SOME IMPORTANT POINTS

Discussion in 'Australian Medical Council (AMC) EXAM' started by Guest, Jun 25, 2006.

  1. Guest

    Guest Guest

    SOME IMPORTANT POINTS have 2 know

    GASTROENTEROLOGY

    Vitamin A Night blindness, conjunctival dryness, corneal keratinization

    Vitamin D Ricketts - kids, long bone bowing; Osteomalacia-adults, demineralization

    Vitamin K Clotting deficiency with prolonged PT

    Thiamine (B1) Beriberi - peripheral neuropathy, Cardiomyopathy - dry or wet (high output failure)
    Wernicke-Korsakoff - Alcoholics, confabulation, nystagmus, confusion

    Niacin Pellagra - Diarrhea, dermatitis, dementia, death

    Pyroxidone (B6) Rare, neuropathy, Cheilosis (swollen cracked bright red lips)

    Cobalamin (B12) Macrocytosis, Pernicious Anemia- megaloblastic, neuro chg. ataxia, Schilling test , more in Strict Vegitarian.

    Folate Macrocytosis, megaloblastic anemia w/o neuro chgs., common in alcoholics

    Vitamin C Scurvy, bleeding gums, Connective Tissue problems, Can manifest 1 yr post defic.

    Failure to Thrive Org.= decr. wt gain w/ other disease; Nonorg.=growth failure due to neglect ßstimulation
    < 80% wt for Ht

    Obesity mild 20-40%, moderate 41-100, severe <101%; age, black women, low income
    BMI= body wt (kg)/Ht (mm2) Normal 20-25
    Pickwickian Syndrome = obesity, dyspnea, hypovent, CO2 retention, hypoxia

    Boerhaave's Syndrome esophageal rupture due to forceful vomit; Gastromediastinal fistula, dyspnea w/o hemetemesis, + Hammonds sign = pneumomediastinum, L lung effusion

    Dysphagia Obstructive - solids 1st; Motor -solids = liquids

    Infectious Esophagitis Candida (thrush), HSV, CMV, immunocomp, diabetics, Dysphagia & odynophagia

    Esophageal Atresia Proximal esophagus, blind pouch

    Trachesoph Fistula Congenital defect, distal esoph, coughing & cyanosis when feeding, abd distention

    Achalasia Dysphagia for solids & liquids, nocturnal cough, aspiration; Absent peristalsis & tight LES, "Beak" esoph on x-ray, 20-40 yrs old

    Esophageal Cancer squamous 90% Dysphagia solids 1st, Cough & hoarse = laryngeal nerve, constricting bands = annular lesion, Risk factors= smoking, alcohol, GERD, Barretts Esoph = adeno CA

    Gastritis Antral Creep=fundal tissue replaced by antral mucosa, Not preCA,
    Risk Factors = NSAIDS, Alcohol, H.Pylori

    PUD Gastric = NSAIDS, eating no help, COPD,blood type A; 25%
    Duodenal = H.Pylori, better w/ food, Liver cirrhosis, Blood type O ; 75%

    Cullen's Sign Periumbilical cyanosis d/t hemoperitoneum = hemorrhagic pancreatitis, ruptured ectopic, ruptured spleen

    Zollinger-Ellison Synd. Gastrinoma ( incr. gastrin); recurrent ulcers, ½ are malignant

    Gastric CA Adeno, H.Pylori gastritis, Virchow's Nodes, Types = ulcerating (shallow edges); polyploid (intraluminal late mets); superficial (early CA) ; Linitus Plastica (all layers decr. elasticity) Mets to ovary = Krukenberg Tumor

    Diarrhea Osmotic = incr. H2O lumen incr. solutes in bowel; Secretory = electrolytes & H2O secreted not absorbed; Malabsorption; Exudative secretion of blood plasma & mucus (mucosal inflammation); decr. transit time (short bowel); incr. transit (bact. Proliferation)

    Ischemic Colitis Vascular compromise (atherosclerotic or embolic); abrupt abd pain after eating, bloody diarrhea, systemic sx.; Barium X-Ray - Thumbprint = pseudo tumor

    Irritable Bowel Synd. Dx of exclusion (psych?); Tx: bulk supp, anticholinergics, antidiarrheals, TCA

    Colonic Polyps villous>tubular ; sessile>pedunculated for being CA; familial adeno polyps autodom.

    Lactose Intolerance Lactase deficiency, bloating & explosive diarrhea after milk; Ages 10-20

    Celiac Sprue Gluten sensitivity (wheat, rye, barley); amenorrhea 1st sx girls, Infants = FTT, abnormal stool, bloating, Adults = malabsorption, vit deficiency; X-ray - dilated loops of bowel with thin mucosal folds; most common cause of malbsorption

    Tropical Sprue nutritional defic, small bowel mucosal abnormal; Acquired - Caribbean, India, SE Asia; Megaloblastic Anemia, glossitis, diarrhea, wt loss Tx Folic Acid & Tetracycline

    Whipple's Disease Infectious; middle aged men; multi-organ; Thickened mucosal folds, Foamy macrophage with rod shaped bacilli that stain w/periodic acid (Schiff's Reagent)

    Intestinal Lymphangiectasia Children & young adults; cong or acquired telangiectasia of intramucosal lymphatic
    Massive extremity edema w/ diarrhea, N/V; Tx: low fat w/ triglyceride supplement

    Toxic Megacolon Dilation > 6cm, Adults preceded by IBD (UC or Crohn's) Kids preceded by Hirschsprungs Ds; Sx: severely ill, incr. temp, abd pain, rebound, leukocytosis; X-ray - intraluminal gas along continuous seg of dilated bowel; Tx: NPO, IV fluids & electrolytes, Antibiotics & Steroids, Rectal tube may alleviate but can cause perforation

    Inguinal Hernia Indirect = infants, persistent processus vaginalis, protrudes thru ring, lateral Inf Epig.
    Direct = Adults, medial to ing ring & inf epig artery, Weakness in Hesselbach's

    Ulcerative Colitis Colon & Terminal Ileum w/o skip lesions, w/ rectal bleeding, "lead Pipe" on X-ray (shortened, narrowed, loses haustrations) Tx: Sulfasalazine, steroids, Immunosuppresents; Complications=perf, hemorrhage, Toxic Megacolon, Colon CA

    Diverticular Disease Diverticulosis = false diverticulae, pearl sign on xray
    Diverticulitis = infection, acute abd pain usually on left, may form fistulas to bladder, vagina or skin, CT w/ water soluble contrast during acute attack

    Crohn's Disease Granulomatous colitis; No bloody stools, 1st in terminal ileum, transmural, skip lesions, cobblestoning: Complications=small bowel abscess, obstruction, perianal disease, malabsorption, toxic megacolo, Colon CA. Surgery is not curative

    Colon CA Right Sided=napkin ring, anemia Left Sided=Apple core, pencil stools; Genetic; Annual rectal>40, Annual Guaiac >50; Flex Sig q3-5y >50; Rectal CA-hematochezia

    Volvulus Rotation of Bowel; Newborns & elderly; Double Bubble; Birds Beak on Barium Enema, Tx: Left Sided = decompression; Rt sided & kids = surgery

    Intussusception Telescoping of large bowel into an adjacent section; most common cause of obstruction in kids under 2; Episodic Abd pain 1-2 min. Reflex = early vomit; Obstructive = omit late; Currant Jelly Stool; Small Infants = Pallor, sweating, and vomiting. Leukocytosis with hemoconcentration, BE to reduce x 2 before surgery

    Necrotizing Enterocolitis Premature, decr. birth weight, older infants with malnutrition; bilious vomit, abd distention, bloody stool, lethargy; Thrombocytopenia; Small Bowel Distention; pneumatosis (air in bowel wall) TX; NG, TPN, IV antibiotics, surgical Rx necrotic part

    Cholera Fecal - Oral, Rice Water Stools, Vibro Cholera; Endemic gulfcoast, Asia, Africa, Mid East; Severe dehydration, Metabolic Acidosis, Tx: Tetracycline or Doxycycline

    Shigella Dysentery Small bact dose needed, Blood & mucous, Kids worse than adults, Fluid Replacement & Ciprofloxacin

    Staph Enteritis Onset 3-6 hrs; "Church Picnic epidemic; N/V/D, HA, fever recovery w/in 24 hrs

    Salmonella Enteritis Undercooked Poultry; nausea & cramps => watery &/or bloody diarrhea; No antibiotics prolongs excretion of the organism

    Viral Enteritis Norwalk = yr round, Rota (kids) = winter; Coxsackie A1; echo, adeno

    Botulism Clostridium Botulinum, neuromuscular; onset 12-36 hrs; N/V/D, cranial nerve palsy, fixed dilated pupils, resp failure, no fever, Wound induced = neuro w/o gi sx
    Infants constipation 1st=> cranial nerve sx => cranial nerve Sx => Neuromuscular

    Hemorrhagic Colitis E coli 157, cramps, => watery diarrhea => bloody diarrhea Complications= Hemolytic-Uremic Syndrome, thrombotic thrombocytopenic pupura

    Pseudomembraneous Colitis Antibiotic induced (clindamycin, ampicillin, cephalosporin) C. Diff; mail -> severe bloody diarrhea; Tx: stop antibiotics, oral metronidazole in severe cases

    Acute Pancreatitis Pain radiates to back w/ N/V; Grey Turner's Sign (blue flank) Cullen's Sign (blue at umbilicus; Amylase & Lipase incr. ;
    Ranson's Criteria: 3 or more = incr mortality
    Admission: >55, gluc>200, LDH >350, AST >250 WBC > 16000
    Within 48 hrs: Hct decr. 10%, BUN incr. >5, Ca< 8, PaO2 < 60, Base Def > 4, Fluid Seq>6L

    Chronic Pancreatitis ERCP to Dx; Alcoholics, Malabsorption & diabetes are results

    Hepatitis Hep A = Fecal oral, shedding before Sx; IG to travelers & contact with HAV infected
    Heb B= Blood & STD; HbsAg early if persists = carrier; HbcIGM then HbcIgG for life
    HBIG for needle sticks and infants born to + moms; assoc w/ hepatocell CA
    Hep C Most common post transfusion hepatitis
    Hep D = Co infection with B; Hep E = fecal oral

    Cholelithiasis Female, fertile, fat, forty; Ultrasound, RUQ pain after fatty meals, Calcified = preCA

    Cholangitis Charcot's Triad = Biliary Colic, Jaundice, Fever; Leukocytosis, incr. Alk Phos

    Hepatocellular CA Mets 2x more than primary CA (breast, lung, colon), Budd Chari-thrombosis hep V.
    Risk Factors = HBV, HCV, Alcoholic cirrhosis, Aflatoxins (fungal metabolites)

    Benign Hep Adenomas oral contraceptives

    Exocrine Pancreatic CA Ductal CA, Courvoiser's Law=palpable nontender GB in a jaundiced patient is a head of Pancreas tumor. Tumor Body or Tail=splenic vein obstruction=> splenomegaly, gastritis, esoph varices

    Insulinoma Insulin hypersecretion, hypoglycemic symptoms, Insulin levels still incr. after fasting
    Whipple Triad: confirms hypoglycemia as source of Sx 1. Hypoglycemia, 2. Relieved with carb ingestion 3. Sx occur while fasting

    VIPoma Makes Vasoactive peptide (VIP); Sx WDHA (watery diarrhea, hypokalemia, achlohydria; unexplained secretory diarrhea; laparoscopy for Dx

    Glucagonoma tumor of alpha islet cells; 80% women; 80% malignant; Necrolytic Exfoliating Erythema characteristic exfoliating lesion of the extremities

    Pompe's Disease a 1,4 glucosidase deficiency; fatal by age 2

    VonGierke's Disease glucose-6-phosphatase def.; big liver & kidneys, growth retardation, electrolyte prob.

    McArdles Disease musclephosphorylase is absent, muscle cramps & incr. myoglobin after exercise

    Jaundice Prehepatic = hemolysis, gilbert's disease, Crigler Najjar; Hepatic = hepatocellular or cholestatic; Post Hepatic = Biliary obstruction, AST & LDH also incr. ;
    incr. unconj prehepatic; incr. conj = intrahepatic cholestasis or post hepatic disease ; incr. all fractions = hepatocellular, hyperbilirubinuria = conj bili water soluble

    ETOH Hepatic Disease Fatty liver => ETOH hepatitis => cirrhosis; AST incr. > ALT incr. ; incr. PT; decr. II, VII, IX, X Clot

    Cirrhosis necrosis and fibrosis, decr. serum albumin, anemia incr. PT, Not curable or reversible

    Esophageal Varices veins that expand to circumvent congested hepatic flow; Tx: vasopressin, balloon tamponade, endoscopic sclerotherapy, transjugular hepatoporto shunt (TIPS

    Hepatic Encephalopathy altered consciousness, incr. ammonia incr. glutamine in CSF, EEG abnormal

    Ascites Complication of hepatic disease; Paracentesis to examine ascitic fluid values should equal serum if incr. albumin = malignant; incr. LDH > 60% of serum = malig or infective;
    incr. WBC = infection

    GI Bleeding Upper GI = melaena (black tarry) ; Lower GI = hematochezia (bright red) decr. Lig Trietz

    Intestinal Obstruction Vomiting common in small bowel, late in lg bowel, High pitched "tinkling" BS.
    X-ray - prox dist = lg bowel; dilated loops of bowel with air fluid levels = sm bowel

    Ileus Paralytic obstruction of bowel due to loss of peristalsis

    Pyloric Stenosis Projectile vomit in neonates, visible peristaltic wave, String Sign

    Meconium Ileus Abnormal thick Meconium with undigested protein, associated with CF

    Hirschsprung's Disease No autonomic nerves in colon, Obstipation, late vomit, Megacolon, Toxic Enterocolitis if left untreated, BE proximal dilated & distal narrow, Colostomy

    If it will help u guys just let me know I'll post rest of the systems
    Thxn 2 eaziz

    Cheers
  2. mrsali

    mrsali Guest

    very well!

    yep it does help to do quick brushing to overburdened memeory of ours to have somehing like this short and straight.
  3. Peter W

    Peter W Guest

    Thank you very much, they are very helpful. Waiting the rest of the list
  4. rex

    rex Guest

    thank you so much

    That was really beneficial.God save you.
  5. Guest

    Guest Guest

    help

    Dear all,
    i m doing my internship at nair hosp, mumbai..my internship will end in feb 2007..im planing to give the AMC-MCQ in march 2007..
    the AMC has given me FORM-A which requires a degree certificate amongst the various documents required.
    As you guys must be aware that we get the degree certificate and permanent registration only after finishing the internship..
    howevere after passing final mbbs they give us passing certificate and provisional registration certificate..
    will the passing certificate be eligible for the amc ?
    the degree certificate takes a lot of time to come as there are always procedural delays in the university.
    i may lose 6-7 months in the whole process.
    please guys help me and do reply..
    thankx
  6. Guest

    Guest Guest

    Here r all the systems that I have :D
    (sorry for late reply :cry: )
    ------------
    CARDIOVASCULAR
    Contraindications to BP meds Asthma/COPD = Bblockers, DM = Thiazides & Bblockers, Cardiac Failure = Bblockers & Ca Channel Blockers; Pregnancy = Thiazides & ACE

    Rheumatic Fever post strep infection, migratory arthritis, endocardits, subcutaneous nodules on extensor surface, chorea, erythema marginatum, incr. Sed, WBC & ASO

    ASD L=>R; Wide split & fixed S2; patent foramen ovale

    VSD L=>R; pansystolic murmur left sternal border, thrill; most common defect; Eisenmenger's Syndrome = shunt direction reversed due to incr. pulm vasc resistance

    Patent Ductus Arterio L=> R; Continuous machinery murmur; Indomethacin inject may close

    Tetralogy of Fallot VSD, RVH, Pulmonic Stenosis, Overriding Aorta

    Pulmonic Stenosis R=>L, Early systolic click, High pitched systolic ejection murmur, soft or absent S2

    Coarction of the Aorta HTN arms but not legs, murmur heard on back, X-ray scalloping of ribs,

    Bacterial Endocarditis Acute: S.aureus, Group A strep, N Gonh., Sub acute: Strep Viridans; New heart murmurs, petechia over incr. half of body, Splinter hemorrhages on fingernails, Osler's Nodules (nodules on fingertips) Roth's Spots (retinal hemorrhages)

    Noninfective Endocarditis Libman Sacks Disease associated with SLE

    Aortic Aneurysm Abdominal = pulsatile mass on exam, atherosclerosis, smoking HTN >4 cm = surgery Thoracic =Marfan's & syphilis >7c = surgery; Dissecting =split between medial & adventitial layers "ripping in chest" Normal EKG vs abnormal in MI

    Peripheral Vascular Disease Weak pulses, Atrophic skin, Little Hair growth, Nonhealing ulcers, intermittent claudication 5P's = pallor, pain, pulseless, parathesia, paralysis

    Raynaud's Phenomenon Pallor, cyanosis, erythema of fingers, most are idiopathic, others related to collagen vascular disease Tx vasodialators

    Heart Dysfunction Diastolic = difficulty filling ventricles; Systolic = problem ejecting blood from ventricle

    Polyarteritis Nodosa inflamed medium arteries->ischemia in tissues; men 3x> women, usually 40-50; Dx confirmed by biopsy or angiography showing aneurysm of medium arteries

    Giant Cell Arteritis Temporal Arteritis; women >50; severe temporal or occipital HA, Amaurosis Fugax (temp blindness 1 eye) Temporal artery swollen & tender, Dx confirmed by biopsy

    Cor Pulmonale COPD most common cause; Dyspnea & syncope on exertion, S/Sx Rt heart failure

    Mitral Stenosis Mitral facies = red rash on cheekbones, Loud S1 and opening snap after S2; Right heart failure TX with diuretics; LAH=>Pulm HTN=>RVH Bblockers & Ca Channel Blockers to decr. HR & preload; Progressive Dyspnea

    Mitral Regurge Midsystolic click; Harsh blowing holosystolic murmur; MVP; LAH & LVH; wide S2 that widens more with inspiration; Bblockers for Sx Valve replacement

    Aortic Stenosis Triad = Angina, Syncope & Dyspnea on exertion; Cong bicuspid valve, weak long pulse, LVH T wave invesions; Left sided failure; Bblockers decr. HR & incr. coronary flow

    Aortic Regurge Decrescendo murmur, widened pulse pressure, "Water Hammer Pulse" (rapid up & down stroke); "Pistol Shot over femoral Artery; 2o Austin Flint murmur= diastolic murmur as blood goes thru AV to hit MV. Kids = cong VSD w/ MVP

    Supraventricular Tachycardia Sudden attacks due to reentry rhythm, P on T on EKG; #1 AV Nodal Reentry #2 Wolff Parkinson White = reentry thru accessory muscle bundle, can cause V fib in a Pt with Afib; Torsades De Point is drug induced

    Left Sided Failure Dyspnea, Orthopnea, Paroxysmal nocturnal dyspnea, LVH

    Right Sided Failure Most common cause is Left sided failure; Neck vein distention, Liver big, Edema

    MI ST elevation, T wave inversion; CPK-MB 12 - 40 hr for peak; LDH peaks 3-6 days

    Congestive Cardiomyopathy Alcohol = chronic; Infection Coxsackie B or Trypanosoma cruzi (Chagas Disease)

    Hypertrophic Cardiomyopathy Cong or acquired VH with normal afterload; incr. venous pressure, JVD, ascites, edema, edema, pleural effusion, S4 on exam

    Chronic Pericardtis Causes right sided failure; Kussmaul's Sign ( incr. neck vein distention on exertion) Dyspnea on exertion and Orthopnea; pulsus paradoxus; Surg removal of pericardium is curative.

    Pericardial Effusion Friction rub, distant heart sounds, "water bottle" on x-ray; acute pericarditis = exudate; neoplasm or fibrosis =transudate; symmetrically enlarged cardiac silhouette

    Cardiac Tamponade Pulsus paradoxus, Kussmauls Absent; pericardial fluid compresses heart, Becks Triad = Hypotension, (ß decr. pulse pressure), JVD, Muffled heart signs

    Heart Murmurs AI: precordium, early diastolic, >S2, + heave; AS: 2nd R ICS & radiates to carotids, harsh, < S2; Diastolic = r/o malignancy, check BP both arms; MR: Apex radiates to axilla, + heave, assoc w/ sever anterior MI, endocarditis prophylaxisis; MS: Apex, late diastolic, opening snap after S2; MVP: Apex, blowing, holosystolic, incr. w/ valsalva; PR: 2nd L ICS, pulm HTN, clubbing, PE; PS: harsh; TR: 4th L ICS, incr. loud w/ inspiration; bounding JVD, pulsatile liver; VSD: loud holoystolic, assoc w/ Down's

    RESPIRATORY
    Peritonsillar Abscess uvula away; Head tilted toward, Trismus (can't open mouth)Strep or Bacteroides

    Epiglottitis H.flu type B, Insp. Stridor, Dysphagia with drooling, Thumbprint sign on xray

    Larengitracheitis Croup; Paraflu #1, RSV, Flu, barking cough, stridor hoarse, r/o epiglottitis

    Acute Bronchitis non smokers = M. pneumonia; smokers=S.pneumonia & H.flu

    Bronchiolitis Circumoral cyanosis (blue around mouth) RSV; kids < 2

    Strep Pneumonia Red-brown sputum, lobar pneumonia, most common adult community acquired
    Pneumovax vaccine = >65, immunocompromised, chronic disease

    H.Flu Pneumonia COPD, children, slow onset with URI sx 1st, patchy bronchial infiltration on xray

    Viral Pneumonia Most common cause in kids, flu like prodrome, patchy infiltrates; WBC not incr. a lot

    Klebsiella Pneumonia Alcoholics, aspiration, Currant Jelly Sputum, Encapsulated gram neg rod

    Staph Pneumonia Salmon colored sputum, Nosocomial, pneumatoceles on xray are pathognomic

    Mycoplasma Pneumonia atypical no cell wall to stain, young adults in close contact; xray worse than pt looks

    Pseudomonas Pneum. hospital acquired, CF, immunocompromised

    Legionella Pneumonia atypical, CNS & GI sx; confusion & ataxia, aerosolized water (air conditioning)

    TB fever, night sweats, wt loss, bloody sputum, Miliary = disseminated; Acid fast stain, PPD>10mm nonimmunocompromised; ppd>5mm AIDS; Extrapulmonary manifestations= meningitis, pericarditis, bone invasion (Pott's Disease)

    Bronchiectasis chronic destructive; dilation of bronchial tree, cough with incr. incr. incr. sputum, dyspnea, hemoptysis, Xray = incr. bronchial markings, "honeycombing"

    Emphysema Destroyed alveolar walls, Risks: smoking, alpha 1 antitrypsin deficiency;
    PFTS: ß decr. FEV1; decr. VC, FEV1/FVC < 60% normal

    Blue Bloaters Bronchitis>Emphysema; cough w/ mucous 3mos/yr x 2y; cyanosis, pulm HTN

    Pink Puffers Emphysema >Bronchitis; gradual dyspnea not hypoxic, underweight

    Cystic Fibrosis auto recessive, COPD, Pancreatic insufficiency; meconium illeus, incr. sweat chloride

    Sarcoidosis non caseating granulomatous, increased Calcium, ground glass, bilateral hilar & paratracheal adenopathy is pathognomic

    Asbestosis Increased risk of lung CA & mesothelioma, gradual dyspnea, nonproductive cough; no wheeze; diffuse linear opacities on xray

    Silicosis increased risk of TB, SiO2 inhalation; metal mining; multiple small nodules & calcification of hilar lymph nodes

    Resp Failure ABG=> PO2 50-60 mmHg; PCO2 >45 mmHg

    Laryngeal CA squamous cell, smoking & alcohol, hoarsness for several weeks

    Lung CA squamous>adeno>small(oat) cell; Squamous = hilar; Adeno = peripheral; Horner's Syndrome=invasion of the cervical symp. Ganglion= miosis, ptosis, anhydrosis
    Pancoast tumor = Horners + pain in arm or shoulder on affected side

    Asthma PFTs decr. FEV1; ABG resp alkalosis, decr. CO2; If CO2 incr. or normal resp failure imminet

    Massive Hemoptysis >600 ml blood in 24 hrs; trauma; PE, aortic aneurysm, heart failure

    Pneumothorax Spontaneous = 15-35 y/o males; Tension = pressure in pleural spaces; displaces heart & lungs (mediastinal shift) = surgical emergency

    ARDS acute lung injury with non-cardiogenic pulm edema, ABG =acute resp alkalosis (ßO2 & ßCO2; Xray =pulm edema with normal cardiac silhouette, Positive pressure or PEEP ventilatory support

    Pleural Effusions decr. tactile fremitus; dull; egophony (incr resonance; chg voice to high pitched)
    Transudates: <3g protein, Plasma/serum protein<0.5; Plasma/serum LDH <0.6 caused by CHF, cirrhosis, nephrotic syndrome
    Exudates:Reverse labs; neoplasms & infections; incr. triglycerides = chylous effusion; Pus = empyema (s. Aureus); Meiggs syndrome = pleural eff, ascites pelvic tumors)

    Pulmonary Edema Pink, frothy sputum, Kerley B lines on xray; Incr cardiac silhouette if cardiac origin

    Pulmonary Embolism DVT (iliac & femoral) V/Q useful, angiography is god std for dx

    RDS <37 wks gestation, Lung maturity: L/S ratio >2, + PG; Beclomethasone hastens maturity; artificial surfactant for kid

    Pulm HTN Primary = dx of exclusion; secondary valvular heart disease, L=>R shunt, chronic ateletasis (localized collapse of alveoli)

    ENDOCRINOLOGY
    Hypothyroid Weight gain, Lethargy, Coarse hair & dry skin, irregular menses, cold intolerance, myxedema; Acquired = Hashimoto's; Congenital = cretinism, severe I deficiency = hoarse cry; resp distress, cyanosis, poor feeding, decr bone growth, ßT4 incr. TSH
    Wolff Chaikoff effect = inhibition of thyroid hormone release due to high doses of I during thyroid scan

    Hyperthyroid 1. GRAVES: most common, autoimmune, antibodies bind to TSH receptors; incr thyroid hormone, pretibial myxedema, Incr radio I uptake
    2. SUBACUTE THYROIDITIS: tender, enlarged, Decr Radio I uptake, Sed Rate up, maybe followed by period of hypothyroid
    3. SILENT LYMPHOCYTIC THYRODITIS: transient, postpartum, no pain or fever, Radio I uptake decr, lymphocytic infiltration, Tx Bblockers
    4. TOXIC ADENOMA: multinodular goiter; nodules function autonomously, Excess T3 & T4; Scan shows a few hot spots with cold background
    5. THYROTOXICOSIS FACTITIA: exogenous thyroid hormone, no goiter
    6. PLUMMERS : multinodular goiter, nodules become autonomous and secrete thyroxine

    Sick Euthyroid acutely ill patients; T3&T4 decr due to chgs in hormone metabolism; TSH not decreased => not truly hypothyroid

    Thyroid CA Papillary = most common, best prognosis, Follicular = older, hematogenous spread to bone, lung, brain, liver; Anaplastic = worse prognosis, local invasion, hoarse & dysphagia; Medullary= Calcitonin producing Cells, MEN Type II(parafollicularC cells)

    Diabetes Dx: elevated random glucose sx, fasting BS > 140 x 2 days; Oral challenge >200 after 2 hrs; Type I: alpha islet cells, HLADR3, HLADR4, HLADQ, ketoacidosis
    Type II: insulin resistance; no HLA association, endogenous production enough so no ketoacidosis but do get hyperosmolar coma(dehydrated, glucose 600-2000

    Parathyroid Hormone incr. Ca mobilization from bones, incr. Vit D production decr. phos reabsorption in distal tubules = decr. serum phos.

    Hypoparathyroidism ßPTH, ßCa, incr. Phos, Tingling, tetany, Chvostek's sign (tap on face & get muscle spasm) ; Trousseau's Sign (BP cuff up 3min => carpal tunnel sx; decr. Mg in alcoholics can lead to decr. Ca due to ßPTH secretions

    Hyperparathyroid Bones, stones, abd. Groans and psychic moans; 1o = excess PTH; 80% benign adenoma; 2o due to decr. serum Ca=> vit D defic, renal tube prob and Ca loss

    Diabetes Insipidus Lack of ADH, polyuria and polydypsia

    Kallman's Syndrome Male, anosmic, small testicles, azospermic d/t head trauma; decr. FSH & LH, no GNRH

    SIADH Excess ADH, Tumor, trauma, pulm disease, drugs; Hypoatremia, Conc. urine;

    Acromegaly Excess GH; bone & tissue enlargement; glucose intolerance, osteoarthritis

    Addison's Disease Decreased cortisol (aldosterone) Wt loss, fatigue, skin pigmentation, eosinophilia; Decr aldosterone, decr Na, incr K; Give ACTH if cortisol doesn't increase Dx made

    Cushing's Syndrome Incr cortisol, Buffalo hump, moon facies, central obesity, Osteoporosis, #1 Cushing disease due to pit. Adenoma, #2 Ectopic- ACTH from lung tumor, #3 Adrenal Cortical tumor- incr. cortisol, ACTH suppressible, cortisol not #4 Chronic glucocorticoid Tx

    Waterhouse Friedrickson Syndrome hemorrhagic infarct of adrenals, assoc w/ meningococcemia

    Pheochromocytoma Episodic HTN, Dx by urinary catecholamines

    Familial Hypercholesterolemia Autosomal dominant, Xanthomas (lipid on tendons) Xanthelasmas (lipids on eyelids) MI's in 40's, Homozygous usually has incr. total cholesterol

    Familial Hypertriglyceridemia Trig incr. , LDL normal, Autosomal dominant, Pancreatitis, milky serum

    Familial Combined Hyperlipidemia Auto dominant, incr. trig and cholesterol; no xanthomas

    Familial Dysbetalipo-proteinemia rare, problem with lipoproetin catabolism; palmar or tuberous xanthomas, incr. risk periph vasc disease & CAD, Abn VLDL, cholesterol & triglycerides

    MEN I Parathyroid , pituitary & Pancreatic tumors

    MEN II Pheochromocytoma, Parathyroid & medullary thyroid tumors

    Hemochromatosis Auto recessive, incr. GI absorption of Fe; Excessive Fe, incr. Ferritin, incr. Transferrin saturation, cirrhosis, diabetes, bronze skin

    Wilson's Disease Auto recessive, excessive Cu accumulation, ataxia & dementia, Kayser Fleisher rings on cornea

    Hyperaldosteronism Aldosterone works on distal renal tubule to facilitate incr. Na retention and incr. K loss
    excretion due to decr. Na, decr. BP (renin angio), incr. K
    1o Conn's Syndrome = adrenal hyperplasia, adrenal adenoma Tx: spironolactone
    2o incr. renin angiotensin system activity => decr. BP

    GENTOURINARY
    Neurogenic Bladder Bladder control requires: intact sensation(full) motor function (start void) Cerebral control (timing)
    Atonic, distended with overflow= acute spinal cord injury or sensory impaired
    Motor defect = sense full bladder but can't start emptying
    Autonomous = spinal cord injuries after acute; bladder fills & empties reflexively


    Hydronephrosis dilation of renal pelvis, incr. pressure in urinary system w/ or w/o ureter dilation

    Fanconi's Syndrome renal tubule defect; Urinary excretion of glucose, phos, AA; Tx: Vitamin D

    Pyelonephritis & Pyelitis Pyelonephritis = dilation of renal parenchyma, pyelitis = dilation of renal pelvis; E. coli; Different from cystitis since there are WBC casts not just WBC's

    Cystitis WBC in spun sample, E. coli, freq, urge, dysuria & suprapubic pain

    Bladder Ca transitional cell CA; Risk factors = smoking, schistosomiasis, aniline dyes

    Renal Artery Stenosis Cause of 2o HTN; Fibromuscular dysplasia (young women) Atherosclerosis (older)

    Urolithiasis incr. Ca = Calcium stones; Struvite Stones = post UTI w/ urea splitting bact (proteus or pseudo) when urine basic MgNH4PO4 (struvite) stones ppt.

    Uremic Syndrome Symptomatic renal failure = GFR< 20 ml/min; CNS chgs, asterixis (flapping tremor) pericarditis, N/V, yellow-brown skin (uremic frost) Normochromic, normocytic anemia due to decr. erythropoietin; incr. Phos & decr. Ca = renal osteodystrophy

    Glomerulonephritis Hematuria, proteinuria, RBC casts: Post strep = give Antibiotics only if still strep +, steroids no help; Goodpastures- autoimmune, high dose steroids, uremia 3-9 mos.

    Nephrotic Syndrome Proteinuria > 3g/day, Edema, hypoalbuminemia & hyperlipidemia (milky serum); minimal chg disease in kids; idiopathic Glomerulonephritis in adults

    Acute Tubular Necrosis most common cause of acute renal failure; ischemia or toxins; resolves in several weeks may need dialysis

    Polycystic Kidney Disease Auto dominant; multiple bilateral renal cysts; gross hematuria, proteinuria, pyuria, HTN, UTI's; asymptomatic until adult; 15% have associated subarachnoid hemorrhage

    Alport's Syndrome X-linked, Type IV collage, deafness & renal failure in males

    Wilm's Tumor nephroblastoma, kids < 4yrs commonly, hematuria, abd mass; resection & chemo

    Renal CA adenocarcinoma; Triad: hematuria, abd mass & flank pain

    Chronic Renal Failure >90% glomeruli destroyed; uremia incr. K, ßNa incr. phos, ßCa = renal osteodystrophy

    Hypernatremia > 155 mEq/L; due to dehydration, CNS depression (neuronal shrinkage); Diabetes Insipidus= decr ADH = lots of dilute urine = dehydration = urine output incr.

    Hyponatremia <135 mEq/L; pseudo if lipids are incr. incr. incr. high to displace polar Na; Osmotic = diabetes incr. Na 1.6 for 100 mg/dl glucose value is above 140.; SIADH, Central Pontine Myelinosis if corrected to fast

    Hyperkalemia > 5.5 mEq/L; muscle weakness, cardiac arrhythmia, met acidosis, oliguria, K sparring diuretics

    Hypokalaemia <3.5 mEq/L; muscle weakness, cardiac arrhythmias, resp failure, GI or renal loss

    Urethritis GC (gram - rodds in WBC, + thayer martin culture); nonGC = chlamydial; coinfection, Ceftrixone for GC, Doxycycline for Chlamydia

    Epididymitis Induration & tenderness of spermatic cord; support relieves pain

    Torsion of the Testes adolescents, swelling & tenderness, superior displacement, support does not relieve pain, Emergent SURGERY

    Hydrocele Painless lump, can be transilluminated; congenital process vaginalis remains in communication w/ abdomen = indirect inguinal hernias

    Varicocele "bag of worms", assoc w/ infertility

    Seminoma Painless lump; does not transilluminate, most common testicular neoplasm in men < 30; Undescended testes at greater risk even after surgical correction

    Prostatitis Nonbacterial > bacterial (GI organisms); recurrent UTIs; Rectal - warm, tender, boggy prostate; Tx TMP/SMX

    BPH Enlarged rubbery prostate on rectal; Urinary retention, a blockers; TURP, transrectal US more sensitive for Dx; PSA can be falsely elevated

    Prostate Ca Firm, nodular irregular prostate, Bone mets; Alk Phos and PSA are incr.

    Bacters Syndrome pre-auricular skin tag and kidney agenesis

    INFECTIOUS DISEASES & IMMUNOLOGY
    Fever most common cause immed post op = atelectasis; 3-5 days postop = infection; > 2 wks post op = PE or thrombophlebitis

    Fever of Unknown Origin > 100F for > 3 weeks despite active search for cause for > 1 week; need to get CBC w/diff, blood cultures; kids = usually infection; adults = infectious, neoplasm, autoimmune

    Inflamation Rubor, Tumor, Calor, Dolor

    Types of Immunity Active Acquired= direct exposure - infection or vaccination; Passive Acquired = temporary, serum Ab given (IG, breast milk)

    Bacteremia bacteria in blood but asymptomatic

    Septicemia bacteria in blood with symptoms

    Immunizations in Kids HEP B = mom + HbsAG = HBIG & 1st Hep B vaccine at birth
    DTP = contraindications => progressive neuro disorder, Hx encephalopathy w/ in 7 days of previous dose; Pertussis not given if > 7 y/o or if currently have pertussis
    H FLU = not in kids > 5
    POLIO = IPV if immunocompromised
    MMR = not effective before age 1; don't give if less than 3 months since transfussion or IG use; ok for HIV +; suppresses TB - give Tine(PPD) & MMR at same time or 4-6 weeks apart.

    Adult Immunizations TETANUS = booster q10y, No Hx immunization 2 td 1-2 mos apart then booster at 6-12 mos then on normal 10 y cycle
    FLU = chronic resp problems, metabolic diseases, adults > 65; can cause false positive HIV test

    HIV/AIDS RNA retro, CD4 cells, Dx based on concurrent related diseases &/or CD4 , 200 cells/mm3; Flu-like illness, antibodies 1 - 6 months after infection

    AIDS related infections CMV, HSV, VZV, EBV, TB, mycoplasma avium-intracellular, candida coccidioides, histoplasmosis, cryptococcus, Pneumocystic carnii (protozoa) Toxoplasmosis, cryptosporidiosis, Giardiasis

    DeGeorge's Syndrome Thymic aplasia, Absent T cells, congenital heart disease, craniofacial abnormalities

    Wiskcott- Aldrich Syndrome X linked, no antibodies against encapsulated bacteria, eczema, decr. platelets,

    Chronic Granulamatous Disease Autosomal recessive, defect in phagocytic enzymes, recurrent bacterial & fungal infections

    Chediak-Higashi Syndrome Autosomal recessive, recurrent strep & staph infections

    Bruton's Disease x-liked, agammaglobulinemia, N B cells or antibodies

    Ataxia Telangectasia Auto recessive, lymphopenia & IgA deficiency; gait abnormal, telangiectasia

    Severe Combined Immunodeficiency Deficits of B & T cells, IgA deficiency, recurrent infections esp resp & GI, IG administration contraindicated

    HEMATOLOGY & ONCOLOGY
    Microcytic Anemia MCV < 80; IRON DEFICIENCY = decr. ferritin; CHRONIC DISEASE decr. Fe, decr. Transferrin, incr. Ferritin; LEAD POISONING; THALASSEMIA

    Normocytic Anemia MCV 80 - 100; Hemolysis, Chronic disease, Bone marrow suppression (drugs, leukemia) (aplastic)

    Macrocytic Anemia MCV > 100; FOLATE DEF. = most common cause, decr. folate normal B12;
    B12 DEFICIENCY: B12 absorbed when linked with IF from parietal cells, neuro sx,

    Alpha Thalassemia Acanthocytes (rounded projections from cells); Poikilocytosis (variable size); target cells, Very low MCV but mild anemia, Hemoglobin H = a chain missing; Asians, Dx by Hb electrophoresis,

    Beta Thalassemia Peripheral Smear = basophillic stippling, nucleated RBC, anisocytosis (chgs in size) Mediterranean & African heritage; Minor = heterozygous, Major = homozygous

    Sickle Cell Anemia sickled cells, decr. Hct & incr. reticulocyte count, electrophoresis HbS + HbA neg. Salmonella osteomyelitis, S. pneumonia sepsis.

    Hemophilia X linked factor VIII (A) or IX (B) deficiency; Prolonged PTT, Joint & soft tissue bleeding; Tx cryoprecipitate & FFP

    Von Willebrand's Disease autosomal dominant deficiency of VIII & vWF, epistaxis, menorrhagia, bruising, increased PTT & bleeding time

    Eosinophilia Allergic Drug Reaction; NAACP = neoplasm, asthma/allergies, Addison's disease, connective tissue disorders, parasites

    Thrombotic Thrombocytopenic Pupura adults > kids, women > men; platelets consumed in clotting reactions, Fluctuating neurologic defects, decr. platelets, decr. HCT, incr. retic count, incr. incr. incr. LDH, acute onset not autoimmune

    Idiopathic Thrombocytopenic Pupura kids > adults, autoimmune destruction of platelets, Purpurea & Petechia , Platelets<10000, Epistaxis, menorrhagia

    Hemolytic Uremic Syndrome Usually caused by E. coli toxin, RBC fragments on smear, RBC destruction => acute renal failure, 2o thrombocytopenia, abd pain & diarrhea after a flu or URI prodrome; platelets derc, LDH greatly increased

    Hodgkin's Lymphoma Painless cervical lymphadenopathy, Reed Sternberg cells (multinucleated reticular cells), 80% survival

    Burkitt's Lymphoma B cell lymphoma, Associated with Epstein-Barr virus, children & young adults

    Hereditary Spherocytosis dominant deficit in RBC membrane proteins, damaged cells get trapped in spleen. Spherical RBC & reticulocytosis on smear. Coombs neg.

    G-6-PDase Deficiency X linked hemoglobin accumulates in RBC (Heinz bodies) hemolysis occurs after ingestion of oxidant

    Agranulocytosis neutrophils = decr production or incr destruction

    DIC wide spread activation of coagulation cascade. decr. platelets, fragmented RBC, incr. PT & PTT ; decr. fibrinogen, Pregnancy, malignancy, infections, massive trauma

    Acute Lymphocytic Leukemia 80% childhood leukemia, peak age 3 - 7; usually B cell origin; incr. lymphoblasts, few other cells on bone marrow biopsy

    Acute Myelocytic Leukemia affects myeloid cells (N,B,E,erythrocytes, megakarocytes) adults > kids; DIC possible, gram neg and fungal infections, Auer Rods (red staining intracellular inclusions.

    Chronic Myelocytic Leukemia Philadelphia Chromosome (acquired translocation chromosome 9 & 22), tumor cells are more mature, Dx in middle aged, WBC > 150000; incr. uric acid, incr. B12 (B12 carrier protein produced by WBC); leukocyte alkaline phos decr or absent, RBC normal
    Blast crisis transforms it to acute leukemia

    Chronic Lymphocytic Leukemia Disorder of mature B cells (rarely T); B cells don't differentiate into plasma cells, men > women; usually > 50; No Blast Crisis

    Hairy Cell Leukemia B cell transformed into tumor cell with fine hair like projections; pancytopenia, red pulp of spleen infiltrated

    Multiple Myeloma Plasma cell proliferation and monoclonal IG; men = women; peak 50 - 60, 1 - 3 year survival; xrays show osteolytic bone lesions, Increased urine protein (Bence Jones)

    Waldenstrom's Macroglobulinemia single B cell line = monoclonal IM over production; decr. RBC with normal WBC & platelets; Rouleau Formation = RBC pile up forming cylinders

    Mycosis Fungoides Clonal proliferation of CD4 T cells; infiltrates dermis & epidermis, thickened & nodular skin lesions

    Polycythemia Vera overproduction of all 3 cell lines; RBC > 1,000,000, Hct > 60%; men & women peak age 60; Bone biopsy- hypercellular with absent Fe stores; R/O spurious polycythemia = incr. RBC due to dehydration; R/O 2o polycythemia = RBC mass incr. due to decr. oxygenation.

    Eaton Lambert 90% assoc w/ small cell CA, decr. presynaptic Ca release = proximal muscle weakness; hyporeflexia, dysautonomia, function incr. w/ stimulation; weakest in AM (opposite MG) Tx Tubocurare

    DERMATOLOGY
    Seborrheic Dermatitis Red skin with greasy scales, worse in winter & when under stress, Se or Tar soap

    Psoriasis HLA-B27, Similiar sx to RA but w/ neg RF, Silvery scaled plaques w/ sharp demarcations, Pitted fingernails

    Pilonidal Cyst Hair lined tract in sacral area = "Jeep Seat"

    Actinic Keratoses Firm, yellow scale, Due to sun exposure, can lead to squamous cell CA

    Skin CA Basal Cell > Squamous; Basal Cell = pearly papule w/ dilated blood vessels and central depression; Squamous Cell: Red papule w/ crusted surface, later nodular and ulcerated, rarely mets; Assoc w/ sun exposure

    Malignant Melanoma Change in size, shape or color of a mole, Usually superficial spreading, Mets incr. as invasion goes deeper than 0.76 mm; itchy & ulcerated

    Contact Dermatitis 1o = irritant contact - direct injury, all w/ contact affected, Occurs w/ 1st exposure
    Allergic = type IV hypersensitivity, T cell medicated, Never 1st exposure

    Carbuncle Abscess of skin caused by several boils coming together

    Dermatopytoses TINEA CORPORIS: ring worm of body (round lesion w/ raised borders, spreads peripherally w/ central clearing) TINEA CRURIS: Jock Itch; TINEA PEDIS: Athletes Foot; TINEA UNGUIUM : Toenails; TINEA CAPITIS: ring worm of scalp;

    NEVI PIGMENTED: (Benign) sun exposed areas in children & adolescents
    DYSPLASTIC: 2-12 mm, more irregular, unexposed areas, Multiple dysplastic Nevi = familial incr. risk of melanoma

    Hemangiomas NEVUS FLAMMEUS: Port wine stain - flat, purple, does not fade
    CAPILLARY: strawberry mark, raised, bright red, regress spontaneously by age 5
    CAVERNOUS: Raised red or purple, enlarged vascular spaces

    MUSCULOSKELETAL & CONNECTIVE TISSUE
    Osteoarthritis incr. morning stiffness, bone spurs, osteophytes, DIP = heberdon's nodes, PIP = Bouchard's nodes, also affects hips, knees, spine

    Rheumatoid Arthritis Symmetric, PIP & MCP joints NOT DIP, Subcutaneous nodules, 70% +RF

    Gout Affects big toe (Podagra), pinna of ear; Negatively birefringent crystals; Sodium urate; Colchicine or NASIDS for acute attacks

    Pseudo Gout Calcium pyrophosphate dihydrate; Knee most affected; Positively birefringent

    Phocomelia Hands & feet attached to trunk, Thalidomide

    Slipped Capital Femoral Epiphysis Overweight Teens; stiffness=>weakness=>pain radiating down anteromed thigh to knee, ext rot of leg; avascular necrosis

    Lyme Disease Borrelia burgdorfi, Ixodes tick, arthralgias, Rash w/ central clearing = erythema chronicum migrans, CNS chgs 1 month after exposure

    Osteoporosis decr. mass of bone; hip & wrist fx most common; decr. estrogen, Ca & Phos normal; Risk factors = post menopause, Caucasian, Asian, smoking, alcohol, corticosteroids, Cushings, hyperparathyroid, hyperthyroid; Etidronate - inhibits osteoclast activity, used for men & women who can't take estrogen

    Systemic Lupus Erythematosus Malar (butterfly) rash, arthralgias (raynauds), ANA sensitive; Anti dsDNA specific; Neuro = HA, psychosis, seizures, aseptic meningitis; Check for hemolytic anemia w/ Coombs; Renal = incr. BUN incr. Cr, + protein = immune complex glomerulonephritis

    Polymyositis & Dermatomyositis inflammation of skeletal muscles; violet discoloration of eyelids (heliotrope rash), elevated muscle enzymes (CPK, SGOT, SGPT, LDH) symetric proximal muscle weakness; hips & shoulders 1st

    Ankylosing Spondylitis "Bamboo shoots" = vertebral squaring w/ bony outgrowths, paraspinal lig. Calcifications on xray; sacroiliac involvement is diagnostic; HLA-B27; incr. ESR

    Shoulder Hand Syndrome Pain, stiffness, swelling in hand and shoulder; Occurs 1 month after MI or other acute disease

    Bone Mets from Primary breast, lung, prostate, kidney, thyroid

    Paget's Disease Osteolytic => osteoblastic; Frontal "bosing" (enlarged skull with rounded forehead) bow legs and shortened spine; incr. alk phos, Ca & phosphorus levels normal; "Cotton Wool" appearance on skull xray; high output cardiac failure

    Congenital Hip Femoral head partially or completely dislocated from acetabulum; BARLOWS: dislocates hip when abducted and decr. pressure; ORTOLANI'S: reduces dislocation by abduction and flexion

    Osteochondritis Inflammation of bone & cartilage; Osgood Schlaters - teens, tibial tubercle, pain& swelling at the insertion of the patellar tendon

    Osteomyelitis Bone infection; Local or hemtogenous spread; Prepuberty infection is in metaphysis; Salmonella - sicklers; S. aureus; pseudomonas; incr. ESR; incr. WBC; Radionucleotide bone scan w/ in 72 hrs; 4-6 wks organism specific antibiotics

    Septic Arthritis S, aureus = most common; N. Gon most common sexually active; synovial fluid = incr. WBC and + culture; Ceftriaxone NG infection; Nafcillin for others

    Degenerative Disk Nucleus Pulposa herniates post or postlat.; Lumbosacral = sciatics = L3L4; + pain on straight leg raise;

    CaudaEquina Syndrome Lg midline post. Hemorrhage compressing C.E. Urinary and bowel incontinence; bilateral leg weakness

    Polymyalgia Rheumatica older women; assoc w/ temporal arteritis; Morning stiffness; swelling 1-2 joints; no weakness; incr. ESR; neg. Rheum factor; steroid response immediate

    Fibromyalgia "Trigger Points" reduce pain, IBS, depression, anxiety

    Osteosarcoma teenage boys, distal femur & proximal tibia; mets to lungs

    Eosinophillic Granuloma 20-40; granuloma w/ histiocytes, eosinophilic infiltrate & fibrosis; multifocal = poor prognosis

    NEUROLOGY
    Blindness visual acuity 20/400 with best possible correction

    Open Angle Glaucoma Increased intraocular pressure, gradual, bilateral vision loss => tunnel vision, elderly, diabetics, African Americans, familial; halos around lights, cuping of ocular disc, Beta Adrenergic blockers to treat; decr. amt aqueous humor produces

    Closed Angle Glaucoma Rapid rise in pressure due to blockage of aqueous drainage in the eye; Severe pain, blurred vision, halos, Nausea, Abd pain; Reddened eye, upper lid edema, steamy cornea, dilated non-reactive pupil; mannitol, oral glycerin or carbonic anhydrase in acute attack, Beta adrenergic blockers for prevention

    Diabetic Retinopathy Black spots, "cobwebs", flashing lights; cotton wool spots (infarct of vessel wall) neovascularization, hard yellow exudates

    Cataracts Painless clouding of lens; Age most common cause, Assoc. W/ smoking & alcohol; Absent red reflex.

    Senile Macular Degeneration Main cause of vision loss in the elderly; Atrophic degeneration or Leakage of Retinal Vessels , gradual loss of VA, Decr central vision, hemorrhagic or pigmented regions in the macula; Neovascular Membranes (Bruch's membrane)

    Conjunctivitis Acute inflammation, Adenovirus, a lot of discharge, no blurring, purulent if bacteria

    Uveitis Inflammation of the uveal tract (iris, ciliary body & choriod layer), haziness, floating spots; Photophobia & redness = iridocyclitis; "salt & pepper fundus = syphillis

    Central Retinal Occlusion sudden painless loss of sight in one eye, Pale fundus, cherry red spot fovea & boxcar appearance of veins

    Central Vein Occlusion unilateral loss of sight that is more gradual, Swelling of optic disc, cotton wool spots & tortuous dilated veins

    Retinoblastoma Childhood malignancy of immature retina, associated with other malignancies later in life, "white reflex or "cat's eye.

    Hearing Loss Rinne's Test: hold against mastoid process then adjacent to pinna, norm = pinna louder, if not maybe conductive loss; Weber Test: Midline of forehead, unilateral conductive loss = louder in affected ear; unilateral sensorineural = louder in unaffected ear

    Presbycusis normal loss of hearing associated with age, sensorineural

    Mastoiditis Usually following otitis media, Redness & swelling w/ fever & pain; X ray = destroyed mastoid air cells & fluid in the air pockets, IV antibiotics

    Meniere's Disease Severe vertigo w/ N/V, hearing loss, tinnitus worse during attack of vertigo

    Acoustic Neuroma Vestibular Schwannoma; tumor of CN VIII; Hearing loss, dizziness, tinnitus;

    Migraine 2x women : men; Age of onset 10 - 30; gone by age 50; family Hx; stress, bright lights, menstruation, fatigue, tyramine, monosodium glutamate, nitrites; Aura prior to onset; visual, scintillating scotomas (small areas of visual loss) , dull throbbing, unilateral; N/V, photo & sound sensitivity;

    Cluster Headache Men age 20-50; alcohol & vasodilators; severe, nonthrobbing, unilateral, recur same time each day for weeks, Horners syndrome & periorbital pain; Tx: ergot & lidocaine

    Tension Headache cause unknown, most common type; bilateral, occipital, constant; muscles tight

    Tumor Associated Headaches progressive, increasing, dull, nonthrobbing, worse w/ postural chgs, exertion. Disrupt sleep, assoc w/ N/V

    Trigeminal Neuralgia Tic douloureux; severe, "lightening" pain in V1 & V2 distribution of CN V; Trigger Pts
    Tx: carbamazepine & phenytoin; Surgical decompression of CN V

    Partial Seizures Simple = focal sx, conscious, Jacksonian = simple muscle twitch that spreads progressively; 2o generalization = simple becomes grand mal; Complex Partial = automatism, olfactory hallucinations, fear, deja vu, loss of contact w/ environment; postictal confussion

    Generalized Seizures Absence = petit mal; brief, freq. Loss of consciousness w/o loss of muscle tone, rapid eye blinks, no aura, no postictal
    Grand Mal= tonic clonic, preceded by GI upset or mood chg; tonic - 30 sec, clonic 1-5 min w/ alternating relax & contract of muscles, unconscious, then confussion & postictal

    Status Epilepticus continuous seizures w/o regained consciousness, grand mal progress or withdrawal of anticonvulsants; Complications = high fever, circulatory collapse, brain damage; Diazapam until controlled, Treat potential causes (glucose, thiamine, narcan)

    TIA sudden, brief, emboli or arterial stenosis, Risks: obesity, smoking, DM, hyperlipidemia, Carotid artery= unilateral, contralateral hemiparesis & parathesia w/ ipsilateral blindness; Aphasia if dominant hemisphere involved, Vertebrobasillar = brainstem dysfunction => vertigo, confusion, blindness, diplopia, weakness, parathesia of extremities

    Aneurysm localized vessel dilation, Berry Aneurysm = circle of Willis assoc w/ polycystic kidney disease & coarction of aorta

    Subarachnoid Hemorrhage between pia & arachoid; usually rupture of a cerebral artery aneurysm or AV malformation; Worst HA, syncope, nuchal rigidity, vomiting, nonfocal abnormalities, decr consciousness, CT first if neg then lumbar puncture mandatory.

    Intracerebral Hemorrhage Chronic HTN or local thrombus 2o to ischemia; Supratentorial: transtentorial herniation, w/ brainstem compression & midbrain bleeding, hemiparesis; Cerebellar : acute hydrocephalus due to CFS flow blockage; Acute onset HA w/ progressive neurological chgs.

    Stroke Middle Cerebral: most often, contralateral limb weakness, sensory loss, homonymous hemianopsia, dominant hemisphere = aphasia, nondominant = sensory neglect & apraxia
    Posterior Cerebral: contralateral homonymous hemianopsia & sensory loss, thalamic pain, hemiballistic movement disorder
    Vertebrobasilar artery: fatal, unilateral occlusion = ipsilateral CN abnormalities, contralateral weakness; Complete occlusion = opthalmoplegia, defective pupil constriction, bilateral weakness, paralysis, decreased consciousness, dysphagia & dysarthria; completed = neuro stable; Evolution = progressive signs over 1-2 days
    CT positive 48 - 72 hrs after onset.

    Cavernous Sinus Thrombosis CN palsies, fever, exophthalmos, papilledema, HA, decr. consciousness, occasional seizures; IV antibiotics immediately

    Acute Subdural Hematoma rapid bleed between arachnoid & dural layers; Tearing of bridging veins, Sx slower to progress, Signs of transtentorial herniation w/ deepening coma, progression from decorticate to decerebrate posture, mid position or fixed & dilated pupils, spastic hemiplegia w/ incr. DTR. LP is contraindicated because may lead to herniation

    Chronic Subdural Hematoma Delayed formation of a subdural clot, Sx weeks after head injury, Elderly & alcoholics; Progressive daily HA, fluctuating consciousness & mild hemeparesis

    Epidural Hematoma Between dura & skull, less common than subdural, injury to arteries (middle meningeal); Rapid brain compression, permanent neurological problems or death; Brief lucid period after head injury; progressive neuro signs

    Concussion Injury due to blunt trauma; short loss of consciousness w/ intact brainstem function; post traumatic confussion syndrome w/ transient retrograde or anterograde amnesia; HA, vertigo, mild cognitive dysfunction

    Toxic Vestibulopathies Alcohol: positional vertigo & nystagmus w/ in 2 hrs of ingestion
    Aminoglycosides: ototoxic, vertigo, N/V ataxia, sx last 1-2 wks after ending tx
    Salicylates: reversible vertigo, tinnitus, sensorineural hearing loss
    Quinine & Quinidine: cinchonism (color vision defects, tinnitus, hearing loss, vertigo, flushed skin, N/V, abd pain & sweating
    Cisplatin: ototoxic, reversible vertigo, tinnitus, hearing loss, sensory neuropathy

    Toxic Neuropathies Lead: multi motor neuropathy; acute encephalopathy in children
    Organophosphates: delayed motor neuropathies, cholinergic crisis
    Arsenic and Thallium: acute onset symetrical sensorimotor polyneuropathy
    Isoniazid: Reversible sensory polyneuropathy reversible w/ concurrent pyridoxine Gold: symetrical polyneuropathy

    Bacterial Meningitis 1st month life = group B strep & E. coli; Older kids = H. flu; Adults = S. pneumonia
    N. meningiditis at any age = 50% have petechial rash
    Brudzinski sign = neck flexion when supine causes involuntary hip & knee flexion
    Kernig's Sign: extension of knee in pt w/ flexed hip is painful
    CSF: decr. glucose, incr. neutrophils, incr. protein, incr. opening pressure; Tx: ampicillin & cefotaxime = infants; 3rd generation cephlosporin in kids > 3mos and adults

    Aseptic Meningitis nonbacterial meningeal irritation; CSF = incr. lymphocytes, normal glucose, neg gram stain & bacterial cultures, mild incr. protein, normal opening pressure; supportive Tx

    Fungal/TB Meningitis CSF: incr. lymphocytes, decr. glucose, incr. protein, incr. opening pressure; AIDS = cryptococcal meningitis

    Encephalitis Inflammation of brain tissue; Viral etiology = CSF lymphocytes, normal glucose & negative bacterial cultures; Acylcovir x10 days

    Reye's Syndrome follows viral infection; fatty infiltrate of organs; Usually kids; Salicylates can induce
    Sudden onset of encephalopathy, severe vomiting, & liver dysfunction; liver biopsy w/ fatty infiltrates confirms Dx.

    Neurosyphillis Argyll Robertson Pupil (small, reacts to light but not accommodation); Psych disorders, Tabes Dorsalis; Tx: Procaine Penn G x 21 days; Examine CSF q 3-6 months until normal x 2 yrs.

    Rabies Dogs worldwide; wild animals in US, Sx: malaise, fever, restlessness 1st. Sx progress to extreme excitement w/ painful laryngeal & pharyngeal spasms, Tx: Passive IG and active vaccine

    Polio Fecal-oral; aseptic meningitis, paralysis w/o loss of sensation; Asymmetric paralysis during a febrile illness suggests it; Tx is palliative; OPV for all except immunocompromised who get IPV

    Primary Neoplasms Glioblastoma Multiforme: most common in adults, high mortality; Meningioma: most common benign tumor in adults; Cerebellar Astrocytoma & Medulloblastoma: most common in kids

    Huntington's Disease Autosomal dominant, Age 30-50; subtle dementia, irritability, antisocial, chorea, death 10-15 yrs after onset, atrophy of caudate nucleus & cerebral cortex, Tx D2-receptor antagonists (haloperidol)

    Parkinsonism Idiopathic - loss of dopaminergic cells in substantia nigra; Pin rolling temor, masklike facies, lack of arm swing when walking, cogwheel rigidity, difficulty initiating movement, small shuffling steps w/ increasing speed (festinating gait). Tx: Levadopa (dopamine precursor), Amantadine, bromocriptine (dopaminergic agonists), Benzotropine (anticholinergic)

    ALS
    (Lou Gehrig's Disease) Progressive loss of anterior horn cell function; Initially = LMN dysfuntion w/ hand & foot weakness & atrophy; asymmetric progression, No sensory abnormalities; Later= UMN dysfunction w/ muscle spasticity, incr. DTR, extensor plantar reflexes

    Tay Sachs Disease Autosomal recessive; Eastern Europe jews & french Canadians; Absence of Hexosaminidase A, can't metabolizes lipid gangliosides, build up in brain; Progressive dev. delay, paralysis, blindness, dementia; death by age 4

    Multiple Sclerosis Progressive demyelinating, women>men; Peak onset 20 - 40; Gradual & variable CNS sx suggest dx; CSF = mild incr. proteins, mild lymphocytes , oligoclonal bands, MRI = multi plaques in white matter

    Guillain-Barre Syndrome polyneuropathy after mild viral illness, inoculation or surgery; Most common acquired demyelinating disorder; progressive bilateral weakness of legs, proximal weakness, abnormal DTR, instability of temp & BP; CSF = incr. protein w/ normal pressure, glucose & cell numbers; Plasmaphresis speeds recovery; Corticosteroids are contraindicated

    Cerebral Palsy CNS damage before age 5; Risks: Prematurity, IUGR, inutero complcations, neonatal jaundice, birth trauma, asphyxia, spastic syndrome, incr. DTR, incr. tone, weakness, toe walking, scissors gait

    Myasthenia Gravis autoimmune, antibodies against acetylcholine receptors at neuromuscular junctions, incr. women, age 20 - 40; Ptosis, diplopia, dysarthria, enhanced muscle fatigue, thymoma on chest x-ray; Tx exogenous anticholinesterase (edrophonium or neostigmine); Thymectomy in pts < 60; steroids or azathioprine if unresponsive to tx

    Muscular Dystrophy Duchenne most common type; X linked recessive, mutation in dystrophin gene; CK incr. before onset of sx; By age 5 toe walking, waddling gait, can't run; Prox legs 1st then prox arms; Pseudohypertrophy of calves = fat infiltrates in muscles;

    Coma dysfunction both cerebral hemispheres or RAS; Acute onset = subarachnoid hemorrhage or brainstem infarct; progressive min-> hours = Intracerebral hemorrhage; days => weeks = chronic subdural hematoma, tumor or abscess; No laterialization following delirium = metabolic; Pupil size: dilated nonreactive = at or below midbrain, pinpoint = pontine; opiod OD, Constriction intact w or w/o extraoccular impairment = metabolic; Localizing response to pain = superficial coma; Decorticate (flex @ elbow, ext leg) = thalamic lesion of compression; Decerebrate (elbow & leg extension) = midbrain; No response to pain = pontine or medullary

    Gait Abnormality Cerebellar lesions = truncal ataxia, broad based, unsteady, irregular; can't turn
    Corticospinal = affected leg circumducts as it steps forward, scissors if bilateral
    Extrapyramidal = festinating gait, flexed posture, small rapid steps, no arm swing
    Motor System = Footdrop - anterior tibial; Calf muscle - can't toe walk; Pelvic muscle - waddling gait.

    Arnold Chiari Syndrome Cong. Protrusion of medulla thru foramen magnum; unusual sensory & motor chgs, Onset ~ 40

    Cold Calorics Test vestibular system, Slow deviation toward ear w/ cold water = brainstem intact, fast nystagmus away = contralateral cortex intact; COWS = cold opposite Warm same for fast component

    GYNECOLOGY
    Trichomonas Vaginitis Yellow green discharge, Strawberry patches, Motile flagellated, Tx: Metronidazole

    Gardenerella Vaginitis KOH whiff test = fish; Clue cells, most common symptomatic infection; Metronidazole

    Condyloma Acuminata Warts, HPV 6, 11, Not assoc w/ cervical cancer

    PID Cervical motion tenderness, Purulent discharge, assoc w/ ectopic pregnancy & infertility; Leukocytosis, neutrophilia, incr. ESR

    Candida cottage cheese, red vulva; Pseudohypahe & spores on wet mount, DM, antibiotics, OC, pregnancy

    UTI E coli, Dysuria, frequency, urgency; Tx: TMP-SMX, Bactrim, Septra

    Toxic Shock Syndrome Staph aureus exotoxin, rash, high fever, hypotensive shock

    Chancroid H. Ducreyi, tropical & sub tropical climates, gram neg; Tx Emycin or Ceftriaxne

    Chlamydia Trachomatis Intracellular, columnar epithelium, mucopurulent, Immunofluoresent discharge, Tx: Doxycycline (Emycine if pregnant)

    Herpes Genitalis HSV II clear sores , multinucleated giant cells w/ intracell inclusions; Tzanck smear

    Molluscum Contagiosum umbilicated nodule, remove & cauterize

    Endometriosis Ectopic endometrium tissue, Dysmenorrhea, Dyspareunia, infertility

    Paget's Disease of Breast Intraductal Ca in main excretory ducts; crusting erosion of nipples w/ or w/o discharge

    Polycystic Ovarian Disease incr. LH, decr. or normal FSH; hirsutism, obesity, menstrual irregularities, infertility

    Menopause Avg age =51; incr. FSH & LH; Hot flashes, Atrophic vaginal epithelium

    Urinary Incontinence Stress = incr. intra abd pressure, leak small amts of urine; Kegel exercises, estrogen
    Urge = detrussor instability; lg amts of urine leaked immediately after urge to void

    1o Amenorrhea Absence age 16 w/ 2o sex development or absence by age 14 w/o 2o characteristics
    Anatomic Abnormalities; Ovary Failure ( incr. FSH & LH, decr. estradiol) (XO, turners, no ovary); Pituitary = Prolactinoma presents w/ galactorrhea (Bromocriptine to Tx), Hypothalamic = decr. FSH & LH, (anorexia, incr. exercise, stress); XY karotype

    2o Amenorrhea Absence for 6 mos if prev normal; absence for 12 months if prev oligomenorrhea; r/o pregnancy; Galactorrhea = prolactinoma; Hirsutism = polycystic ovarian; Tx: 1st = progestin challenge (bleed w/ in 2 wks) if no bleed measure FSH levels

    1o Dysmenorrhea correlates w/ 1st day of menses, cyclic, begins in adolescence, low back & abd pain, N/V/D, fatigue, HA

    2o Dysmenorrhea acquired, Sx don't correlate w/ 1st day of cycle, Endometriosis most common cause

    Asherman's Syndrome intrauterine adhesions after D&C; destruction of endometrium => amenorrhea

    Fibroademoma Age 19 -29, stromal fibrosis; nontender, estrogen sensitive, regress w/ menopause

    Fibrocystic Breast Disease Age 29 - 39, may have green nipple discharge; tender w/ ovulation, regress w/ pregnancy,

    Breast Disease Age 39-49 malignant = intraductal Ca (bloody nipple discharge); Papillary #1 cause of nipple discharge; Sclerosing Adenitis

    Breast Ca Upper outer quadrant, Mets = bone, liver, lung, brain; Risks: Family Hx, menarche < 12, 1st pregnancy > 35; late menopause, null parity, obesity, other breast, radiation, reserpine

    PAP Smear Atypia = inflamm, infection HPV (16 & 18); Mild Dysplasia = lowgrade epithelial lesion; Mod/Severe=high grade intraepithelial;

    Carcinoma in situ incr. nuclear/cytoplasm, dense chromatin, crowding, incr. mitosis; Koilocytes = HPV, pyknotic nucleus, perinuclear halo; Risks: early sex, multi partners, smoking, decr. social class, HPV; Culposcopy = white epithelium, mosiacism, punctation, atypical vessels

    Cervical CA 90% squamous cell; s/sx: Early = postcoital bleeding, intermenstral bleed, Late= backache, leg pain, edema, hematuria Tx: Ia=TAH, iB & IIA = rad hysto & pelvic lymph nodes, IIB -IVA = Radiation - Brachytherapy => Radium, Cesium

    Endometrium CA most common gyn malignancy; Risks: obesity, DM, HTN, anovulation, early menses, later menopause, nullparous, unopposed estrogen; Dx : abnormal menses, post menopausal bleeding; EMB, D&C; Histologic= grade 1-3 based on differentiation;
    AdenoCA=70%; Adenocanthoma=benign squamous, best prog; adenosquamous= malig squam, poor prog; Papillary Serous = acts like ovarian CA, Clear Cell = poorest prog, older, DES, least common Tx; TAH/BSO, perioneal wash, pelvic & aortic nodes, Adjuvant Rad if + nodes, cervical +, > ½ myometrium, higrade

    Ovarian CA Abd./pelvic mass, ascites, early satiety, CA125, CEA, CA19-9, 75% w/ stage 3; Path types = Serous (psammoma bodies), Mucinous, Endometroid, Clear Cell (hobnail bodies) Brenner; Staging: 1A= 1 ovary, 1B = both ovaries; 1C= + wash, tumor rupture; IIA = fall tubes/uterus, IIB other pelvic structures, IIB + wash rupture w/ spread; IIIA gros in pelvis, micro to diaphragm or omentum, IIIB Intra abd < 2 cm, IIIC: intra abd > 2cm, pelvic/aortic nodes, inguinal nodes; IV = distant spread, pleural effusion w/ malig cells, liver/spleen mets; Tx: debulk tumor surgery, Chemo = cisplatin/cytotoxin, taxol; Radiation (bowel obstruction);

    Teratomas immature (neuro epithelial); mature (dermoid)=95% of all teratomas, hemolytic anemia; LDH elev, CA125

    Dysgerminomas most common malignant, 15% bilateral, radiosensitive

    Endodermal Sinus Tumor Schiller Duvall Body, AFP

    Embryonal CA HCG, AFP, CA125

    Choriocarcinoma HCG

    Sexcord-Stromal Tuors Granulosa: 50% post menopause, incr. estrogen, Call-Exner bodies
    Sertoli-Leydig: most often virilizing; Gonado Blastoma: gonadal dysgenesis

    Krukenburg Tumor: Ovarian mets from GI & breast; Signet ring cells

    Vulvar CA TNM staging, squamous cell, Vulvar pruritus; Pagets= adenoca of vulva, 20% assoc w/ breast, GI, cervical CA

    Gestational Trophoblastic - Benign: Complete Mole = 46 XX, paternal, no embryonic tissue; Incomplete = 69 XXY triploid, paternal, no fetal/ embryonic tissue
    Malignant: Invasive= molar villi; Choriocarcinoma = no villi, any pregnancy; Placental Site = non molar gestations
    S/Sx: size > dates, hyperemesis, hyperthyroid, large theca lutein cyst
    F/U = CBC. Liver function, BUN, CR, TSH, HCG, US, CXR; TX = D&C
    Weekly HCG' until 3 values that are non detectable then 1/mo x 1yr, BCP x 1 yr

    Ca in Pregnancy Melanoma = worsened by preg, can met to placenta or fetus
    Breast CA = most common CA in pregnancy

    Chemotherapy Cyclophosphamide (Cytoxan) = ovarian, hem, cystits, alopecia, decr. bone marrow, N/V
    Cisplatinum = ovaian, renal toxic, ototoxic, bone marrow ß, N/V
    Adrimycin (Doxyrubicin)= endomet, ovarian; cardiotoxic (heart failure)
    Bleomycin= cervical, germ cell, Pulmonary fibrosis
    Vincristine= cervical germ cell; neurotoxic
    Methotrexate = GTN, germ cell, hepatic & renal toxic, decr. bone marrow

    OBSTETRICS
    Hydantiform Mole Preeclampsia 1st TM, Very high Beta HCG, Snowstorm on US

    Ectopic Pregnancy Beta HCG rises slowly, Amenorrhea, spotting, pain, Empty gestational sac on ultrasound, Ampulla of fallopian tube is most common site

    Gestational Age Nagel's = Add 7 days to FDLMP subtract 3 months; fundal ht in cm after 13 weeks

    Amniocentesis Adv maternal age, abn AFP - incr. Spina bifida, decr. Down's, detect lung maturity, early 2nd trimester

    CVS Adv. Maternal age, late 1st trimester

    Non stress Test > 2 fetal movements accompanied by incr. FHR of 15 bpm for at least 15 sec w/ in 20 min period

    Contraction Stress Test Negative = 3 contractions in 10 min, lasting 40 sec w/o late decelerations
    Positive = consistent & late decelerations

    Biophysical Profile Nonstress test, fetal breathing, movement, adeq, amniotic fluid, limb extension

    Fetal HR normal 120-160, Brady = mild 100-120, < 100 severe; Tachy = mild 161-180; severe > 180

    Decelerations Early = shape is mirror of contraction, head compression
    Variable = shape varies, cord compression
    Late = starts as contraction peaks, recovery after contraction is terminated, uteroplacental insufficiency

    Placental Previa Partial - partially over os; Complete= covers OS, Marginal = at edge of OS, Complete Previa is indication for C section

    Placental Abruption Premature separation of a normally implanted placenta, vag bleed, uterine tenderness, back pain, hypertonic uterus, fetal distress

    Preeclampsia HTN w/ proteinuria & edema after 20 wks gestation

    Eclampsia Preeclampsia + seizures

    Gestational Diabetes 1 hr > 140 then do 3 hr; 3hr test = fast > 120, 1 hr > 190; 2 hr > 165, 3 hr > 145; Macrosomia, RSD, Cong abnormalities

    Types of Pelvises Gynecoid = round inlet, nonprominent spines, wide subpubic angle
    Anthropoid = heart shaped inlet, decr. transverse and incr. AP diameters, decr. subpubic angle
    Android= triangular inlet, decr. subpubic angle, prominent spines
    Platypoid= incr. transverse and decr. AP diameters

    Leopold's Maneuvers fundal palpation, sides of uterus from feet of mother, lower part of uterus, sides of uterus from head of mother

    Stages of Labor 1. Onset contract => full dilation 2. Full dilation to delivery of head 3. Delivery of fetus to delivery of placenta 4. Delivery of placenta to 1 hr later

    Cardinal Movements Engagement, descent, flexion, int rotation, extension, ext rotation, expulsion

    Post Partum Hemorrhage Uterine Atony (most common); Placental Accreta: Accreta = superficial invasion into myometrium, Increta = deeper, Percreta = invasion to serosa of uterus; Undiagnosed lacerations, Coag defect; Retained placental fragments

    Apgar Scoring Heart Rate, Resp. Effort, Muscle Tone, Reflex Irritability, Color

    Shoulder Dystocia Maternal obesity, diabetes mellitus, postterm pregnancy

    Cesarean Section Indications Health of mom or baby endangered by labor, Dystocia precludes vag delivery, Emergent situation, Herpes, Prev C section if contributing factor still exists, Malpresentation of fetus

    Premature Rupture of Membranes Pooling of fluid in vagina, + nitrazine test, + ferning test, risk of endometritis

    Polyhydraminos Duodenal Atresia, Tracheoesophageal fistula, Anencephaly

    Oligohydraminos Renal Agenesis, Pulmonary hypoplasia

    PEDIATRICS
    Fetal Alcohol Syndrome IUGR, Microcephaly, Short palpebral fissures & philtrum, Cardiac Abnormalities, SGA, mental retardation, microencephaly

    Fetal Narcotic Exposure Hypertonicity, Sweating, Stuffy Nose

    Fetal Cocaine Exposure Limb reduction malformations, Intestinal Atresia, Jittery, tremors

    Grey Baby Syndrome chloramphenicol use, decr. metabolism due to immature liver, CV collapse, maybe fatal

    Erythroblastosis Fetalis Rh neg mom Rh + baby; Subsequent Rh + babies are at risk; Give RhoGam - binds to fetal RBC, prevents Antibodies from being made

    Beckwith Weiderman neonatal hypoglycemia d/t hyperinsulinemia, macroglossia, giantism, omphalocele, kidney anomalies, facial nevus flammus, poor prognosis

    Apt Test Determine cause of neonatal rectal bleed; differentiates adult vs fetal hemoglobin

    Dubin Johnson Chronic idiopathic jaundice

    Erb Duchenne C5-C6, flail arm (int rotation & abduction) due to traction on head during delivery; If c4 involved - paralytic diaphragm also present

    Henoch Schoenlein Pupura kids, allergic vasculitis, non-blanching petechiae or pupura on lower extremities only, arthralgias, abd pain, hematuria, proteinuria, coag & platelets are WNL; Immune mediated after virus or strep

    Kawasaki's look sick w/ fever > 5d, truncal rash, incr. cervical nodes, URI sx, "glove" desquamation on palms, feet, lips; Assoc w/ coronary artery aneurysm; TX: High dose asa, IV gammaglobin, Steroids contraindicated
    4 out of 5 =bulbar conjunctivitis, erythematous mouth, lips & tongue; polymorphous erythematous rash, induration of hands & feet w/ erythema, solitary unilateral cervical lymph node < 1.5 cm; Thrombocytosis after 10th dy is common

    Kleinfeltters XXY, most common hypogonadal syndrome; + BARR body, small firm testicle, azospermia, incr. FSH

    Meckel's Diverticulum 2 ft from ileocoecal valve, 2 in long, 2& population, 2 tissue types (gastric or pancreatic) sx before 2 yrs old

    Newborn Blood 85 cc/kg, Hgb 14 - 22 gms/dl HCT 44-64%; incr. alk phos than adults & is incr. until adolescent growth spurt

    TORCH Toxoplasmosis, syphillis, rubella, CMV, herpes

    CMV maybe asymptomatic or deafness, blindness, jaundice, petechia, fever, seizure, mental retardation, IUGR; Transplacental passage of virus

    Cong. Rubella IUGR, cataracts, glaucoma, microphthalmia uveitis, retinitis

    Kernicterus unbound bili crosses blood brain barrier resulting in neuro problems or death

    Prolonged Hyperbili Bili > 10 at 10 days of life
    Photo therapy can be used as long as direct isn't > 1 mg%

    Hemorrhagic Disease of Newborn Deficiency of vitamin K dependent factors (2-7-9-10)

    Intrauterine Shunts placental, ductus venousus , foramen ovale, ductus arteriosus Ductus venosus = ligamentum venosus; Ductus Arteriosus = Ligamentum Arteriosus

    Growth & Development 1st teeth - 6-9 mos; Neuromuscular development in cephalocaudid direction; 4 wks regard face, smile 4-6 wks, social laugh 4-5 mos; 15 mos stack 2 blocks; 18 mos stack 3 blocks; walk up stairs 20 mos ; w/ alt feet 3 yrs;
    Drawing = circle 2.5-3; cross 3-4; Square 4-5; Triangle 5; Diamond 6 yr
    Wt Gain = BW by 10d; 15 lbs 1st yr, 6-7 lb 2nd yr
    Length = 10 in 1st yr, 5 in 2nd yr; < 2in / yr is abnormal
    Head Circumference: 0-35; 3-40, 9-45, 3-50, 9-55 cm
    # Alveoli increase as lungs grow; # nephrons don't increase after term

    ADHD 3x more male than female; inattentiveness, impulsivity, hyperactivity

    SIDS Peak 2-4 mos, declines after 6 mos; 60:40 male:female;
    Risk Factors: < 20yrs old, poverty, smoking
    Apnea of prematurity in infants < 34 wks gestation; Tx: tactile stimulation, decr environmental temp, incr O2, transfuse to get Hct to 45%; CPAP, theophylline, last resort = mech vent

    Special Human IG hepatitis B, Rabies, Tetanus, Varicella Zoster, CMV

    CHF in Peds cardiomegaly, tachypnea, hepatomegaly

    Noncyanotic Cong Heart Disease ASD, VSD, AV septal defect, PDA, coarction of aorta, aortic stenosis, MVP

    Cyanotic Heart Disease Tetralogy of fallot, pulm Atresia w/ VSD, tricuspid Atresia, hypoplastic left heart, transposition of great vessels, anomalous pul venous return, truncus arteriosus

    Rheumatic Fever carditis, polyartheritis, sydenham chorea, erythema marginatum, subcutaneous nodules; Mitral insuffucuency most common valvular residual = Carey Coombs murmur

    Acute Myocarditis Coxsackie B #1, Coxsackie A, CMV, mumps, herpes, adenovirus

    Otitis Media Moraxella Catarrhalis #1 cause of bacterial in infants < 18 mos

    Epiglotitis prior to vaccine H. flu most common cause; peak ages 3-8 ys

    Resp Infections < 5 Viral pneumonia = RSV, Bacterial pneumonia = strep; Lower resp infection = mycoplasma pneumonia ( Eaton Agent, 1o atypical pneumonia or walking pneumonia); Croup = rhino, RSV #2;

    Pyelonephritis poor feeding, irritability, and seizure ; r/o sepsis

    Hemorrhagic Cystitis Adenovirus

    Neurogenic Diabetes Insipidus x linked recessive, renal ADH receptors; Sx polyuria, polydipsia, FTT; r/o psychogenic polydipsia; Due to hypofunctioning hypothalamus or posterior pituitary w/ ADH deficiency

    Rashes Measles (rubeola); Face then body; Cough, Coryza, Conjunctivitis, Koplik's spots
    Scarlet Fever = red skin folds (Pastia sign), strawberry tongue, sandy exanthum on trunk => flexor surfaces
    German Measles (Rubella)
    Filatov Dukes Disease (4th. No longer used)
    Erythema Infectiosus (5th disease) parvo B19, slapped cheek; circumoral pallor => lacy reticular rash
    Roseola infantum (herpes 6)High fever then after fever get rash 1st on trunk then face
    Rash on face 1st = measles, 5ths, Rubella
    Rash on Trunk 1st = Scarletina, Roseolla, Chickenpox
    Rashes on Palms & Soles = Erythema Multiforme (Stevens Johnson); Hand Foot & Mouth (Coxsackie A19; Kawasaki, Rocky Mt Spotted Fever, 2o syphillis, TEN, Dermatomyositis

    Infectious Mono EBV, Dx by positive heterophile test (Paul Brunnel Ab); hepatosplenomegaly

    Conjunctivitis Neonatal infectious = Chlamydia trachomatis,minimal discharge, congestion & edema 7-14 days after birth

    Rocky Mountain Spotted Fever Rickettsia rickettsii, high fever, peripheral rash, Atlantic seaboard, wood & dog ticks

    Cat Scratch Disease R. Henselae; regional lymphadenitis; Chemical = silver nitrate

    PKU blonde hair, MRDD, seizures, eczemoid rash

    Galactosemia Auto recessive, n/v/d, jaundice, hepatomegally, cirrhosis & cataracts if untreated

    Homocysteinuria tall thin stature w/ MRDD sublaxation, lens, genu valgum (knock knee), pectus carinatum

    Lesch Nyhan Purine metabolism; normal until 6-8 mos; loss of motor milestones; incr. spasticity, self mutilation without loss of sensory feeling; Urine has orange uric acid crystals
    Self mutilation w/ loss of sensory = familial dysautonomia

    Hurler's Syndrome mucopolysaceharidosis, grotesque coarse features, skeletal anomalies, dead by age 10

    Glycogen Storage Disease Von Gierke, Pompe, Forbes

    Tay Sachs Lipid Storage, Jewish , defic of hexosaminidase A; normal at birth then loss of motor milestones & hypotonia at 6 mos, Death by age 2; Cherry red macula

    ALL most common malig of childhood, peak at age 4; thrombocytopenia, anemia, elevated uric acid & LDH; Dx by bone marrow biopsy showing infiltration of leukemia blast cells; CXR = mediastinal mass or widening, 2o ary to lymphadenopathy

    Brain Tumors most common solid tumor of childhood; < 2 intratentorial tumors > 2 supreatntorial tumors
    Morning vomiting = posterior fossa ependymoma
    Astrocytoma most common brain tumor

    Hodgkins Lymphoma Reed Sternberg Cells; Painless cervical lymphadenopathy

    Neuroblastoma Neural crest of sympathetic ganglia or adrenal medulla; 50% before age 2; 90% before age 5; and mass that crosses the midline

    Nephroblastoma asymptomatic abd mass; HTN, Ages 2-5; Aniridia (loss of iris) hemihypertrophy Also called Wilm's Tumor

    Rhabdosarcoma Most common soft tissue sarcoma; < 10yrs old; nasal, aural, anus or vaginal area

    Ewing Sarcoma diaphyses
    Osteosarcoma Metaphyses, #1 site distal femur
    Retinoblastoma Neuroectodermal malignancy , most occur before age 5; Leukocoria (white pupil reflex)
    G6PDase Defic most common red cell enzyme deficiency that causes hemolytic anemia; usually asymptomatic until exposed to stress, infection or certain foods; Cause of hyperbilirubinem
  7. Guest

    Guest Guest

    PSYCHIATRY
    Axis Determination I = clinical psych disorders II personality disorders, III Coexisting medical conditions IV psychosocial stressors, V global assessment of functioning

    Schizophrenia Positive Sx: delusions, hallucinations, bizarre behavior; Negative Sx: alteration of affect, ambivalence, apathy, loosening of associations; males=females; industrial nations have incr. prevalence; Misalignment of cells in cortex; incr. ventricle size; decr. activity in frontal cortex on PET scan.
    Disorganized: insidious, incoherent, inappropriate affect, social impaired
    Catatonic: rigidity, posturing or excitement, negativism
    Paranoid: highest functioning type, grandiose, jealous, persecution
    Undifferentiated: not defined by other subtypes
    Melerill = Retrograde ejaculation, Tx: Respiradol (Best side effect profile), Clozaril (agranulocytosis w/ weekly CBC) prescribed weekly,
    Neurolyptic Malignant Syndrome = incr. temp, incr. CPK, rigidity

    Schizophrenifrom same sx as schizophrenia but have lasted for less than 6 months

    Schizoaffective mood disorder and separate psychotic sx. Must experience 2 weeks of psychotic sx w/o mood impairment for dx to be made; Antidepressants are 1st line tx

    Major Depression loss of interest in activities, sleep, wt, concentration, hopelessness, suicidal ideation, nihilism; Seasonal affective, Vegetative (non functioning can be terminal) Dysthymia(chronic low level); Reactive related to environment w/o severity id sx; Masked 1o depression denied or hidden by other sx
    Depression & anxiety can occur together & can be treated w/ an antidepressent; Left anterior or rt posterior stroke => incr. possibility of depression; Tx: 1st Tricyclic (Imiprimine); SSRI = side effects; Trazadone=priapism Asendin (Amoxipine) = Extrapyramidal Symptoms

    BiPolar Bimodal peak 20's & 30'sCycling mood= highs w/ euphoria, hyperactive, pressured speech, flight of ideas, decr need for sleep, delusions, inflated self esteem, risks, poor judgement; Lows are major depressive episodes tx: lithium

    Panic Attacks Sudden, unprovoked onset of fear, impending doom, palpitations, SOB, chest pain, smothering, dizziness. May be associated w/ agoraphobia Tx: with SSRI's

    Phobias Persistent and irrational fear of a specific object or activity or situation. Tx like a phobia

    Obsessive Compulsive Persistent, unwanted thoughts, impulses or images
    repetitive, purposeful intentional behaviors meant to decrease tension caused by the obsessive thoughts; genetic Tx: Anafranil (Tricyclic) Prozac & Luvox (SSRI)

    PTSD intrusive recollections, daydreams, nightmares, poor concentration, psychic numbing; Tx: don't treat w/ meds unless compulsion component
    Studies: Buffalo Creek Disaster, Beverly Hills Nightclub

    Dissociative Disorder Amnesia = loss of memory, Fugue = assoc w/ physical flight, Identity Disorder = multiple ego states; Depersonalization = feelings of self estrangement or unreality

    Whirndingo Fear of becoming a cannibal

    Amok sudden unprovoked outburst of wild rage usually ending in homicide

    Coprolalia Feces & filth

    Koro penis is shrinking and may disappear

    Latah imitate words or actions to which they are exposed

    Piblotko Run around in snow naked

    White Out Syndrome lack of diverse stimuli in snow clad environment

    Narcolepsy REM sleep, sudden onset of daytime sleep and cataplexy; REM sleep is inappropriately present at beginning

    Personality Disorders Cluster A = Bizarre = Paranoid, Schizoid (no close relationships, restricted emotions) Schizotypical (schizoid + odd or distorted behavior or cognition)
    Cluster B = Over emotional = Antisocial (Disregard for social norms) Borderline, Histrionic, Narcissistic (self centered)
    Cluster C = Anxiety & Fear = avoidant, dependent, Obsessive compulsive
  8. Guest

    Guest Guest

    POISONING & ACCIDENTS
    Burns 1st= only epidermis, red no blister; 2nd = hyperemic, blister; partial thickness; 3rd = full thickness, leathery no pain; 4th = electrical injuries, damage to nerves & bone; entry & exit burn; Fluid resc. If > 20% Parkland formula = 3-4 ml/kg LR x % burn RULE of 9's: head = 9; ant trunk= 18 post trunk = 18, each incr. ext = 9; each decr. ext = 18, Perineum = 1

    Common Poisons & Antidotes: Aspirin = Dialysis; Acetaminophen =N-acetylcystine; Digitalis = lidocaine; Methanol & Ethylene Glycol = Ethanol; CO = O2; Narcotics = Narcan, Naloxone; Iron = Deferoxamine; Cu, As, Pb = Penicillamine; Cyanide = Sodium nitrite, or sodium thiosulfate

    Types of Fx Open(compound); Simple(closed); Greenstick (incomplete, children usually); Spiral (twisting breakage); Comminuted (multi bone fragments)

    Vertebral Fx Most common cause of paraplegia & quadriplegia, Compression Fx seen in elderly due to osteoporosis & DJD

    Hip Fx Avascular necrosis of femoral head if blood flow is compromised; Tx: immobilization, bedrest, surgery; Prevention= safety & Ca supplement in women

    Skull Fx Signs of Fx: 1.Battle's Sign = discoloration over mastoid bone; 2. Blood draining from ears, 3. Bruising of orbit, CN palsies, CSF leakage from ears & nose

    Rib Fx Most common thoracic injury; usually 5-9, local pain worse w/ inspiration

    Colles Fx most common wrist fx; breakage & displacement of distal radius, Attempted to break fall on outstretched hand

    Elbow Fx <10 yrs old, fall on outstretched hand w/ elbow in full extension; Compression or radial or median nerve or brachial artery; Improper care => Volkman's Ischemic Contracture

    Pelvic Fx MVA, 30% blood volume can be lost; Tx as if shock victim

    Tibial Fx Compartment syndrome= bleeding into tight compartments=> blood supply compression=>muscle ischemia; 6 Ps = pain, pallor, pulselessness, puffiness, parathesia & paresis (weakness) or paralysis. Surgical opening of compartment

    Sprains Tx = RICE => Rest, Ice, Compression, Elevation

    Concussion transient loss of consciousness; Coup = bruising under site of injury; Contrecoup = bruising on side contralateral to injury

    Blunt Eye Trauma periorbital echymosis, hyphema (bleed into anterior chamber; edema; Blowout Fx = Fx of orbital bone; Aspirin & anticholinergics are contraindicated

    Blunt Ear Trauma Auricular Hematoma (cauliflower ear) Tx prompt drainage to prevent dissolution of cartilage

    Dog & Cat Bites Pasturella multocida; Tx tetanus & rabies if needed, antibiotics

    Snake Bite Splint affected area & transport; In US usually pit vipers

    Spider Bite Black Widow: Vomiting, abd pain, shock; Tx Calcium gluconate & methocarbamol; Local bite Tx not needed
    Brown Recluse: bite becomes black scab w/ assoc fever, rash, vomiting & jaundice; DIC can occur; Tx: Dexamethasone, dapsone, colchcine & total excision of lesion

    Hypovolemic Shock Hemorrhage, Burns, Vomiting, Diarrhea; pale skin, JVD, incr. vasc resistance, incr. pulse Tx: rehydrate, transfusions,

    Septic Shock Infection, gangrene, necrosis,CV obstruction; pale/pink skin; flat neck veins, incr. pulse incr. or decr. vascular resistance Tx ventilation, Fluids, antibiotics

    Cardiogenic Shock Pale skin, flat neck veins, incr. pulse, incr. vascular resistance; Tx: medication for underlying problem, pacemaker,

    Neurogenic Shock Spinal cord injuries, drug OD; Pink skin, flat neck veins, normal => low pulse, low vascular resistance Tx: ventilation, fluids, drainage
  9. Guest

    Guest Guest

    PUBLIC HEALTH
    Levels of Prevention: 1o = actions to decr. incidence of health problems (prenatal care, immunizations)
    2o = interventions at early stage of disease to limit development (DM screen, PAP)
    3o = interventions to treat problem and prevent further morbidity & mortality

    Special Tests Complement & Complement disorders C3, C4, CH50
    Rheumatiod - ANA, RF
    Lupus - DNA, Anti Smith Antibody
    Scleroderma - Scl-70, Anti Centromere
    Sjogrens -SSA Anti Ro, Anti LA
    Prostate = PSA, Pancreatic = CA 19-9,Ovarian=CA125; Breast = CA15-3 & CA27-29
    Testiclar = BHCG, AFP, Thyroid = Calcitonin
    10 Biliary Cirrhosis = Anti mitochondrial antibody
    Wilson's Disease = Ceroluplasmin Antibody
    Liver = Alpha 1 antitrypsin
    Thyroid - Antimicrosomal antibody, Thyroglobin antibody
    Incidence # new cases / total population
    Prevalence # cases at a given time / total pop at that time
    Disease Frequency # people w/ disease / population at risk
    Case Fatality # who die in a given period/ # people w/ disease

    Relative Risk Only from cohort study; a/a+b divided by c/c+d; >1 positive assoc, < 1 negative association, =1 no association ==> disease if exposed /disease if not exposed

    Odds Ratio Only from case control; odds of getting if exposed / odds of getting if not exposed (ad/bc)

    Mortality Rate # people that die w/ in current population
    Std Mortality Rate Adjusted according to age distribution
    Attributable Risk exposed rate - unexposed rate
    Sensitivity a/a+c; accurate diagnose ; incr. False +
    Specificity d/b+d; Prob of neg test in those truly neg; incr. false neg
    OMM
    Fryettes Laws 1. Side bending then rotation in neutral position
    2. Flexion or extension with rotation then side bending
    3. Motion free in one direction is restricted in the other

    Ribs 1-5 pump handle, 6-10 bucket handle, 11-12 caliper; Elevated = expiration restricted Treat lower ribs 1st; Depressed = inhalation restriction, treat upper ribs 1st

    Flexion Test Standing = ilia sacral; Seated = sacroiliac; false neg = tight hamstrings on standing flexion; False positive = tight quads on standing flexion

    Sympathetic Innervations Head & Neck = T1-4; Lung T2-5 bilat; Heart T2-5 Left, Stomach T5-9 Left; Duodenum T10 rt; Gall Bladder T9 rt; Liver T5-9 Rt, Pancreas T6-9 bilat, Kidneys, Ovaries, Testes T10-L1 of respective side; Adrenals T10-11, Appendix T11-12 Rt, Bladder L3-4, Uterus L4-5, Rectum & Anus L4-5

    Parasympathetic Innervations Eyes=CN III; Nasal sinuses, Eustachian Tube=CN VII; Soft Palate, Salivary Glands=CN IX; Thyroid thru Transverse Colon=CN X (Vagus); Right Colon & Pelvis= Pelvic Splanchnic Nerves S2-4

    Somatic Dysfunction An altered or impaired function of related components of the somatic system
    Qualities: Texture chg, asymmetry, decr. ROM, tenderness

    Treatment Types Direct = engages restricted barrier & pushes thru it, Force takes it from where it is to where it will not go
    Indirect = Move away from the barrier, Leaves the structure in the position it was

    Direct Technique Used For: Subacute or chronic, no assoc osseous pathology post closure of epiphyseal plate, Short restrictors

    Indirect Technique Used For Acute, A lot of pain, a lot of restriction, non closure of epiphysis

    HVLA Contraindications
    Direct, Passive Absolute = Weak bony structure, spinal cord, nerve compressions, Danger of vascular damage;
    Relative: lax ligament, acute inflammation, pregnancy, Calcification of aorta, Recent MI, spondylosis, Ankylosin Spondylitis, Osteoporosis, Chronic Steroid use, Acute disk disease, Extreme scoliosis, Cauda Equina Syndrome, Adv. Degenerative disease, Severe DM, Hx or current malignancy, Agenesis Odontoid process, Vertigo

    Counter Strain
    Passive Indirect Put joint into position of greatest comfort; Agonist-Antagonist pair; Strain due to rapid stretching followed by protective immediate shortening of agonist along with rapid shortening then lengthening of antagonist
    Most comfort of pt (70%) Hold for 90 sec (120 secs for ribs) Reactions to Tx: generalized soreness, treat no more than 6 TP at a time, 3 days between Tx;

    Muscle Energy
    (Active then passive, direct) Type I = Joint mobilization using direct muscle force
    Type II = Muscle lengthening using postisometric relaxation, "Resetting the Gamma Gap or Synaptic Fatigue
    Type III = Muscle lengthening using Reciprocal Inhibition
    Type IV = Muscle relaxation using Crossed Extensor Reflex - Used w/ sever injury (flexor muscle on one extremity is contracted the flexor on opposite extremity relaxes & extensor contracts)

    Natural Body Rhythms Cardiac/Vascular, Ventilatory, Visceral, Cranial Rhythmic Impulse (CRI), Slow Undulating (Breath of life)

    Articular Mobility of Cranial Bones Newborn: Base is cartilage for stability, vault is membrane for accommodation Sphenoid motion - influences facial & frontal bones; Occipital Motion - influences temporals (mandible & hyoid) & parietals

    Motion of Sacrum between the Ilium Superior transverse axis, Located at S2, Only area of anterior convergence & posterior divergence of the SI joint

    Coordination of motion Inhalation = midline flex, paired ext rotate, sacral base post, SBS rises
    Exhalation = midline extension, paired int. rotation, sacral base anterior SBS falls
    Sacrum & Temporal follow movement of occiput; Facial bones follow motion of sphenoid

    Strain Patterns Torsion, Side bending rotation, Vertical Strain, Lateral Strain, Compression

    Naming Convention Vert unit, AP, side bending, rotation

    Type of Motion C0-C1 (OA) Type I; C1-C2 Rotation; C2-C7 Type II; C7-L5 Type I & II

    ACID BASE
    pH acedemia < 7.35-7.45 < alkalemia
    pCO2 Resp alkalosis < 35 - 45 < Resp acidosis
    HCO3 Metabolic Acidosis < 22-26 < Metabolic alkalosis
    Anion Gap = (NA) - [(Cl) + (HCO3)]
    Primary disorder pCO2 or HCO3 altered same way as pH
    Thanks 2 eaziz
  10. khint

    khint Guest

    Thanks/very helpful
  11. Guest

    Guest Guest

    Dear Doctor ATZ,


    Very very thanx 4 ur contribution.

    It was very nice and comprehensive note/poits u posted.

    We are indebted to u.

    Any such material u have ,plez do post on the web or e-mail me.
    With regards,

    Dr Vaijinath Dhapase
    v.dhapase@yahoo.co.in

    KSA Cellphone-00966 509684899
  12. Guest

    Guest Guest

    Thankx a lot for your great effort.
    it is really good tips.
  13. Guest

    Guest Guest

    this kind of effort is remarkable, please keep up the good work

    will certainly reward you by passing the exam ,

    thanks a lot
    Dr H Sigauke
  14. BLS

    BLS Guest

    Thanks :)

    Thanks a lot!
  15. Guest

    Guest Guest

    REALLY THX ALOT
  16. Oo

    Oo Guest

    Thanks

    It is very useful.
    That's all you can remember and it is really helpful for MCQ
  17. Guest

    Guest Guest

    Hi,

    Thank you for your helpful post.
  18. li_brizi

    li_brizi Guest

    thanks...

    thanks a lot.....very interesting way of freshing up the mind !
  19. Guest

    Guest Guest

    Thanks that was a quick and good excercise for the brain expecting more and keep it up.
  20. kavidhai

    kavidhai Guest

    Thank u

    Dear ATZ,
    Thank u so much for generously sharing ur notes.It is very very useful to remember many facts.we are greatly indebted to u for ur post.
  21. musaab

    musaab Guest

    thank you

    oh thanks really, God Bless your steps..it was very helpful indeeed :)
  22. random

    random Guest

    Thank u..it takes a lot of hardwork to do this...really appreciate it!
  23. chinni2009

    chinni2009 Guest

    hey ANZ...thanx a lot for the quick notes....very helpful....
  24. Dr  Iman

    Dr Iman Guest

    thanx:)

    thanx alot for helping us out.its really very helping
  25. Guest

    Guest Guest

    Nice post, thanks for sharing this information.
    Good to know that this topic is being covered. Keep up with the good work.

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