreased LES pressure :SCLERODERMA , These patients are therefore at risk for severe GERD and subsequent complications of peptic stricture and Barrett's esophagus. 79.Patients with this erythema infectiosum (Fifth disease) are only infectious before the onset of the rash, during the period with the nonspecific febrile illness. The virus typically only causes a significant, severe illness in individuals with sickle cell disease and other hemoglobinopathies. In rare cases, parvovirus contracted during pregnancy has been associated with fetal hydrops and death. 80.If a pergnant woman was in contact with a patient with fifth disease during the phase of the illness before the onset of the rash, she should have serologic testing and a fetal ultrasound to evaluate the health of her and the baby. It should be mentioned that the complications of parvovirus in pregnant women typically occur during the first half of pregnancy. 81.Most authorities think that it is appropriate to initiate a progestin-only method of contraception immediately postpartum. It has no impact on lactation or the quality of breast milk. 82.The triad of miosis, respiratory depression, and coma is suggestive of opioid intoxication 83.Phenelzine is an antidepressant monoamine oxidase inhibitor (MAOI) that causes hypertensive crises and the serotonin syndrome (hypertension, tachycardia, fever, coma, and possibly death) when combined with tyramine-containing food (cheese) and serotonin-altering drugs.Pseudoephedrine and other nasal decongestants, bronchodilators, amphetamines can cause severe hypertension when monoamine oxidase is inhibited and should be avoid. 84.the classic signs of chronic plaque psoriasis are silvery or pink well-defined plaques, which can span the whole body from the scalp to the feet. The most classically involved areas include the scalp, ears, elbows, knees, sacrum and ankles. 85.Fiberoptic bronchoscopy is part of the evaluation of a patient with hemoptysis, but it is typically performed after a chest x-ray. It is the next step if a chest x-ray shows a mass, if the chest x-ray is normal and there are major risk factors for cancer, or if the chest x-ray is normal and there are no risk factors for cancer, but there is a recurrence of hemoptysis after weeks to months of observation. then remeber if you have a patient with hemoptysis with past history of smoking ,your first step is CXR even if he/she is normal right now!but!!!!!!!Keep in mind that a chest x-ray is not part of a routine physical examination of an asymptomatic smoker. 86.Complications of ovarian torsion include infection, peritonitis, sepsis, adhesions, chronic pelvic pain, and infertility due to the loss of the viability of the torsed ovary. 87.Remember One of the most important considerations in evaluating patients with conjunctivitis is to rule out any vision-threatening conditions such as iritis, keratitis, glaucoma, or a corneal ulceration. Symptoms such as marked photophobia, decreased visual acuity, or globe pain suggest that ocular structures other than the conjunctiva are involved and should trigger immediate ophthalmologic evaluation. 88.The pathophysiology of ITP: involves antibody (IgG or IgM) binding to platelets. These antibody- coated platelets are subsequently destroyed in the spleen. 89.Remember an extremely important aspect of management of the asplenic patient includes permanent penicillin prophylaxis in addition to pneumococcal and Haemophilus influenza vaccines. These measures decrease the risk of morbidity and mortality associated with overwhelming sepsis by encapsulated organisms in asplenic patients. 90.Multifocal glioblastoma multiforme (GBM) , the most frequent malignant primary brain neoplasm, manifests as an ill-defined mass in the white matter. 91.Wernicke encephalopathy is characterized by nystagmus progressing to ophthalmoplegia, truncal ataxia and confusion. 92.Korsakoff syndrome refers to alcohol-related amnesia and confabulation. Wernicke-Korsakoff syndrome is due to vitamin B1 deficiency, which is often seen in chronic alcoholics. This deficiency results in degeneration of periaqueductal gray matter. 93.Remember Huntington disease autosomal dominant condition is caused by an unstable expansion of a CAG trinucleotide repeat and MRI examination of the brain reveals hyperintensity in the region of the caudate on T2-weighted images. 94.The pathologic substrate of this condition(Huntington disease ) is degeneration of the striatal neurons, especially those in the caudate nucleus. 95.the pathogenesis of stress-induced gastritisiffuse gastric mucosal vasoconstriction 96.Right-sided endocardial fibrosis, with pulmonary stenosis and tricuspid regurgitation, is common in carcinoid patients and is the result of toxic damage to the heart 97.Ondansetron, a 5-hydroxytryptamine3 antagonist, is the most potent antiemetic available for chemotherapy-induced vomiting.It has side effects only infrequently, the most common being constipation. 98.Copper deficiency can present with anemia and neutropenia, Zinc deficeincy will present with alopecia, impaired wound healing , dermaititis, selenium def will present with dilated cardiomyopathy 99.Bernard-Soulier syndrome is an autosomal recessive disease of platelet adhesion which causes prolonged bleeding times in the presence of normal platelet counts. These patients' platelets cannot bind to subendothelial collagen properly because of a deficiency or dysfunction of the glycoprotein Ib-IX complex. Clinically the patients have impaired hemostasis and recurrent severe mucosal hemorrhage. The only treatment for an acute episode is a transfusion of normal platelets. This patient has a slightly decreased hemoglobin due to blood loss. 100.Von Willebrand's disease causes increased bleeding times with normal platelet counts. It is the most common inherited bleeding disorder, caused by a defect in von Willebrand factor, which aids the binding of platelets to collagen. Even though the platelets themselves are normal, binding is impaired, thus a platelet transfusion would not correct the problem. Cryoprecipitate, a plasma fraction rich in von Willebrand factor, would help in the case of von Willebrand's disease, but would not help with Bernard-Soulier syndrome. Coarctations account for approximately 7% of congenital cardiac abnormalities, occur more frequently (2x) in men than in women, and are associated with gonadal dysgenesis and bicuspid aortic valves. Adults will present with hypertension, manifestations of hypertension in the upper body (headache, epistaxis), or leg claudication. Physical examination reveals diminished and/or delayed lower extremity pulses, enlarged collateral vessels in the upper body, or reduced development of the lower extremities.