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Pediatrics:
1. With supracondylar fractures, the brachial artery can be compromised, resulting in the
loss of the radial artery pulse; therefore, the radial artery pulse must be assessed when the
fracture is reduced. Supracondylar fractures are the MC fractures in the pediatric
population.
2. Pure riboflavin (vit. B2) deficiency is unusually in industrialiaed nations, but has been
documented in regions of the world with severe food shortages. The condition is typically
mild and nonspecific in presentation, but symptoms may include sore throat, hyperemic
and edematous oropharyngeal mucous membranes, cheilitis, stomatitis, glossitic,
normocytic-normochromic anemia, seborrheic dermatitis, and photophobia.
3. Ascorbic acid deficiency (Vit C): ecchymoses, petechiae, bleeding gums,
hyperkeratosis, Sjogrens syndrome, arthralgias, impaired wound healing. Systemic
manifestations include: weakness, malaise, joint swelling, arthralgias, edema, coiled hair,
depression, neuropathy, vasomotor instability.
4. Pellagra: (niacin deficiency): symmetric reddish rash present in exposed areas of skin,
a red tongue, nonspecific symptoms such as diarrhea, vomiting, insomnia, anxiety,
disorientation, delusions, dementia, encephalopathy. May be observed in alcoholics,
long-trem users of isoniazid, and those stricken with carcinoid syndrome or Hartnup
disease.
5. Leiomyomas: MCC of hysterectomy, Malignant transformation is extremely rare.
6. Depression: is a valid reason for a patient to be considered incompetent to make
decisions. Refer the patient for psychiatric evaluation of depression first, then treat the
patient.
7. Retinal detachment: usually painless, sudden onset, seeing flashes of light, seeing
floaters of black spots in the field of vision, unilateral involvement.
8. Asthma:
Acute attack: 2-antagonist
Chronic obstructive pulmonary disease exacerbation: Ipratropium
Prophylaxis: cromolyn and zafirlukast
Prednisone doesnt provide immediate relief but reduce inflammation several hours
later and often are useful adjuncts to 2-antagonist
9. Thiamine deficiency: associated with beriberi, Wernicke-Korsakoff syndrome.
Manifestations of infantile beriberi appear between the ages of 2 and 3 months, and
include a fulminant cardiac syndrome with cardiomegaly, tachycardia, cyanosis, dyspnea,
and vomiting.
10. Adult beriberi: is categrorized as dry or wet.

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Dry beriberi is characterized by a symmetrical peripheral neuropathy accompanied by

sensory and motor impairments, especially of the distal extremities.
Wet beriberi includes neuropathy in addition to cardiac involvement (e.g. cardiomegaly,
cardiomyopathy, congestive heart failure, peripheral edema, tachycardia)
11. Stranger anxiety: is the normal anxiety experienced by infants when they are exposed
to unfamiliar individuals. It peaks at 12-15 months.
12. Acute post-streptococcal GN: is the MC form of GN in children. It may occur
following pharyngitis or pyoderma.
HTN+edema
C3 and CH50, but C4 is normal (this indicates the activation of the alternate
complement pathway).hypocomplementemia resolves in 8-12 weeks.
hematuria, proteinuria (renal function returns to normal in 1-2 weeks)
ASO titer.
13. Bed rest with the hip joint in a position of comfort is the Tx of choice for transient
synovitis of the hip. (the condition will get better in 3-4 days)
14. Meingococcemia: suspect ~ in a neonate with signs of meningitis and a petechial
rash. H.Influenza may cause meningitis but without the rash. Listeria can cause
meningitis but without the rash either. GBS can casue meningitis and with a rash, but it is
very rare in 18 M infant, but shortly after birth.
15. Myotonic muscular dystrophy (MMD): an AD disease which is known as Steinert
disease. The 2nd MC muscular dystrophy in the U.S. The pathology is distinct in that all
types of muscles (ie. Smooth, striated, cardiac) are involved. Presentations: muscle
weakness, progressive muscle wasting, posterior forearm muscles, anterior compartment
of the lower legs. Temporal wasting, thin cheeks, an upper lip in the shape of an inverted
V. Myotonia is defined as delayed muscle relaxation, and the classic example is the
inability to release the hand after a handshake.
16. Causes of amblyopia: --std Tx: occlusion of the normal eye.
Strabismus (MCC)
Errors of refraction
Opacity of media along the visual axis
17. Clubfoot is initially managed with stretching and manipulation of the foot, followed
by serial plaster casts, malleable splints, or taping. Surgical Tx is indicated if
conservative management gives unsatisfactory results, and is preferably performed
between 3 and 6 months of age. (mild atrophy of the calf, calcaneum and talus are in
equines and varus positions, midfoot is in varus position, forefoot in adduction.
Dorsiflexion and plantar flextion of the ankles are limited. Normal neurologic
examination.)

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18. Todds paralysis: represents a postictal condition that usually rapidly improves with
restoration of motor function within 24 hours. (hemiparesis. Sudden loss of
consciousness with following disorientation and slow gain of consciousness is a
characteristic description of a seizure, if the convulsive episode was missed.) It may
follows a generalized as well as focal seizures.
19. Neuroblastoma: the 3rd MC cancer in the pediatric population (after leukemia and
CNS tumors). Arise from neural crest cells, which are also the precursor cells of the
sympathetic chains and adrenal medulla. Calcifications and hemorrhages are seen on
plain X-ray and CT scan. The levels of HVA and VMA are usually elevated. May arise
from adrenal or any location along the paravertebral sympathetic chains. Easy to
metastasize.
20. Psoriasis: more common in white, positive family history, pitting of the fingernails,
arthritis (DIPs always involved).
21. Whenever IV access cant be obtained in emergent pediatric cases, intraosseous
access should be attempt next.
22. Guillain-Barre syndrome: suspect ~ in a child who presents with an ascending
polyneuropathy one week after apparent viral infection. The underlying pathology
involves mainly the peripheral motor nerves, although sensory and automomic nerves
may also be affected. Associated with Campylobacter jejuni enteritis. Tx. plasmapheresis,
immunoglobin (IV), no prednisone here (ineffective and may prolong recovery.
23. Child developments:
Language development:
Social smiles: 2 M
Babbles: 6 M
2-words, obeys 1-step command: 1 Y
2-3 phrases, obeys 2-step command: 2 Y
Gross motor development:
Holds head: 3M
Rolls back to front and front to back: 4 M
Sits well unsupported: 6 M
Walks alone: 1 Y
Walks up and down stairs without help: 2 Y
Fine motor development:
Raking grasp: 6 M
Throw object: 1 Y
Build tower of 2 blocks: 15 M
Build tower fo 6 blocks/turn pages of books: 2 Y

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Social development:
Recognizes parents: 2 M
Recognizes strangers (stranger anxiety): 6 M
Imitates action/comes when called: 1 Y
Plays with other children : 18 M
Parallel play: 2 Y
24. Osgood-Shlatter disease: typical patient is a 10-17 yo boy with knee pain at the tibial
tuberosity, which is the site of insertion of the quadriceps tendon.
25. Septic joint in a child is a true surgical emergency and needs immediate surgical
drainage. A delay of even 4-6 hours can lead to avascular necrosis of the femoral head.
26. Subarachnoid hemorrhage (SAH): can be cuased by an intraventricular hemorrhage,
which is common in premature infants. Accumulation of the blood in the subarachnoid
space may lead to destruction of the arachnoid villi and cisterns, thereby blocking the
flow or decreasing the absorption of CSF and leading to communicationg hydrocephalus.
SAH is the MCC of communicating hydrocephalus.
27. MCC of syncope: vasovagal.
28. Sudden infant death syndrome (SIDS): is the leading cause of mortality in infants
between 1 M and 1 Y, and the 3rd MCC of mortality in infants <1 Y.
29. Perinatal problems: is the leading cause of mortality in infants < 1 M.
30. Drugs/diseases associated with hirsutism:
Minoxidil (anti HTN agent, used to treat alopecia)
Polycystic ovary syndrome
Cushing syndrome
cyclosporine
31. Pyloric stenosis: a 4-6 week old infant with projectile vomiting that worsen over time.
Peristaltic waves are seen over the upper abdomen, and an olive-sized mass is palpated.
Tx: surgical correction.
32. Vesicourteral reflux: Reflux is a risk factor for UTI. Repeated attacks can lead to
progressive renal scarring, which is the major cause of end stage renal disease and HTN
in children. Dx of VUR is best made with a voiding cystourethrogram (VCUG) or a
radionucleide cystogram (RNC). Suggested after 1st UTI.
33. Bedwetting: is considered normal until the age of 4-5 yrs. If nocturnal enuresis
persists, DDAVP (DOC) or imipramine may be used.
34. Mild protein intolerance: should be suspected when a neonate presents with bloody
diarrhea (maroon-colored), eosinophils in the stool, and a positive family history of

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atopy. (e.g. mom is asthmatic)

35. Precocious pubarche with signs of severe androgen excess is suggestive of precocious
pseudo-puberty that is casued by a gonadotropin-independent process (typically an excess
of sex steroid, such as in a late onset congenital adrenal hyperplasia-21 hydroxylase
deficiency)
36. Tuberous sclerosis (infantile spasm): best Tx is im ACTH. Presents with: episodes of
jerkey movements of the neck, arms, and legs onto the trunk, occur in clusters, last for a
few minutes, often preceded by a cry. Multiple small 1-2 cm oval irregular
hypopigmented macules, ash-leaf spots, shagreen spots (orange peel lesions, sebaceous
adenomas on her trunk and extremities. A head CT: cortical tubers in the cerebral cortex
and multiple subependymal nodules in the lateral ventricles. EEG: hypsarrhythmia.
Chromosome 9 & 16
37. An immediate anaphylactic reaction, an encephalopathy, or any CNS complication
within 7 days of administration of the vaccine is a contraindication for further
administration of DTaP. In these instances, DT should be substituted for DTaP since the
adverse reactions are usually attributed to the pertussis component of the vaccine.
*extremely HY Q for USMLE*
38. Congenital anomalies are the 2nd leading cause of death in infants < 1 Y.
39. Cyclical vomiting: recurrent self-limiting episodes of vomiting and nausea in
children, in the absence of any apparent cause, suggest the Dx. Its incidence is high in
children whose parents have a history of migraine.
40. Chlamydia: is the MC causative agent of infectious neonatal conjunctivitis.
Chlamydial pneumonia can develop in infected infants (congenital chlamydial infection).
41. Friedreich Ataxia (FA): autosomal recessive disease. (triplet repeatstocopherol
transfer protein abnormality): progressive with poor prognosis. vibratory and position
sense in the lower extremities, feet are deformed with high plantar arches. MRI of the
brain and spinal cord shows marked atrophy of the cervical spinal cord and minimal
cerebellar atrophy. Nerve conduction velocity normal. EKG shows T-wave inversions in
the inferior and lateral chest leads.
42. T wave inversion differentials:
MI
Myocarditis
Old pericarditis
Myocardial contusion
Digoxin toxicity
43. Tx of choice for local impetigo: topical mupirocin, or, oral erythromycin.

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44. Febrile seizure: Consider the Dx of ~ when an otherwise healthy child presents with a
fever and isolated seizure. These seizures are benign and mangaged with antipyretic
therapy.
45. Pubertal gynecomastia: is seen in approximately one-half of adolescent boys, at an
average age of 14 years. It is often asymmetric or transiently unilateral, and frequently
tender. In prebubertal males the testicular size is normally 2 cm in length and 3 mL in
volume. The initial management involves reassurance and watchful waiting/observation.
*extremely HY Q for USMLE*
46. APGAR:
Color of the newborn:
0 body and extremities are blue/pale
1 body is pink and extremities are blue
2 body and extremities are pink
Heart rate:
0 heart shows no activity
1 HR <100
1 HR > 100
Reaction to nasal stimulation:
0 no response
1 grimace
2 active cough
Tone/Activity
0 limp
1 some flextion of extremities
2 active flextion of extremities
Respirations:
0 completely absent
1 slow and irregular
2 good respiratory effort
47. Craniopharyngioma: a young boy with symptoms of increased intracranial pressure
(headache, vomiting), bitemporal hemianopsia, and a calcified lesion above the sella has
a ~ until proven otherwise. Presence of a cystic calcified parasellar lesion on MRI is
diagnostic of craniopharyngioma.
48. Tetralogy of Fallot: the MC cyanotic congenital disease in children less than 4 yo,
presents with cyanotic spells and pansystolic murmur on examination.
Overringding aorta
Right ventricular hypertrophy
Subpulmonary stenosis (single S2)

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VSD (pansystolic murmur)

49. Turners syndrome with 46 XY karyotype: is associated with a higher incidence of
gonadoblastoma; hence, prophylactic bilateral gonadectomy is indicated in the
management of such patients.
50. Endocrinology:
1. A 35yo white male presents with fatigue, decreased appetite, weight gain, constipation
and cold intolerance. He cant recall any stressful event. He does not take any
medications. No smoking no alcoholic. HR 47, BP:145/91mmHg.PE revels cool, pale
skin, coarse hair, and brittle nails. There is delayed relaxation of DTR. The thyroid gland
is normal on palpation. Lab studies reveal increased serum free T3 and T4 level, and
normal serum TSH level. Which of the following is the most likely Dx.?
A. Primary hypothyroidism
B. Secondary hypothyroidism
C. Subclinical hypothyroidism
D. Generalized resistance to thyroid hormones.
E. Graves disease
Answer is D. Patients with generalized resistance to thyroid H. have high serum T4 and
T3 levels with normal to mildly elevated TSH levels. Patients typically have features of
hypothyroidism despite having elevated free thyroid hormones.
2. Elevated serum DHEA-S (Dehydroepiandrosterone-sulfate) levels are specifically seen
in patients with androgen-producing adrenal tumors.
3. A 40 yo asymptomatic male comes to the office for a routine physical examination.
His serum chemistry panel shows:
Sodium:140 mEq/L, Potassium 4.0 mEq/L, Bicarbonate 25 mEq/L, chloride 101 mEq/L
Calcium 11.6 mg/dL Phosphorus 2.2 mg/dL
24-hr urine collection reveals a calcium level of 200 mg, and creatinine level of 1.5 g.
Bone mineral density by dual energy X-ray absorptiometry (DXA) shows normal bone
mineral density. Neck examination reveals no masses. What is the most appropriate next
step in the management of this patient?
A. Bisphosphonate therapy
B. Surgical exploration of the neck
C. Medical surveillance
D. Loop diuretics
E. Thiazide diuretics
Explanation: B. The patient most likely has asymptomatic primary hyperparathyroidism.
Laboratory findings of hypercalcemia, hypophosphatemia and elevated PTH levels are
very suggestive of the Dx. Asymptomatic primary hyperPTH is a common disorder,
particularly in females over 60 yo. Most patients are usually identified during routine
chemistry screening. While surgical intervention is needed for all patients with
symptomatic primary hyperPTH, not all asymptomatic patients require such as. The

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indication for surgery in asymptomatic patients is the presence of at least one of the
following features:
1. Serum Cacium level at least 1mg/dL above the upper normal limit with urinary
calcium excretion greating than 50mg/24hr
2. Urinary calcium excretion greater than 400 mg/24hr.
3. Young patients (<50 yro)
4. Bone mineral density lower than T-2.5 at any site.
5. Difficulty in follow-up of the patient.
4. Spot urine collection and times urine collection for the measurement of urine
microalbumin to creatinine ratio are generally accepted as good screening methods for
microalbuminuria. Although 24-hr urine collection is slightly more accurate in screening
for microalbuminuria, its inconvenience to patients makes it less preferred by physicians.
5. Suspect DKA in stuporous patients with rapid breathing and a history of weight loss,
polydipsia and plyuria.
6. Hyperpigmentation of the skin and mucous membranes is characteristic of primary
adrenocortical deficiency, and is due to the increased levels of ACTH (MSH like). This
clinical feature is not seen in patients with secondary adrenal insufficiency, which is due
to hypothalamo-pituitary failure.
7. The most likely Dx. In a patient who presents with clinical features of adrenal
insufficiency and calcifications in the adrenal glands is adrenal tuberculosis. Adrenal
tuberculosis continues to be the prominent cause of primary adreanal insufficiency in
developing countries. In contrast, autoimmune adrenalitis is currently the MCC of
primary adrenal insufficiency in developed countries.
8. Suspect the following conditions whenever a patient presents with hypokalimia,
alkalosis and normotension.
Surreptitous vomiting
Diuretic abuse
Bartter syndrome
Gitelmans syndrome
Physical findings that are characteristic of surreptitious vomiting are scars/calluses on the
dorsum of the hands, and dental erosions, hypovolemia and hypochloremia, which in turn
lead to a low urine cl concentration.
Always suspect surreptitious vomiting as a cause of hypokalemic alkalosis in a
normotensive patients, and be able to distinguish it from other entities (e.g. diuretic
abuse, Bartters syn.) using the urine chloride concentration.
9. .Diabetes insipidus presents as poly uria, polydipsia, and excretion of dilute urine in
the presence of elevated serum osmolarity.
. Primary polydipsia is due to excessive water drinking; both plasma and urine are
diluted.

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. SIADH results in hyponatremia, low serum osmolality and inappropriately high urine
osmolality.
10. -glucosidase inhibitors block dietary carbohydrate breakdown in the intestinal tract.
The most significant side effects are GI disturbances due to the increased undigested
carbohydrate concentration in the stool.
11. Metabolic acidosis observed during diabetic ketoacidosis is typically accompanied by
hyperkalemia; this is sometimes called paradoxical hyperkalemia because the body
potassium reserves are actually depleted. (extremely HY Q for the USMLE!)
12. The serum albumin level should always be measured simultaneously with the serum
calcium level in order to calculate the correct total serum calcium value. With every 1
g/dL change in serum albumin, serum calcium changes by 0.8 mg/dL.
13. Nonketotic hyperosmolar syndrome (NKHS) occurs in type 2 DM because the level
of insulin in these patients is sufficient to prevent ketosis, but not hyperglycemia. In most
cases, severe hyperglycemia develops, thereby resulting in glycosuria and severe
dehydration. The severe hyperosmolality is also responsible for lethargy, weakness,
altered mental status, focal neurological deficits and eventual coma.
14. Fasting blood glucose measurement is now the recommended screening test for DM.
126 mg/dL on two separate occasions is diagnostic of DM.
15. Untreated hyperthyroid patients are at risk for rapid bone loss resulting from
increased osteoblastic activity in the bone cells. Untreated hyperthyroid patients are also
at risk for cardiac tachyarrhythmias, including atrial fibrillation.
16. Increased extracellular pH levels (e.g. respiratory alkalosis) can cause an increase in
the affinity of serum albumin to calcium, thereby increasing the levels of albumin-bound
calcium, and consequently decreasing the level of ionized calcium. Ionized calcium is the
only physiologically active form, which means that decreased levels of this form can
result in clinical manifestations of hypocalcemia.
17. Important causes of thyrotoxicosis with low radioactive iodine uptake include:
subacute painless thyroiditis
subacute granulomatous thyroiditis
iodine-induced thyroid toxicosis
levothyroxine overdose
struma ovarii
18. Arterial pH or anion gap is the most reliable indicator of metabolic recovery in
patients with diabetic ketoacidosis.
19. Suspect primary hyperaldosteronism in a young patient with hypertension, muscle
weakness and numbness; the most specific lab value for the patient with primary

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hyperaldosteronism is high aldosterone/rennin ratio, indicating automomic aldosterone

secretion.
20. MEN II consists of medullary carcinoma of the thyroid (MTC), hyperparathyroidism
and pheochromocytoma. The serum calcitonin level is elevated in patients with medullary
thyroid cancer. Virtually 100% of patients with MENII have c-cell hyperplasia or MTC,
50% have pheo, and 20-30% have hyperparathyroidism.
21. In the treatment of a patient using both sildenafil and an alpha-blocker, it is important
to give the drugs with at least a 4-hour interval to reduce the risk of hypotension.
22. In patients with MEN IIa syndrome, genetic testing has replaced biochemical
measurement of serum calcitonin as the recommended screening test. If genetic analysis
is positive for a RET proto-oncogene mutation, total thyroidectomy is indicated.

GIT
a. Laxative abuse is characterized by very frequent (10-20), watery, nocturnal diarrhea.
The Dx. can be confirmed with the characteristic biopsy finding of dark brown
discoloration of the colon with lymph follicles shining through as pale patches (melanosis
coli)
b. CT scan is the best test for the Dx. of diverticulitis in acute setting.
c. Suspect ischemic colitis in patients who have evidence of atherosclerotic vascular
disease, present with abdominal pain followed by bloody diarrhea, and have minimal
abdominal exam findings. The most commonly involved segment of the colon is the
splenic flexure, because it is supplied by end arteries.
d. Always suspect Crohns disease in a young patient with chronic bloody diarrhea.
e. Know the stepwise approach of the Tx for ascites:
1. Sodium and water restriction
2. Spironolactone
3. Loop diuretic (not more than 1 L/day of diuresis)
4. Frequent abdominal paracentesis (2-4 L/day, as long as the renal function is okay)
b. Most colon cancers develop from polyps. The risk factors for a polyp progressing into
malignancy are villous adenoma, sessile adenoma, and size >2.5 cm. Only adenomatous
polyps are clearly premalignant, but <1% of such lesions progress to malignancy.
Hyperplastic polyps are non-neoplastic and do not require further work-up. (extremely
HY for USMLE)

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c. Suspect celiac disease in any patient who presents with malabsorption and iron
deficiency anemia. Celiac disease (sprue) is associated with anti-endomysial antibodies.
d. D-xylose absorption is abnormal both in bacterial overgrowth and Whipples disease.
However, with bacterial overgrowth, the test becomes normal after antibiotic Tx.
e. Bacterial overgrowth is a malabsorption syndrome which can be associated with a
history of abdominal surgery.
f. The initial Tx of both acute and chronic anal fissures includes dietary modification (e.g.
high-fiber diet and large amounts of fluids), a stool softener, and a local anesthetic.
g. Suspect tropical sprue in patients with malabsorption, along with a history of living in
endemic areas for more than one month. Tropical sprue involves the small intestine; the
typical biopsy is characterized by blunting of villi with infiltration of chronic
inflammatory cells, including lymphocytes, plasma cells and eosinophils.
h. The two MCC of painless GI bleeding in an elderly patient over 65 years of age are
diverticulosis and angiodysplasia (vascular ectasia). There is a well defined association
between aortic stenosis and angiodysplasia.
i. Iron deficiency anemia is one of the MC presentation of celiac sprue. Upt to 24% of
cases of celiac disease is associated with dermatitis herpetiformis.
j. Drug-induced pancreatitis is mild and usually resolves with supportive care. CT scan is
diagnostic for pancreatitis. Remember the following scenarios for drug-induced
pancreatitis:
Patient on diuretics? Furosemide, thiazides
Pateint with inflammatory bowel disease? Sulphasalazine, 5-ASA
Patient on immunosuppressive agents? Azathioprine, L-asparaginase
Patient with a history of seizures or bipolar disorder? Valproic acid
AIDS patient? Didanosine, pentamidine
Patient on antibiotics? Metronidazole, tetracycline
k. The BUN level is often elevated in patients with upper GI bleeds because the bacterial
breakdown of Hb in the GI tract results in the absorption of urea. A BUN level > 40 in
the presence of a normal serum creatinine level may include an upper GI bleed. The other
common scenario where you can see elevated BUN without increased creatinine levels is
the administration of steroids.
l. Currently, quantitative estimation of stool fat is the gold std for the Dx of steatorrhea.
(72 hrs fecal fat collection)
m. Esophagoscopy is indicated when a patient with gastroesophageal reflux disease
(GERD) fails to respond to empiric Tx., or when a patient has features of complicated

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disease.
n. Abdominal CT scan is the next Dx test when abdominal ultrasound doesnt explain
cholestatic jaundice.
o. No matter what the underlying disease of the patient is, remember that the management
of any patient arriving in the ED begins with assessment of the patients ABCs.
p. Noninvasive tests for H. pylori should be the first step in the management of patients
with dyspepsia under age 45 who do not have alarming symptoms.
q. Manometry (esophageal motility studies) establishes the Dx of diffuse esophageal
spasm.
r. Carcinoids are most commonly found on the appendix; however, patients who present
with carcinoid syndrome usually have carcinoids located in the small bowel.
s. Recognize when to order upper endoscopy in GERD:
Nausea/vomiting
Weight loss, anemia or melena/blood in the stool
Long duration of symptoms (>1-2 yrs), especially in Caucasian males >45 yo
Failure to respond to proton pump inhibitors
t. Remember the pancreatic choleraVIPoma
u. A combination of hepB virus immune globulin and lamivudine is the most effective
measure to prevent recurrent HBV infection after liver transplantation. But it is not
effective in fulminant hepatitis.
v. Whipples disease can mimic many illnesses, such as hyperthyroidism, connective
tissue disease, alcoholism and AIDS. It should be suspected in all patients with fever of
unknown origin (FUO), generalized lymphadenopathy, arthralgias, weight loss,
abdominal pain and diarrhea. Dx of Whipples disease can be readily made using upper
gastrointestinal endoscopy and PAS-staining of the obtained small intestinal biopsies.
The classical findings are PAS-+ material in the lamina propria and villous atrophy.
w. Painless jaundice in an elderly patient should make you think about pancreatic head
carcinoma.
x. Increased intragastric pressure during vomiting can cause tears in the mucosa of the
cardia, and sometimes of the distal esophagus. These are called Mallory-Weiss tears
y. Lactose intolerance is characterized by a positive hydrogen breath test, a positive
Clinitest of stool for reducing substances, and an increase stool osmotic gap.
z. The extent of a malignancy determines the most appropriate, timely, and individualized

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patient care. CT is a std Dx tool employed in patients with newly diagnosed gastric ca. to
evaluate the extent of the disease. Surgical removal of the affected tissueds remains as the
mainstay of therapy.
aa. MI is one of the differential Dx of acute abdominal pain and should be ruled out in
patients with risk factors. (ECG)
Infectious Diseases
1. Mitral regurgitation is the most common valvular abnormality observed in patients
with infective endocarditis not related to IV drug abuse.
2. Any HIV-positive patient with bloody diarrhea and normal stool examination should
have a colonoscopy and biopsy done to look for CMV colitis. CMV colitis is
characterized by bloody diarrhea with abdominal pain, multiple ulcers and mucosal
erosions on colonoscopy; biopsy shows characteristic cytomegalic cells with inclusion
bodies.
3. Diarrhea, in HIV-infected patients, can be due to multiple etiological agents therefore;
and etiologic Dx must be made before starting antibiotic therapy. (stool examination for
Salmonella, Shigella, Campylobacter, Clostridium difficile, Giardia, Cryptosporidium,
Mycobacterium avium complex and CMV.
4. A 32 yo male comes to his physician with a 2week history of fatigue, fever, muscle
and joint pains. His vitals are, BP:115/75 mmHg;T: 37.7 C; RR: 14/min; PR: 75/min.
Physical examination is unremarkable, except for splenomegaly. Lab studies show: Hb:
13 gm/dL; WBC count: 15,000/microL; Neutrophils: 42%; Lymphocytes: 50%,
monocytes: 5%, Basophils: 1%; Eosinphils: 2%; Platelet count: 300,000/microL. Large
basophilic lumphocytes with vacuolated appearance are seen. Monospot test is negative.
What is the most likely cause of this patients symptoms?
a. chronic fatigue syndrome
b. CMV infection
c. Acute toxoplasmosis
d. Acute retroviral syndrome
e. Chronic lymphocytic leukemia
Explanation: The patient described in this vignette has a mononucleosis-like syndrome in
which atypical lymphocytes are found in the blood. Atypical lymphocytes are large
basophilic cells with a vacuolated appearance. They may be found in CMV infection,
acute toxoplasmosis, and acute retroviral syndrome, but CMV infection is the MC of all
the listed causes.
For a Dx of chronic fatigue syndrome to be made symptoms must be present for over 6
months.
In CML, lymphocytes are small, mature, and they constitute 70-80% of WBCs.

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Educational objective:
Blood smear with atypical lymphocytes should make you rank CMV higher on the list in
a patient with mononucleiosis-like symptoms.
5. Condyloma Lata and bilaterally symmetrical maculopapular rash involving the entire
trunk and extremities are characteristic of second stage of syphilis. Remember the rash is
present on palms and soles. Serological tests are positive in secondary syphilis.
6. IV cefotetan, ampicillin/sulbactam, or the combination of clindamycin and a
fluoroquinolone is the appropriate empirical Tx for limb-threatening infections in
diabetics, whereas mild, or non-lim-threatening, infections can be treated with oral
antibiotics like cephalosporin, clindamycin, amoxicillin/clavulanate and fluroquinolones.
7. Always consider malaria in patients from endemic areas with high-grade periodic fever
and chills. Anemia and splenomegally are the clinical clues.
8. Proteus is the most likely cause of urinary tract infection in patients with alkaline
urine.
9. In a HIV patient, bilateral interstitial pneumonia is most likely due to Pneumocystis
carinii infection.
10. VDRL testing, PPD skin testing, Hep A and B serology and ab titer for Toxoplasma
are indicated as a part of initial work-up in all newly diagnosed HIV-positive patients.
11. A nail puncture wound in an adult resulting in osteomyelitis is most likely due to
Pseudomonas aeruginosa. (Clostridium tetani doesnt cause ostomyelitis)
12. Mucormycosis requires aggressive surgical debridement plus early systemic
chemotherapy with amphotericin B.
13. Whenever a health care worker is exposed to HIV, baseline HIV testing should be
performed immediately and postexposure prophylaxis with combination of two or three
antiretroviral drugs should be started without any delay.
14. In case of suspected oestomyelitis, blood cultures and x-rays should be taken and the
patient should be started on IV antibiotics. If the x-ray are negative, three-phase
technetium bone scan should be considered. Needle biopsy can be done to identify the
organism if the blood cultures are negative.
15. Streptococcus bovis endocarditis is associated with colorectal cancer and
colonoscopy is advisable in such patients.
16. Untreated LGV (lymphogranuloma venereum) caused by Chlamydia trachomatis
serotypes L1-3) may progress to a severe and chornic disease causing ulceration

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(painless), proctocolitis (inflammation of colon and rectum), rectal stricture, rectovaginal

fistulas and elephantiasis.
17. Any patient from southwestern region with history of tick bite developing systemic
symptoms along with leucopenia and thrombocytopenia should make you think about
Ehrlichiosis. (Tx. Doxycycline)
18. Enterotoxigenic E. coli is the most frequent offender causing travelers diarrhea.
Travelers with abdominal cramps, diarrhea and malaise should be suspected for infection
by this organism.
19. Always consider the risk of splenic rupture in case of infectious monomucleosis (IM)
and advise the patient to avoid contact sports to prevent this hazard. (no exercises till PE
is normal)atypical lymphocytes, EBV. Heterophil antibody test is sensitive and specific
for Dx. of IM
20. Cutaneous larva migrans (creeping eruption, is a helminthic disease casued by
infective stage larva of dog or cat hookworm, also called Ancylostoma braziliense.) is a
common cause of dermatological disease in travelers from tropical regions, and is
characterized by pruritic elevated serpiginous lesion on the skin.*Remember sand box
handling*
21. Urethral cultures have higher yield than synovial or blood culture in cases of
suspected gonococcal purulent arthritis.
22. Consider CMV pneumonitis as a late complication in post BMT recipients with
dyspnea and cough (CT: ground glass attenuation and innumerable small nodules.)
23. Osteomyelitis in DM that involves the bone adjacent to the foot ulcers is explained by
the contiguous spread of infection.
24. Intermittent catheterization is an effective measure to reduce the risk of UTI in
patients with neurogenic bladder.
25. Patients with hemochromatosis are vulnerable to listeria monocytogenes infections
and some other bacterial infections. Know the various bugs that are likely to jeopardize
such patients.
26. Campylobacter is the MCC of bloody diarrhea in USA. Presence of severe abdominal
pain along with diarrhea is a helpful clue.
27. Albendazole or mebendazole is the first line Tx. For E. vermicularis infection
(pinworm). Pyrantel palmate is an alternative.
28. Vibro paraheamolyticus is usually transmitted by ingestion of seafood. Patients
having symptoms of food poisoning after intake of seafood should be suspected for this.

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29. Steptococcus pneumoniae is the MC pathogen causing pneumonia in nursing home

patients.
30. Patients with trichinosis, presents with GI complaints followed by muscle pain,
swelling, and weakness. Presence of subungual splinter hemorrhages, conjunctival and
retinal hemorrhages, periobital edema and chemosis should make you think about
trichinosis.
31. Pseudomonas is commonly responsible for nosocomial pneumonia in intubated
patients. Cefepime or ceftazidime are the commonly used medications.
32. HIV infected patients who develop esophagitis are first started on fluconazole
directed against candidiasis.
33. Glucocorticoids are indicated in a case of IM complicated by upper airway
obstruction, autoimmne hemolytic anemia, and thrombocytopenia.
34. Gonorrhea is a common organism,which causes STD. It is also a common cause of
pharyngitis, generally acquired from oral sex.
35. Immunocomplex disease is primarily responsible for glomerulonephritis, Roth spots
and Oslers nodes. Janeway lesions result from septic embolism. * Extrememly HY Q for
USMLE.
36. The Tx. Of PCP is always triemthoprim-sulfamethoxazole. However, the second
choice agent is pentamidine.
37. Always suspect endocarditis whenever a patient is febrile and has other constitutional
features in the presence of a new heart murmur
38. Anti TB therapy should always be supplemented with vitamin (pyridoxine) to avoid
neurological complications.

Poisoning
1. Duration of QRS complex is the best measure for assessment of severity of tricyclic
antidepressant toxicity. (Toxicity with TCA is characterized by anticholinergic effects
and QRS widening on EKG.)

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2. Pyridoxine (Vit. B6) is an antidote for isoniazid.

3. Bromocriptine is used in the Tx. of neuroleptic malignant syndrome, which is
characterized by marked hyperthermia, muscular rigidity, tremors, altered mental status,
and diaphoresis.
4. Phenothiazine cause hypothermia by causing vasodilatation and by inhibition of
shivering.
5. Methanol intoxication is associated with visual loss. Ethylene glycol poisoning is
associated with renal failure and crystalluria. Methanol is not hepatotoxic.
6. Suspect caustic poisoning in a conscious patient with a white tongue, heavy salivation,
mouth burns, drooling of saliva and dysphagia. The patient is usually in severe pain.
7. Impaired concentration and conjunctival injection are important features of marijuana
use. Also, it causes behavioral changes and 2 or more of the followings: dry mouth,
tachycardia, increased appetite.
8. Spider bites:
Acute abdomen is a feature of black widow bite and is best treated with a combination
of calcium gluconate and musle relaxants.
Brown recluse spider bites produce an extensive localized skin necrosis resembling a
pyoderma gangrenosum. Dapsone is used to reduce the extent of local necrosis in patients
who have been screened for glucose-6-phosphate dehydrogenase (G6PD) deficiency.
9. Sodium bicarbonate prevents the development of arrhythmia in patients with TCA by
alleviating cardio-depressant action on sodium channels.
10. Calcium is useful in reversing cardia effect of calcium channel blocker.
11. Flumazenil, a benzodiazepine antagonist, is antidote for acute benzodiazepine
intoxication.
12. Alcohol competes with CYP2E1, so in acetaminophen intoxication, results in
decrease production of toxic metabolite.
13. Decision of use of N acetyl cysteine as an antidote for acetaminophen overdose is
generally based on 4 hour post-ingestion acetaminophen levels. Gut emptying procedures
are best effective if carried out in the first hour.
14. Dextromethorphan interacts with monoamine oxidase inhibitors and can produce
severe hyperthermia.
15. Diphenhydramine toxicity produces seizures as well as anti-cholinergic effects.

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16. Chlordiazepoxide is the treatment of choice for delirium tremens that is characterized
by disorientation, hallucination, tachycardia, hypertension, and agitation (such as alcohol
withdrawal).
17. Magnesium is an effective Tx for torsade de pointes.
18. First step in the management of pesticide poisoning is to remove the source of poison.
19. Sodium bicarbonate is effective for the Tx of cardiac dysfunction induced by
thioridazine toxicity.
20. Pinpoint pupils and respiratory depression are the hallmark features of acute opioid
toxicity for which naloxone is the drug of choice.
21. Contrast studies with gastrograffin are indicated in addition to upper gastrointestinal
endoscopy when a patient with acute alkali ingestion is suspected of having esophageal
perforation.

Preventive Medicine
1. Bupropion has been approved by FDA for smoking cessation program.
2. Dysthymia= depressed mood for most days for at least two years.
3. Pap smear: if 3 consecutive pap smears are normal, screening may be performed less
frequently (every 3 years) in a low-risk patient. Screening is usually started at 18 and
stopped at 60-75 years.
4. Patients with egg allergy can have severe allergic reaction or anaphylaxis with
influenza, yellow fever or MMR vaccine.
5. Hepatocellular cancer is a vaccine-preventable cancer (hepatitis B vaccine)
6. Hepatitis A is the MC vaccine-preventable disease among travelers. It should be
considered in people who are planning to visit developing countries.
7. The USPSTF recommends that screening for lipid disorders should include
measurement of total cholesterol (TC) and HDL with fasting or non-fasting samples.
8. USPSTF recommends the use of total cholesterol and HDL cholesterol for the purpose
of screening, however, for treatment purposes, the recommendations are based on total
risk assessment and LDL cholesterol levels.

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9. Female patients over the age of 50 are required to undergo annual mammograms until
the age of 75. In general, screening studies are not routinely recommended for people
older than 80.
10. All adults should be immunized against diphtheria and tetanus every 10 years.
11. USPSTF strongly recommendes routine screening of male at/above 35, and females
at/above 45 for lipid disorders. * HY Q for USMLE.
12. Human studies have demonstrated a significant association between type A
personality and exaggerated cardiovascular response.
13. Women who (1)are immunocompromised, (2) had in utero exposure to DES, or (3)
have a history of CIN II/III or cancer should have annual Pap smear, even if their prior
Pap smears are negative.* HY Q for USMLE.
14. Influenza vaccine is recommended on an annual basis for all adults above 65 yo, and
adults of any age who are at risk for developing complications from influenza infection
(as listed above).
15. Even though MMR is a live attenuated vaccine, it should be given to all HIV patients
who are not severely immunocompromised.

Cardiology
1. The hyperdynamic type of septic shock is characterized by
an elevated cardiac output
low systemic vascular resistance, right artrial pressure and pulmonary capillary wedge
pressure, (PCWP)
a frequently normal mixed venous oxygen concentration.
2. Diagnose right ventricular infarct, which should always be suspected in the setting of
an inferior wall MI, with hypotension. Understand its pathophysiology and
hemodynamics.
3. A clear association has been found between excessive alcohol intake and development
of HTN. ( greater than smoking effect).
4. Clopidogrel should be included as secondary prevention following UA/NSTEMI for at
least 12 months. It should also be prescribed for 30 days (bare metal stent) to one year
(drug eluting stents) following PCI, as it has been shown to help prevent subacute stent
thrombosis.
5. Clopidogrel + apspirin: is more effective than aspirin alone for the first 30 days

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following percutaneous coronary interventions (PCI), as it helps prevent subacute stent

thrombosis. Patients who receive drug-eluting stents need a longer duration because
epithelialization occurs slowly.
6. Know how to Dx restrictive cardiomyopathy in the setting of amyloidosis. Speckled
pattern on echocardiogram is very specific for amyloidosis.
7. Restrictive cardiomyopathy: characterized by severe diastolic dysfunction due to a stiff
ventricular wall. Chest X-ray shows only mild enlargement of the cardiac silhouette.
Echo usually shows a symmetrically thickened ventricle wall, normal or slightly reduced
LV size and normal or near normal systolic function. Kussmauls sign may also be
present. The apical impulse is easily palpable in restrictive cardiomyopathy as opposed to
constrictive pericarditis.
8. Restrictive cardiomyopathy is difficult to differentiate from constrictive pericarditis.
With constrictive pericarditis, chest X-rays may show pericardial calcifications and the
CT scan usually shows increased thickness of pericardium. Kussmals sign may be
positive in both contitions. With constrictive pericarditis, the thickness of myocardium
will be normal.
9. Mitral valve prolapse (MVP) is the MCC of mitral regurgitation in U.S.A.
10. MVP symptoms: substernal chest pain not related to exertion or ingestion of food.
Palpitation, Murmur type: mid systolic click with late systolic crescendo-decrescendo
murmur. Click and murmur occurs earlier with Valsava maneuver and it disappears with
squatting. EKG is normal. Best Tx for this chest pain: -blockers.
11. -blockers are used to treat chest pain, palpitation, and autonomic symptoms of MVP.

12. Murmur of MVP: mid systolic click with late systolic crescendo-decrescendo
murmur. Click and murmur occurs earlier with Valsalva maneuver and it disappears with
squatting. EKG can be normal.
13. The mechanism of mitral regurgitation in HOCM is the systolic anterior motion of
mitral valve leaflet.
14. First-degree heart block is a completely benign arrhythmia and requires no Tx. (eg.
HR 68, PR interval >0.2)
15. Know how to manage a case of CHF exacerbation due to A. Fib with a rapid
ventricular response. Digoxin is the DOC in this situation. Also anticoagulant should be
given, as this is one of the most important interventions in reducing the morbidity and
mortality associated with atrial fibrillation.
16. Atrial fibrillation in MS is due to left atrial dilatation. (history of Rhematic fever, mid

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diastolic rumble, and loud S1) Left atrial enlargement that results from MS predisposes
the patient to the development of AFib.
17. The hallmark of MS: elevated left atrioventricular pressure gradient.
18. Antihypertensive management should be the first step in patients with aortic
dissection with HTN. Transesophageal echocardiogram (TEE) is the initial investigation
of choice to Dx suspected aortic dissection. But it is indicated after HTN Tx is initiated.
19. Recognize infective Endocarditis in a patient who has recently undergone GU
instrumentation (cytoscopy).
20. Its better to keep systolic pressure<130 mmHg to slow end-organ damage in patients
with diabetes and chronic renal failure. 120/80 mmHg is considered optimal in DM
patients.
21. Even though IV -blockers improve mortality in acute MI, they are contraindicated in
the presence of pulmonary edema. (severe shortness of breath, bilateral crackles half way
up to the lungs. Obvious jugular venous distension and 2+ pedal edema bilaterally). This
case, DOC is furosemide.
22. Thiazide diuretics have some unfavorable metabolic side effects including
hyperglycemia, increased LDL cholesterol, and plasma triglycerides. Electrolyte
abnormalities that can be induced by thiazide diuretics include hyponatremia,
hypokalemia, and hypercalcemia (good for kidney stone patient, though).
23. The diagnosis of ventricular septal rupture can be made if there is evidence of left to
right shunting on Swan-Ganz catheter readings, when a 2D-echo is not available.
24. Recognize the clinical presentation of pulmonary edema. Iatrogenic fluid overload is
one of the common causes of pulmonary edema in perioperative patients. (increased urine
volume is an evidence)
25. Emphasize the importance of CK-MB for the Dx of recurrent myocardial infarction.
It begins to rise within 4-5 hours after MI and returns to baseline within 48-72 hours. Its
high specificity and rapid return to the baseline makes it the biomarker of choice for the
Dx. of a recurrent MI. (CK-MB fraction has a high specificity for an acute MI (slightly
lower than cardiac troponins).
26. Primary biochemical tests used for the Dx of acute MI: Cardiac troponins T and
troponins I. They begin to rise 4-6 hours after an MI, and remain elevated for 10 days.
They have also replaced LDH for the retrospective Dx of MI. But because of their
persistent elevation for 10 days after an MI, they cant be used to establish the Dx of reinfarction within 1-2 weeks after an MI.
27. Tobacco and alcohol are reversible risk factors for the development of atrial

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premature beats.
28. GI endoscopy is a low-risk procedure for infective endocarditis. For GI endoscopy,
prophylaxis is optional in high-risk patients and not recommended in moderate-risk
patients.
High risk to develop infective endocarditis:
All prosthetic heart valves.
Any history of previous bacterial endocarditis
Complex cyanotic congenital heart disease and surgical constructed systemic
pulmonary shunts.
Moderate risk to develop infective endocarditis:
Congenital cardiac malformations not falling into the high or negligible risk categories
(such as PDA, VSD, Ostium primum ASD, bicuspid aortic valve and coarctation)
Acquired valvular heart disease (such as rheumatic heart disease, valvular stenosis and
reguregitation)
MVP with regurgitation and/or myxomatous leaflets.
Hypertrophic cardiomyopathy.
Conditions that do not require IE prophylaxis include:
Isolated ostium secundum ASD and surgically-reparied ASD, VSD and PDA (beyond
six months and without sequelae)
MVP without mirtral regurgitation and without thickened leaflets.
Innocent or physiologic murmurs (echo required in the adult population to rule out
valvular lesion).
Cardiac pacemakers and defibrillators.
History of isolated bypass surgery, history of Kawasaki disease without valvular
dysfunction and history of rheumatic fever without valvular dysfunction.
29. Syncopal episode without following disorientation (post-episode confusion is more
characteristic for a seizure), hearing impairment, normal PE, and family history of sudden
cardiac death should make you think of congenital long QT syndrome. Beta-blockers are
the DOC.
30. Aspirin, ACEIs and beta-blockers have been shown to reduce mortality in the setting
of acute MI.
31. Know how to recognize and treat right ventricular infarction. IV NS to increase the
outflow from right ventricle should be considered in these patients (avoid lowering
preload, stop nitrate, give a normal saline bolus).
32. Recognize the early complications of an acute anterior wall MI: mitral regurgitation-papillary muscle dysfunction, or rupture, is the MCC of MR in this setting.
33. When A. fib is associated with hemodynamic compromise, cardioversion is the
treatment of choice.

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34. Thrombolytic therapy is not indicated for unstable angina or non-ST elevation (non Q
wave) MI. The treatment of unstable angina primarily includes aspirin, beta-blockers,
heparin and nitroglycerin.
35. In all cases of ST elevation MI, reperfusion therapy with thrombolytics or PTCA
(PCI) with or without stenting must be performed ASAP. PTCA (PCI) is preferred over
thrombolytics.
36. Reentrant ventricular arrhythmia (ventricular fibrillation) is the MCC of death in
patients with acute myocardial infarction.
37. The Tx of ventricular fibrillation is STAT defibrillation with 200-360 joules. If
defibrillation fails, lidocaine or aminodarone (DOC) can be loaded and the patient
shocked again. Epinephrine can sensitize the heart and lower the threshold for
conversion.
38. Think of PE in a postoperative patient with JVD and new onset RBBB.
39. Amiodarone has the potential to cause lung fibrosis and should be avoided in patients
with history of pulmonary fibrosis.
40. Beta-blockers have been shown to decrease the risk of perioperative coronary events.
41. It is important to recognize that oral contraceptives can be a potential cause of HTN,
and simply discontinuing its use can correct the problem. It causes hypercoagulable stage
too.
42. The MCC of aortic dissection is systemic HTN.
43. Calcium channel blockers do not improve survival in patients with acute MI (such as
nifedipine). On the other hand, aspirin, thrombolytics, ACEIs and -blockers have been
shown to improve survival in patients with acute MI.
44. First degree heart block is characterized by a prolonged constant PR interval (>0.2s).
There will not be any dropped beat.
45. Wenckebach or Mobitz type I heart block is characterized by a narrow QRS,
progressive increase in PR interval until a ventricular beat is dropped, then the sequence
is repeated. It is a benign arrhythmia and is transient. Unless the patient is symptomatic, it
requires no Tx.
46. Mobitz type II heart block is a dangerous arrhythmia which can progress to complete
heart block and requires a permanent pacemaker.
47. Morbitz type II block, the PR interval remained unchanged prior to the P wave and

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it suddenly failed to conduct to ventricles. So you will see a dropped QRS complex
with normal PR interval.
48. In third degree AV block, no atrial impulses will travel to ventricles. So atria and
ventricles beat independently and have their respective rates.
49. In AFib, the heart rate is irregular and you will not see any P waves.
50. Suspect aortic dissection as a cause of tearing chest pain in the setting of HTN and BP
difference in the 2 arms.
51. The measurement of serum BNP can help distinguish between CHF and other causes
of dyspnea. A value>100 pg/mL Dx CHF with a sensitivity, specificity, and predictive
accuracy of 90,76, and 83 percnet, respectively.
52. Choose the appropriate initial antihypertensive therapy in a patient with asthma.
Hydrochlorothiazide is the initial DOC in patients with chronic persistent asthma.
53. Recognize the high risk of arterial thromboembolism associated with anterior wall
MIs (LAD, left anterial descending branch). Inferior wall MI is associated with a right
ventricular infarction in more than 1/3 of cases. Lateral wall MIs, posterior wall MIs, and
right ventricular infarctions are not associated with an increased risk of arterial
thromboembolism.
54. TB is the MCC of constrictive pericarditis, in immigrant population. It should be
considered in patients with unexplained elevation of JVP and history of predisposing
condition.
55. High-dose niacin therapy that is used to treat lipid abnormalities frequently produces
cutaneous flushing and pruritis. This side effect is explained by prostaglandin-induced
peripheral vasodilation and can be reduced by low-dose aspirin.
56. Descending aortic aneurysm in a young male is usually due to blunt trauma to the
chest.
57. Decrease in the synthesis of non-cholesterol products may be responsible for some
adverse effects of statin therapy; for example, reduced CoQ10 production is implicated in
the pathogenesis of statin-induced myopathy.
58. In the treatment of cocaine-related cardiac ischemia, the first-line drugs are
benzodiazepines, nitrates, and aspirin. (IV diazepam)
59. Systolic heart failure is characterized by depressed cardiac index (CI) accompanied
by increased total peripheral resistance (TPR) and left ventricular end-diastolic volume
(LVEDV).

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60. Stress EKG or an exercise echocardiogram should be considered for risk stratification
in patients with stable angina.
61. It is important to look for and treat hemochromatosis early in patients who present
with restrictive cardiomyopathy, because this intervention significantly improves
prognosis in these patients. (avoid restrictive cardiomyopathy if early Tx is started).
62. Always suspect malignant HTN in patients with very high BP (>=200140 mmHg).
Presence of papilledema on ophthalmoscopy confirms the Dx. The pathologic change
responsible for end-organ damage in malignant HTN is fibrinoid necrosis of small
arterioles.
63. Think of cocaine intoxication in a young patient presenting with chest
pain/myocardial infarction or stroke. Features of cocaine intoxication are cocaine bugs,
agitation, decreased appetite, dilated pupils, elevated or decreased BP, tachycardia or
bradycardia, and sweating.
64. Patients with artificial pacemakers and defibrillators do not require prophylaxis for
infective endocarditis.
65. Suspect aortic dissection in a patient with acute retrosternal pain and a normal EKG.
Check BP in both arms and auscultate for DM of aortic regurgitation. Transesophageal
echocardiography is the preferred diagnostic tool. Before performing the TEE, HTN
should be controlled.
66. Lidocaine is not used prophylactically in patients with acute coronary syndromes.
Although its use decreases the risk of ventricular fibrillation, it may increase the risk of
asystole.
67. Electrical alternans is an important EKG finding for the Dx of pericardial tamponade.
Other findings include sinus tachycardia and low voltage QRS complexes.
68. EKG:
T wave inversions occur with ischemia of the myocardium.
ST segment depression occurs with subendocardial infarcts and unstable angina.
Prolonged PR interval occurs in cases of first-degree heart block and it is not an EKG
finding of cardiac tamponade.
Delta waves are present in Wolff-Parkinson-White syndrome.
New onset of RBBB is seen in right ventricular strain, especially with massive
pulmonary thromboembolism.
69. Dihydropyridine CCA can cause peripheral edema and should always be considered
in the DD of this condition, along with other causes, such as heart failure, renal disease
and venous insufficiency.

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70. The investigation of choice for the Dx of HCM is echocardiography.

71. Murmur type of HCM( hypertrophic cardiomyopathy)a harsh crescendodecrescendo grade III SM heard most prominently along the left lower sternal border.
The murmur is intensified by Valsalva maneuver and attenuated by leg elevation)
less blood, more murmur; more blood less murmur----characteristic of HCM.
72. Bicuspid aortic valves represent the MCC of aortic stenosis in middle age adults.
73. Senile calcific aortic stenosis is the MCC of aortic stenosis in elderly (60-80 yo).
74. Presence of hypokalemia and HTN warrants investigations for secondary cause.
Measure plasma renin activity and serum aldosterone level.
75. Elderly patients are particularly sensitive to fluid loss, and even mild hypovolemia
may predispose them to orthostatic syncope, especially upon getting up in the morning.
BUN/Creatinine ratio is a useful indicator of dehydration.
76. Left ventricular aneurysm can cause CHF in a patient who sustained an anterior wall
MI in the past. A double apical beat and persistent elevation of the ST segment are
important diagnostic clues.
77.
78. Bluish discoloration and cool fingers in the ICU are a common finding after use of
norepinephrine (pressor Tx.) for hypotension.
79. Manage a patient with ST segment elevation MI with immediate angiography and
PTCA when thrombolytic are contraindicated. Even if the patient has no
contraindications for thrombolytic therapy and a catheterization lab is available in the
hospital, or within 30 mins of the hospital, PTCA with stent placement has been shown to
have better outcomes than thrombolytic therapy in acute ST elevation MI.
80. Prophylaxis drugs for IE:
Amoxicillin is the DOC for prophylaxis of IE in dental and respiratory procedure. In
patients who are allergic to penicillin, alternatives include cefazolin, clarithromycin or
clindamycin.
For genitourinary and GI procedures, other than esophageal procedures, the regimen of
choice is ampicillin plus gentamicin in high-risk patients. If the patient is allergic to
penicillin, a combination of vancomycin + gentamycin is used in high-risk patients. (if
allergic to penicillin, give no ampicillin or amoxicillin?)
81. Hypertrophic cardiomyopathy is the MCC of sudden cardiac death in young athletes.
82. Isolated systolic HTN is an important cause of HTN in elderly patients. It is created
by decreased elastic properties of the arterial wall. Always treat isolated systolic HTN, in

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spite of the fact that diastolic BP is not elevated. The DOC would be hydrochlorothiazide.
83. Isolated diastolic dysfunction: secondary to hypertrophic cardiomyopathy. The cause
of hypertrophy cardiomyopathy (essential HTN caused). Features suggesting isolated
diastolic dysfunction of the LV are the normal cardiac size, the normal ejection fraction
and normal LV EDV, as well as the presence of an S4 gallop. DOC: -blockers as they
improve diastolic filling by lowering the HR and increasing the diastolic filling time.
They also reduce the myocardial oxygen demand and cause regression of LV hypertrophy
due to reduction of BP.
84. Vasovagal syncope is the MCC of syncope. It is frequently recurrent. Upright tilt
table testing may be indicated to confirm the Dx if the syncope is recurrent.
85. The most likely culprit lesion for acute inferior wall myocardial infarction is right
coronary artery (RCA) occlusion, especially if it is complicated by right ventricular
infarction (hypotension) and bradycardia.
86. Cacium channel blockers (diltiazem) are the DOC for variant angina.
87. Nitrates are contraindicated when a patient is continuously or intermittently taking
sildenafil (Viagra). Should not be given to the patient within 24 hours of the last dose of
sildenafil. Otherwise, nitrate will cause syncope, MI or sudden death. They both induce
nitric oxide mediated vasodilatation.
88. Clopedogrel should be included as secondary prevention following UA/NSTEMI for
at least 12 months. It should be prescribed for 30 days (bare metal stent) to one year (drug
eluting stents) following PCI, as it has been shown to help prevent subacute stent
thrombosis.
89. Inferior wall myocardial infarction: can result from the occlusion of either the right
coronary artery or the left circumflex artery. (RCA: bradycardia and hypotension,
involvement of SA node and right ventricle.)
90. The earliest EKG finding in acute MI is peaked (hyperacute) T waves, followed by
ST segment elevation, followed by the inversion of T waves, followed by the appearance
of Q waves. The earliest changes of hyperacute T waves are frequently not seen in
clinical practice because by the time the patient present they already have ST elevation.
91. Diffuse ST segment elevation is seen in: pericarditis, pulmonary edema
92. Acute pericarditis: typical findings are
chest pain, worsened by breathing and improved by leaning forward,
presence of a pericardial friction rub
Diffuse ST segment elevation that is concave upwards.
93. Depressed CO combined with elevated PCWP (an indicator of left atrial pressure, and

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most of the times left ventricular end diastolic cardiogenic pressure) is indicative of left
ventricular failure.-- shock.
94. Age-dependant idiopathic sclerocalcific changes are the MCC of isolated aortic
stenosis in elderly patients. These changes are common and usually have minimal
hemodynamic significance, but sometimes may be severe.
95. Aortic stenosis: systolic ejection murmur and soft S2, displaced apical impulse is due
to the hypertrophied LV. Most appropriate investigation would be and echocardiogram to
confirm the Dx.
96. Torsades de pointes is an arrhythmia of gradually changing QRS morphology and
most often caused by Quinidine. In the acute setting magnesium replacement is the
cornerstone of the Tx.
97. Heparin should be started in all unstable angina patients. Immediate angiography and
possible revascularization are indicated when ischemia is refractory to optimal medical
Tx or when there is evidence of hemodynamic compromise. A decision for PTCA cant
be made unless angiography provides specific indications for this procedure.
98. Infective endocarditis prophylaxis and repeated regular follow-ups are recommended
for all patients of aortic stenosis even if they are asymptomatic.
99. Renal artery stenosis is a common cause of resistant HT in a patient with advanced
atherosclerosis. Carefully auscultate the periumbilical area of such a patient to reveal
continuous (or systolic with diastolic component) murmur characteristic of renal artery
stenosis.
100. Atrial myxomas can present with systemic features and findings similar to MS.
101. TEE (transesophageal echocardiography) or computed tomography are the Dx
studies of choice for suspected aortic dissection.
102. EKG manifestations of digitalis toxicity: atrial tachycardia with AV block. (more
specific).
103. Digoxin causes ST segment depression, T wave inversion, first degree AV block at
therapeutic levels and they do not represent digitalis toxicity and therefore there is no
need for discontinuation of the drug.
104. MVP is the MCC of isolated mitral regurgitation in North America.
105. Controlling the rhythm or rate in patients with prolonged tachysystolic atrial
fibrillation usually improves the LV function significantly, sometimes even dramatically.
106. Presence of hypotension, pulsus paradoxus, and pulseless electrical activity in a

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patient with a recent acute MI should make you think of free ventricular wall rupture.
107. The Tx of verntricular fibrillation is STAT defibrillation with 200-360 joules. If
defibrillation fails, lidocaine or amiodarone (DOC) can be loaded and the patient shocked
again. Epinephrine can sensitize the heart and lower the threshold for conversion.
108. Premature atrial beats are benign and neither require any follow up nor Tx.
109. Pulsus paradoxus: (paradoxic pulse) an exaggeration of the normal variation in the
systemic arterial pulse volume with respiration, becoming weaker with inspiration and
stronger with expiration; characteristic of cardiac tamponade, rare in constrictive
pericarditis; so called because these changes are independent of changes in the cardiac
rate as measured directly or by EKG.
110. A patient who develops a cold leg after an MI should be suspected of throwing an
embolus. An angiogram is diagnostic and an embolectomy is required. (The patient has to
get an ECHO to rule out a thromus in the left ventricle)
111. Any patient who comes from S. America and have findings suggestive of
cardiomyopathy should make you think about Chagas disease (Trypanosoma Cruzi).
Can cause new onset RBBB.
112. Thiazide diuretics are the initial antihypertensive of choice in patients with
osteoporosis (due to the fact that it decrease the excretion of Calcium in urine, hence
increase the blood Calcium.
113. Restrictive cardiomyopathy: Sarcoid, amyloid, hemochromatosis, cancer and
fibrosis-------severe diastolic dysfunction is the pathophysiology.
114. Severe systolic dysfunction and increased left ventricle size are features of dilated
cardiomyopathy.
115. V/Q scan is to rule out PE (pulmonary embolism)
116. LV aneurysm can cause CHF in a patient who sustained and anterior wall MI in the
past. A double apical beat and persistent elevation of the ST segment are important
diagnostic clues. (Chest X-ray shows a characteristic prominence of the left border of the
heart.)
117. Look for electrolyte abnormalities and correct them in patients with arrhythmias.
(when someone is having recurrent VT, first thing to do after stabilizing the patient is to
search for underlying cause. e.g. electrolyte imbanlance due to diuretics (furosemide--hypokalemia)-----lead to digoxin toxicity.
118. The study of choice for diagnosis and follow-up of abdominal aneurysms is an
abdominal ultrasound.

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119. Aortic insufficiency Tx: diuretics, ACEIs, digoxin, then surgery replacement of the
aortic valve.
120. Prevention of recurrent attacks of rheumatic fever with antibiotic prophylaxis may
slow down the progression of MS in adolescents. Asymptomatic MS do not require any
Tx except penicillin prophylaxis.
121. Elevated PCWP (normally should be <12) is the most important finding in
cardiogenic shock.
122. Dipyridamole (and adenosine are coronary vasodilators) can be used during
myocardial perfusion scanning to reveal the areas of restricted myocardial perfusion. The
redistribution of the coronary blood flow to non-diseased segments induced by this
drug is called coronary steal phenomenon.used to diagnose ischemic heart disease.
123. The main mechanism responsible for pain relief in patients with anginal pain treated
with nitroglycerin is dilation of veins and decrease in ventricular preload. (effect on
veins>on arteries) ---------dilation of capacitance vessels.
124. Hyponatremia is a bad prognostic factor in heart failure. It indicates the presence of
severe heart failure and a high level of neurohumoral activation.
Other important electrolyte abnormalities in patients with heart failure include hypo-and
hyperkalemia that may reflect the activity of rennin angiotensin-aldosterone system or
may be due to different drugs and drug combinations.
125. As a result, a patients survival is significantly reduced if the serum Na+ level is
<137 mg/dL. Decreasing the intake of water, not increasing the sodium intake, can help
to control the electrolyte abnormalities.
126. Propranolol is the DOC in patients who presents with HTN and a benign essential
tremor.
127. -blocker can worsen severe peripheral vascular disease while helping for BP.
128. Dressler syndrome typically occurs 2-4 weeks after an MI and presents with a lowgrade fever, malaise and pleuritic chest pain. EKG will reveal non specific ST
elevations and there may be a pericardial effusion. NSAIDs are the agents of choice.
129. Know that prevention of recurrent attacks of rhematic fever with antibiotic
prophylaxis may slow down the progression of mitral stenosis in adolescents.
Asympomatic MS do not require any Tx except penicillin prophylaxis. (history of RF,
apex beat is tapping, a loud S1, opening snap and mid diastolic rumble at the apex. Lungs
are clear, can have normal EKG and chest x ray.)f
130. Exercise EKG testing is recommended for patients with an intermediate pre-test

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probability of angina based on clinical features and risk factors. Medications that should
be withheld prior to testing include anti-ischemic medications, digoxin and medications
that slow the heart. (e.g. beta-blockers).
131. Once sick sinus node syndrome has been Dx, the best Tx is placement of a
permanent ventricular pacemaker.
132. Situational syncope should be considered in the differential Dx of syncopal
episodes. The typical scenario would include a middle age or older male, who loses his
consciousness immediately after urination, or a man who loses his consciousness during
coughing fits.
133. Diastolic and continuous murmurs as well as loud systolic murmurs revealed on
cardiac auscultation should always be investigated using transthoracic Doppler
echocardiography. Midsystolic soft murmurs (grade I-II/IV) in an asymptomatic young
patient are usually benign and need no further work-up.
134. IV adenosine is the DOC for paroxysmal SVT. Know how to recognize the rhythm
on EKG.(narrow complex QRS morphology. SVT is usually recognized by a HR of
>140/min, regular loss of P waves and narrow QRS complex.) If the patient is
hemodynamically unstable, electrical cardioversion should be performed immediately. If
stable, vagal maneuvers should be attempted initially. If these fails to convert him to
normal sinus rhythm, IV adenosine push is DOC.Verapamil can be a second line drug in
this case.
135. Tx of unstable angina in the setting of anemia due to massive GI hemorrhage: blood
transfusion.
Rheumatology
1. Muscle biopsy is the best diagnostic study for polymyositis. ( shows endomysial
infiltration of the inflammatory infiltrate.)
2. The axillary nerve: is the most commonly injured nerve in anterior dislocation of the
shoulder. Its palsy leads to loss of sensation over the lateral aspect of the deltoid.
3. Gouty arthritis: gout can present with nodular swelling of the digits resulting in
significant deforming arthritis. Rheumatoid nodules predominantly occur over pressure
points such as the elbow and extensor surface of the proximal ulna.
4. Diffuse proliferative glomerulonephritis is the severest form of glomerular disease of
SLE. 6 types of SLE related glomerular injury:
Type 1: normal
Type 2: mesangial
Type 3: focal proliferative

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Type 4: diffuse proliferative

Type 5: membranous
Type 6: sclerosing
5. Most specific test for Sjogrens syndrome: Lip biopsy.
6. Acute inflammatory monoarticular arthritis in a previously damaged joint suggests
septic arthritis. Leukocyte counts in synovial fluid exceeding 50,000 or even 100,000/ul
should make you think of septic arthritis.
7. Lyme arthritis is a late manifestation of Lyme infection; suspect this in patients with
history of travel to endemic areas. Intermittent inflammatory arthritis is a typical
presentation.
8. Relapsing polychondritis is an idiopathic disorder characterized by recurrent
inflammation of cartilaginous structures and other internal organs.
9. Thoracic outlet syndrome occurs with signs and symptoms of neurovascular bundle
compression. (compression of the neurovascular structures supplying the upper
extremities: compression by scalene muscles, cervical ribs or congenital fibro muscular
band.) Predisposing factors also include: motor vehicle accidents, playing musical
instruments (music teacher) and chronic illness.
10. Regular exercise/physiotherapy is the only beneficial Tx that halts the disease
progression in ankylosing spondylitis.
11. Low back pain in patients with history of malignancy should always raise the
suspicion of bone metastasis.
12. Disc herniation: presents as low back pain radiating down the buttock and below the
knee. The pain is cuased due to impingemed nerve. A positive straight leg suggests nerve
root irritation due to impingement. The cross straight leg test is very specific for disc
herniation.
13. Though OCPs are safe in most patients with SLE, patients with the increased risk of
thrombosis (anti phospholipids and nephritic syndrome) and active renal involvement
should avoid its use.
14. Next best step in a suspected patient of ankylosing spondylitis: Plain X-ray of the
sacroiliac joint.
15. Typical skin manifestation of Reiters syndrome: Keratoderma blennorrhagicum.
16. Thoracic aortic aneurysm is a serous complication of giant cell arteritis (Temporal
arteritis), which can be fatal so such patients must be monitored continuously.

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17. Rheumatoid factor is usually negative in Reiter syndrome and other

spondyloarthropathies,60-80% patients are HLA-B27 (+)
18. DOC in sarcoidosis: systemic steroids (prednisone)
19. De Quervains tenosynovitis is characterized by tendonitis of abductor pollicis longus
and extensor pollicis brevis as they pass beneath the retinacular pulley. ( pain over the
lateral side of her wrist, pain is severe when she lifts her baby from the crib.)
20. What antibody is primarily involved in the pathogenesis of lupus nephritis: antidsDNA
21. Kidney biopsy is indicated to guide the Tx in all SLE patients with renal involvement.
22. Erosive joint disease in RA is a clear-cut indication for the use of diseases modifying
anti-rheumatic drugs (DMARD) and methotrexate is the intitial DOC for this purpose.
23. Diagnostic of pseudogout: the presence of positively birefreingent crystals in joint
aspiration.
24. Erythema nodosum, arthralgias, diarrhea, and positive P-ANCA in a young patient
are highly suggestive of inflammatory bowel disease (IBD).
25. Amitriptyline and cyclobenzaprine have been shown to be effective in the Tx of
fibromyalgia.
26. Fibromyalgia: a chronic widespread pain disorder associated with fatigue, poor sleep,
and depression. Patients have multiple trigger points of tenderness.
27. Always consider fibromyalgia in a patient with diffuse muscle aches and excessiove
fatigue with non-restorative sleep.
28. Arthritis in SLE is non-erosive and arthritis in RA is erosive.
29. A compression fracture of the vertebrae is a common complication of advanced
osteoporosis. It usually manifests as acute back pain without an obvious preceding
trauma in a predisposed patient. Neurologic examinationg will be normal.
30. Whipple disease presents with joint pain, abdominal pain, diarrhea, and weight loss.
Periodic Acid-Schiff positive material on small intestinal biopsy establishes the Dx.
31. Tennis elbow: lateral epicondylitis, is epicondylitis about the origin of extensors of
forearm; know who to differentiate it from radial tunnel syndrome.
32. Anterior uveitis is the MCC of red eye in patients with ankylosing spondylitis.

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33. Dissenminated gonococcal infection is a syndrome of rash, tenosynovitis and

polyarthralgia.
34. Classic triad of Buergers disease: occlusive disease of the arteries, migratory
superficial thrombophlebitis, Raynauds phenomenon.
35. Parvovirus can be an important causative agent in acute small joint arthritis or
arthralgia (note daycare employees)
36. Eye examinations at 6 months to 1 year intervals should be performed in all patients
who are taking hydroxychloroquine.
37. The MCC of death in SLE: chronic renal failure.
38. HCV infection is associated with 80% cases of mixed essential cryoglobulinemia.
39. MRI is the definitive Dx study for rotator cuff tear! Not X-ray shoulder!
40. Presence of anti RNP is diagnostic of mixed connective tissue disease. Recognize the
overlapping features.
41. Lofgrens syndrome: an acute form of sarcoidosis and consists of triad of bilateral
ankle arthritis (sometimes knees, wrists or elbolws), erythema nodosum and bilateral
hilar adenopathy.
42. In patients with frequent attacks of acute gouty arthritis not controlled by colchicines,
a 24-hour uric acid levels in urine is determined. This evaluates whether hyperuricemia is
due to over production or under secretion of uric acid:
< add 800 mg/day, suggests under secretion; a uricosuric drug
>add xanthine oxidase inhibitor 800 mg/day, suggests over production.
43. The MCC of asymptomatic elevation of alkaline phosphatase in an elderly patient is
Pagets disease. Asymptomatic Pagets disease generally do not require any Tx.
Symptomatic patiens are best treated with oral or intravenous bisphosphonates.
44. Hyperparathyroidism and hemochromatosis patients are more prone for pseudogout.
Joint fluid aspirates reveal rhomboid shaped calcium pyrophosphate crystals, with
positive birefringence.
45. Nerve conduction studies are very useful in diagnosing the carpal tunnel syndrome.
(not carpal compression test---reproduce the symptoms, but not diagnostic)
46. Classical features of dermatomyositis: Heliotrope rash(periorbital edema with a
purplish suffusion), Gottrons sign(scaly patches over the dorsum of proximal
interphalangeal and metacarpophalangerl joints),and proximal muscle weakness.

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47. Low back pain in patients with history of malignancy should always raise the
suspicion of bone metastasis.
48. Side effect of long-trem use of cyclophosphamide: bladder carcinoma.
49. MRI is the investigation of choice for suspected lumbar spinal stenosis.
50. Cessation of alcohol and staying on a low purine diet are important measures in the
prevention of future attacks in patients with acute gouty arthritis. * extremely HY Q for
USMLE.
51. Big toe Qs:
Atherothrombotic plaques: blue toe syndrome. Characterized by intact pulses, painful
cyanotic toe along with features of ischemic lesions in distal limbs, such as livedo
reticularis. Toe is tender, cold, cyanotic. (calf discomfort and tenderness, secondary to
small vessel problems) Lab: significant for ESR, hypocomplementemia, eosinphilia.
Gout: big toe is red, tender, and inflamed (classic USMLE misleading, be careful)
Erythromelalgia: a paroxysmal disorder of peripheral blood vessel dilation with bilateral
burning pain on palms and soles. It then progresses to the entire extremity. The area
becomes red and warm.
52. Young patients with high spiking fevers associated with characteristic salmon colored
evanescent rash, arthralgias, and leukocytosis most likely have adult still disease. (a
variant of RA). Rheumatoid factor and ANA are usually negative.
53. Reflex sympathetic dystrophy is a syndrome of pain and swelling associated with
vasomotor instability. Any extremity may be involved but is more common in the hand.
Tx: physical therapy, prednisone, stellate ganglion block.
54. Psoriatic arthritis (PA) is asymmetrical and oligo-articular and such patients usually
have typical features (silvery scales on erythematous plaques over flexural surfaces) of
psoriasis present for years. Think of PA when pitting nails is present in the history. Skin
rash may not be present all the time. Can present in 5 different forms:
DIP involvement
Asymmetric oligoarthritis
Symmetric polyarthritis, similar to RA
Spondyloarthropathy, including both sacroiliitis and spondilitis
55. Prophylactic allopurinol is the most effective method to prevent gout in patients at
risk for tumor lysis syndrome.
56. Tx of choice for Reiters syndrome: NSAIDs. (reactive arthritis)
57. In patients with acute mechanical back pain without significant neurologic dedicit,
conservative approach is preferred for a period of 4-6 weeks. This includes early
mobilization, muscle relaxants, and NSAIDs. Bed rest and physical therapy has not been

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shown to be helpful.
58. Cortisteroid-induced avascular necrosis of the femoral head usually presents as
progressive hip or groin pain without restriction of motion range and normal radiograph
on early stages. MRI is gold std for the Dx of avascular necrosis of hip.
59. Behcets syndrome is a multi-systemic inflammatory condition characterized by
recurrent oral and genital ulcers,skin lesions, seen most commonly in the Turkish, Asian
and Middle Eastern population.
60. Obesity is a major risk factor for osteoarthritis. Hence weight loss is the most
effective measure in OA management.
61. very helpful in protecting the back from recurrent injury. Keeping the back straight
while lifting objects.62. Frozen shoulder: should be suspected when a patient presents with stiffness and
limited range of motion. This is a result of pericapsulitis. Arthroscopy establishes the Dx
by showing joint space volume, and loss of normal axillary pouch. Tx: NSAIDs,
corticosteroid injection into the joint space, and physical therapy.
63. Rotator cuff tear or Rotator cuff tendonitis presents with severe pain and weakness of
the shoulder abduction. Movements of shoulder like positioning the arm above the
shoulder aggravate pain. Range of motion is limited only on active movement but is
normal on passive flexion. A positive drop arm sign, with inability to actively maintain
90 degree of passive abduction, may be present in large tears.
64. Rotator cuff tendonitis: can be distinguished from rotator cuff tear by injecting
lidocaine that will result in improvement in range of motion in cases of rotator cuff
tendonitis but no effect in range of motion in cases of rotator cuff tear.
65. herniated disc: pain becomes worsened with sitting and lumbar flexion and therefore
is different from pain of spinal stenosis.
66. Cauda equine syndrome: compression of lumbosacral nerve root by infection or
tumor. Usual presentation is with urinary retention or overflow incontinence. Important
physical findings include saddle anesthesia around the anus or perineum and decreased
tone of anal sphincter.
67. Leriche syndrome: occurs as a result of atherosclerotic vascular disease and is
characterized by impotence and intermittent claudication.
68.
69. Reiters syndrome/ reactive arthritis: polyarthritis reactive to genitourinary infection
by Chlamydia. (a form of seronegative spondyloarthropathy). Other enthesopathy

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evidences: heel pain, sausage digits in the patient. Tx of choice: NSAIDs. Tetracycline. If
refractory to the above Tx, then sulfasalazine, infliximab and methotrexate.
70. In patients with acute mechanical back pain without significant neurologic deficit,
conservative approach is preferred for a period of 4-6 weeks. This includes early
mobilization, muscle approach is preferred for a period of 4-6 weeks. This includes early
mobilization, muscle relaxants, and NSAIDs.
71. Anti-B19 IgM is the diagnostic study of choice when Parvovirus infection is
clinically suspected. (school teacher, suffering from acute ~. Joint involvement is
symmetrical. Hands, wrists, kness and feet are the MC involved joints. Rash may or may
not be present. Arthralgias or arthritis. Joint movement most frequently occurs in adult
female.) IgG persists for life. Persistence of IgM indicates chronic infection.
72. Painful legs:
Cellulitis of calf: difficult to DD from DVT. However presence of high-grade fever,
lymphangitis, absence of any risk factor such as orthopedic surgery, or prolonged
immobilization make DVT less likely. (web tinea pedis is one of the MC portals of entry
for the microorganisms, causing cellulitesdiffuse infection of deep layers of skin .
Bakers cyst: complication of RA.
Necrotizing fasciitis: a deep-seated cellulites. Should be suspected in a patient who has
evidence of overlying skin necrosis, bullae, with anesthesia due to destruction of nerves,
crepitus due to gas producing organism, and fever.
Sclerosing panniculitis: acute tender lesion over the medial malleolus. Usually occurs in
a patient with venous stasis of lower limb.
Erysipelas: a superficial cellulites. Usually affects cheek. The area involved become
erythematous, tender, sharply demarcated and with vesicles or bullae. Fever is usually
present, no element of lymphangitis.
Erysipeloid is an edematous, purplish plaque with central clearing. It is caused by
Erysipelothrix insidiosa. It usually on the hands of fishermen and meat handlers. Not very
painful like cellulites. Fever is not present.

Respiratory diseases
1.The common diagnostic features of ABPA (allergic broncho pulmonary aspergillosis)
include:
Astham like symptoms
Elevated IgE
Hypereosinophilia
Central bronchiectasis
Positive Aspergullus skin test
2. Theophylline toxicity usually manifests as CNS stimulation (headache, insomia), GI
disturbance (nausea, vomiting), and cardia toxicity (arrhythmia). The mechanisms

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responsible for the toxicity may include phosphodiesterase inhibition, adenosine

antagonism, and stimulation of epinephrine release.
3. Triad of Wegeners granulomatosis: (cytoplasmic ANCA +)
Upper respiratory tract disease
Lower respiratory tract disease
Glomerulonephritis
4. Atypical pneumonia presents with headache, malaise, low-grade fever, and dry cough.
Patient complaints exceed the physical findings since exam findings are often minimal.
The most common X-ray abnormality is peribronchial pneumonia pattern and have
predilection for the lower lobes. Erythema multiforme is one of the extra pulmonary
manifestations of mycoplasma pneumonia.
5.Use of prophylactic inhaled corticosteroids is beneficial in the long term out come of
chronic persistent asthma. Know the clinical decisions one has to take in various
scenarios of asthma. This is big in USMLE.
6. In a patient who has had recent surgery and presents with SOB and tachycardia, the Dx
of Pulmonary embolus must always be suspected. And order a V/Q scan.
7. Any patient who presents with sudden onset of chest pain, SOB, and has evidence of
hypoxia and the new onset RBBB should be considered as having a PE until proven
otherwise. Best next step: V/Q scan.
8. Excessive alcohol intake can lead to aspiration pneumonia. (key cue: foul-smelling
sputum, right lower lobe pneumonia)
9. The important risk factors for aspiration pneumonia are:
Altered consciousness-Seizures, alcoholism, drug overdose, etc
Dysphagian- esophageal reflux, diverticula, obstruction, etc.
Neurologic disorder- advanced dementian, PD, myasthenia, etc.
Sedation to procedures, such as bronchoscopy, intubation, endoscopy
10. Any chronic smoker with hypertrophic osteoarthropathy should have a chest x-ray to
rule out malignancy. Hypertrophic osteoarthropathy is associated with chronic
proliferative periostitis of the long bones, clubbing, and synovitis.
11. Identify allergic granulomatosis of Churg-Strauss and remember that leukotreine
antagonists are known to cause CSS.Tx: corticosteroids and immunosupressnts.
12. Patients with DVT in whom anticoagulation is contraindicated require placement of
inferior vena cava filter for the prevention of pulmonary embolism.
13. Blood in the chest, if it is not evacuated, can get infected. The majority of patients
will present with a low-grade fever, dyspnea, and chest pain. Surgery is required to

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remove the clotted blood and fibrinous peel.

14. The Dx of cystic fibrosis is made on the basis of compatible clinical findings with
laboratory confirmation. Sweat chloride test (>60 mEq/L) is the gold std test for Dx of
CF and preferred over direct mutation analysis as more than 1,250 mutations in CFTR
can lead to CF.
15. Suspect acute bronchopulmonary aspergillosis in asthmatics with worsening asthma
symptoms, coughing brownish mucous plugs, recurrent infiltrates and peripheral
eosinophilia. Tx. oral prednisone
16. Always consider lung abscess as an etiology of fever and foul-smelling productive
cough in patients predisposed to aspiration.
17. The MCC of pulmonary complications in patients with systemic sclerosis is
interstitial fibrosis.
18. All COPD patients with PaO2<55 mmHg or SaO2<88% are candidates for long-term
home oxygen treatment. Patient with signs of pulmonary HTN or hematocrit >55%
should be started on home oxygen when the PaO2<60 mmHg.
19. When an acute pulmonary embolus occurs with hemodynamic compromise, the best
Tx is fibrinolytic therapy. But, if the patient has contraindications, an embolectomy is the
treatment of choice
20. Criteria for ARDS:
A pulmonary capillary wedge pressure less than 18 mmHg favors ARDS over
cardiogenic pulmonary edema.
PaO2 to FiO2 ratio of 200 mmHg or less, regardless of the level of PEEP
Diffuse, bilateral infiltrates on chest-X ray
21. A bronchodilator response test is used to demonstrate reversible of air way
obstruction. It helps to differentiate between COPD and asthma, although a subset of
patients with COPD may also demonstrate airway reactivity.
22. A mobile cavitary mass in the lung, which presents with intermittent hemoptysis, is
usually indicative of aspergilloma.
23. Glucocorticoids cause neutrophilia by increasing the bone marrow release and
mobilizing the marginated neutrophil pool. Eosinophils and lymphocytes are decreased.
(Extremely HY Q for USMLE)
24. In patients with fever and cough after upper GI endoscopy suspect anaerobic lung
infection. Clindamycin and ampicillin plus metronidazole are the commonly used agents
for this infection.

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25. Suspect choriocarcinoma in any postpartum women who presents with shortness of
breath and hemoptysis. The next step is chest X-ray, pelvic exam, and beta-hCG.
26. An enlarged left atrium in mitral stenosis can cause a persistent cough and elevation
of the left main stem bronchus.
27. Always consider ACEI therapy as a potential cause of chronic cough. Simple
discontinuation of the drug should precede any Dx testing in patients with chronic dry
cough who are taking an ACEI.
28. The MC locations of post aspiration lung abscess in recumbent position are apical
segment of right lower lobe and posterior segment of right upper lobe.
29. TB occurs early in the course of HIV when the CD4 counts are greater than
200/microL. Upper lobe consolidation and/or cavitation is the typical X-ray finding.
30. Anterior mediastinal mass along with elevated AFP and HCG indicates
Nonseminomatous tumor.
31. Remember Blastomyces blasts the lungs, skin and bone.
32. The MCC of superior vena cava syndrome today is bronchogenic carcinoma. Benign
causes of SVCS are rare and relatively easily diagnosed. These lung cancers usually arise
from the right hilar region and invade the superior vena cava. (venous congestion of the
face and arms. Tx: angioplasty with stenting is the std. of care.)
33. Rigid bronchoscopy is indicated in patients with massive hemoptysis as it allows
rapid visualization of the bleeding site and to control bleeding through cauterization or
other means.
34. When the pH of the pleural fluid is less than 7.2, the probability is very high that this
fluid needs to be drained. Glucose of less than 60 mg/dL in pleural fluid is also an
indication for tube thoracostomy. Infected pleural space is usually initially drained with a
chest tube.
35. In ventilation/perfusion scan is inconclusive in patients undergoing diagnostic workup for pulmonary thromboembolism, order venous ultrasonography to reveal DVT or CT
angiogram. Pulmonary angiography is an invasive procedure and should be employed
only if venous ultrasonography or CT angiogram is negative.
36. DVT is not a clinical Dx and therefore all suspected cases of DVT should be
evaluated with noninvasive testing and the test of choice for this purpose is compression
ultrasonography.
37. Proximal (above knee veins) DVT of lower extremities is the most frequent source of
PE. (such as: clot in ileofemoral veins)

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38. PE: an area of perfusion defect without ventilation defect. (V/Q scan mismatch).
39. In any patient who presents with a lung lesion on a chest X-ray, it is best to get old
chest X-ray and compare the lesion. The lesion may have been present for a long time
and may be benign.
40. Patients who are on high dose of beta-2 agonists may develop hypokalemia and
patients should be monitored with daily electrolytes. The other side affects of beta-2
agonists are tachycardia, tremor, and peripheral edema.
41. BAL (bronchoalveolar lavage) is >90% effective in diagnosing pneumocystis carini
pneumonia in HIV positive patients, especially when CD4 count is less than 200.
42. The most serious complication of bronchectasis is hemoptysis.
43. Obstructive sleep apnea is a common condition among obese population. With never
ending pandemic of obesity in USA, this is getting wider clinical attention, know the
management of this condition. Dx: nocturnal polysomnography.
44. Factor V Leiden is the MC inhirited disorder causing hypercoagulability and
predisposition to thromboses, especially DVT of lower extremities. (Factor V Leiden is
the result of a point mutation in a gene coding for the coagulation factor V. As a result of
this mutation, Factor V becomes resistant to inactivation by protein C, an important
counterbanlance factor in hemostatic cascade.)
45. All patients withsuspected bacterial pneumonia should have a chest X-ray done as the
first step, and antibiotics should be administered ASAP without waiting for sputum gram
stain or cultures.
46. A non-productive cough is observed in 5-20% of patients receiving ACEIs. It is
caused by an accumulation of kinins (bradykinins), and possibly by the activation of the
arachidonic acid pathway.
47. The most typical findings of a pulmonary embolism on arterial blood gas sampling
are hypoxemia and hypocarbia.
48. High resolution CT scan of the lung is the diagnostic modality of choice for
bronchiectasis.
49. Suspect cystic fibrosis in patients with bronchiectasis and symptoms suggestive of
intestinal malabsorption due to pancreatic insufficiency. CF is often tested on USMLE
and must be covered thoroughly.
50. Always consider infective endocarditis in any patient who is an IV drug abuser and
comes with fever and heart murmurs heard on examination. Empiric antibiotic therapy:

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IV vancomycin and gentamycin.

51. Remember bronchogenic carcinoma is the MC lung cancer associated with asbestos
exposure while malignant mesothelioma is almost exclusively associated with asbestos
exposure but is not the most common malignancy after asbestos exposure. (plumber)
52. Cough can be a presenting symptom of GERD. A 24-hour pH recording is the most
specific test available for acidic gastroesophageal reflus. It is usually employed to Dx the
cause of chest pain or supra esophageal complications of GERD in patients with negative
esophagoscopy.
53. Acute exacerbation of COPD is treated with a combination of inhaled/nebulized
bronchodilators and systemic steroids.
54. Cor Pulmonale is a term for right-sided heart failure most commonly due to
pulmonary disease. Signs of right-sided heart failure include: jugular venous distension,
right-sided S3, right ventricular heave, hepatomegaly, ascites, and dependent edema.
55. Any elderly patient who presents with pneumonia, abdominal pain, confusion and
hyponatremia should be suspected for Legionella pneumonia. This should also be
suspected in patients who failed to respond to beta-lactam antibiotics and Gram stain
showing many polymorphs with few visible organisms. The Tx of choice for Legionella
pneumonia is high dose erythromycin or azithromycin.
Remember pneumonia, hyponatremia and diarrhea are almost classic for Legionella.
56. IPF is a Dx of exclusion. Idiopathic pulmonary fibrosis is best treated with steroids.
Most patients will have a positive response in the first six months but they fail to have
sustained response.
57. Klebsiella is an encapsulated gram-negative bacillus and can cause pneumonia in
subjects with debilitating conditions, especially alcoholics. Friedlanders pneumonia
generally affects the upper lobe and is characterized by current jelly-like sputum.
58. A-a gradient is increased in interstitial lung disease due to poor oxygenation. In
restrictive lung disease, total lung capacity (TLC), functional residual capacity and
residual volume are all reduced. Flow volumes are also reduced but the ratio of
FEV1/FVC is either normal or increased.
59. After quitting smoking, home oxygen therapy is the only modality known to prolong
survival in COPD.
60. If you suspect a PE clinically, and chest X-ray, ABG and EKG results rule out other
differential diagnoses then you should begin Tx with heparin without waiting for a V/Q
scan to confirm your Dx.
61. When pneumonia fails to heal after two weeks of appropriate antibiotics, a CT scan of

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the chest followed by bronchoscopy is indicated to ensure that the bronchus is not
blocked and there is no lung abscess.
62. Annual influenza vaccine is recommended for all persons aged 65 and older and
persons in selected high-risk groups. Pneumococcal vaccine is recommended for all
immunocometent individuals who are 65 years and older or otherwise at increased risk
for pneumonococcal disease ( post-splenectomy, myeloma).
63. Identify occupational interstitial lung diseases: i.e. Hypersensitivity pneumonitis,
Organic dust (Byssinosis) and inorganic dusts (asbestosis, silicosis, berylliosis and coal
workers pneumonitis).
64. Know the role of beta agonists and mast cell stabilizers in the management of
exercise-induced asthma.
65. Always consider candida albicans as a cause of infection in a patient with
uncontrolled DM. Dx: KOH preparation.
66. In a smoker with arm pain, cough and weight loss, a mass in the lung apex is a
Pancoast tumor until proven otherwise.
67. When it is unclear whether the patient has nocturnal asthma or GERD, a trial of
proton pump inhibitors is both diagnostic and therapeutic.
68. Suspect alpha-1 anti-trypsin deficiency in non-smoker with early onset emphysema.
Dx: estimate alpha-1 anti-trypsin level.
69. Know the 3 major complications of too high a PEEP:
Alveolar damage
Tension pneumothorax
Ventricular failure
70. Indicators of a severe asthma attack include normal to increased PCO2 values, speech
difficulty, diaphoresis, altered sensorium, cyanosis, and silent lungs.
71. Due to high incidence of lung cancer among smokers, it should be suspected in any
smoker presenting with recurrent pneumonia. Admit the patient and order a high
resolution CT scan.
72. A lung mass with cartilage is most likely a hamartoma and can be observed.
73. Congestive heart failure is the MCC of pleural effusion. In patients with this
condition, pleural fluid analysis is consistent with transudative effusion. (pH of 7.35, pH
<7.3 indicate pleural inflammation)
74. Patients with impaired consciousness, advanced dementia, and other neurologic

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disorders are predisposed to aspiration pneumonia due to impaired epiglottic function.

75. Aspirin sensitivity syndrome is believed to be a pseudo-allergic reaction. It results
from aspirin-induced prostaglandin/leukotriene misbanlance in susceptible individuals.
Tx includes avoidance of NSAIDs and the use of leukotriene receptor antagonists (DOC).
Extremely HY Q for USMLE
76. Patients with suspected PE should have a chest X-ray and ABG, followed by EKG
and V/Q scan. Pulmonary embolism Risk factors include:
Venous stasis
Hypercoagulable states (cancer, protein C deficiency, protein S deficiency, antithrombin
III deficiency, malignancy, pregnancy, etc)
Obesity
Prior history of pulmonary embolus
Malignancy
Pregnancy
Estrogen and tamoxifen
Prolonged immobilization
Trauma of lower extremities
77. ARDS can present with dyspnea, tachypnea and bilateral fluffy infiltrates on a CXR.
It is a condition where hypoxemia persists and it becomes difficult to oxygenate the
patient.

Miscellaneous
1. MRI is the imaging procedure of choice in patients with suspected vertebral
osteomyelitis. (back pain + low grade fever + elevated ESR+local tenderness on
percussion over the affected vertebrae and paravertebral muscular spasm)
2. Think of conversion disorder in a female patient with sudden onset neurological
symptoms preceded by an obvious stressor. The Tx of choice would be Psychotherapy.
3. The MCC site of ulnar nerve entrapment is the elbow where the ulnar N. lies at the
medial epicondylar groove. (decreased sensations over the 4th and 5th fingers and a
weaker grip)-cubital tunnel syndrome
4. Severe, excruciating pain (such as motor vehicle accident) should be treated with IV
opioids even if the patient has a history of drug abuse.
5. Atracurium is a neuromuscular blocking agent that is metabolized in plasma and
hydrolysed by serum esterases. Its use is safe in patients with renal and liver dysfunction.
Pancuronium and mivacurium---excreted mostly unchanged in urine. Succinylcholine
in renal dysfunction, may casue apnea and hyperkalemia.

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6. An epidural abscess presenting with neurologic symptoms of spinal compression

requires urgent surgery.
7. Removal of impacted esophageal foreign body is mandatory (through endoscopy).
8. Primary polydypsia (psychogenic polydypsia) is characterized by primary increase in
water intake. Patients taking phenothiazines have this problem due to dry mouth caused
by anticholinergic action of phenothiazines.
9. Hepato-jugular reflex is a useful tool that can be used to differentiate between heart
and liver disease-related causes of lower extremity edema.
10. Mild manifestations of a drug allergy (e.g. urticaria and pruritus without systemic
symptoms) are usually treated with antihistamines and discontinuation of the offending
drug.
11. Nasal eosinophila is characteristic for allergic rhinitis, although this finding is not
specific. Nasal eosinophilia is absent in patients with infectious causes and vasomotor
rhinitis. (Do a nasal cytology to distinguish them)
12. Vit. K deficiency is usually manifested by prolonged PT, normal platelet count and
normal BT. PTT is variable.
13. Beta-blockers decrease the risk of perioperative myocardial infarction, and thus does
decrease mortality in perioperative patients with vascular disease undergoing noncardiac
surgery. Beta 1 selective agents are the DOC for this purpose.
14. Patients who are on high dose of Vit. D and calcium should have a close eye on
serum calcium levels. Signs of toxicity include nausea, vomiting, constipation, polyuria,
and mental status changes.
15. Heat exhaustion, also known as heat prostration is a syndrome characterized by
volume depletion under the conditions of heat stress. It can be distinguished from heat
stroke by T<40 C and lack of severe CNS symptoms.
16. Pellagra, a niacin deficiency syndrome is characterized by a triad of 3 Ds of Diarrhea,
Dermatitis, and Dementia and if untreated eventually leading to Death (4th D).
17. Wernickes encephalopathy is a syndrome characterized by ataxia, ophthalmoplegia,
nystagmus and altered mental status. Wernickes encephalopathy is seen in chronic
alcoholics with thiamine deficiency.
18. Lumbosacral strain is the MCC of acute back pain. The typical clinical scenario
includes acute onset of the back pain after physical exertion, absence of radiation,
presence of paravertebral tenderness, negative straight-leg raising test, and normal

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neurologic examination.
19. Zinc deficiency is associated with alopecia, mental changes, diarrhea, smell
abnormalities, maculopapular rash around the mouth and eyes, and impaired wound
healing. (usually seen in patients receiving long term TPN, total parenteral nutrition).
20. Excessive use of vit C in patients with renal insufficiency can cause oxalate stones.
21. Chloride depletion in patients with vomiting is a common cause of metabolic
alkalosis. It is due to the loss of chloride in vomiting. (GI loss).
22. An aortic aneurysm of the descending aorta may appear on a CXR as a wellcircumscribed lesion. These aneurysms are due to atherosclerosis.
23. Latex allergy can manifest as an anaphylactic reaction during exposure to latexcontaining products (gloves, condoms etc).
24. Hypothyroidism should always be considered in patients with an unexplained
elevation of serum CK concentration and myopathy. (Do a serum TSH test).
25. Hypercarotenemia is commonly seen in patients with anorexia, DM &
hypothyroidism.
26. Consider IgA deficiency in patients with recurrent sionpulmonary and GI infections,
and anaphylactic transfusion reaction. Dx of IgA deficiency is made if the serum IgA
concentration is less than 7 mg/dL with normal serum IgM and IgG levels.
27. Lithium toxicity presents with tremulousness, headache, confusion, GI distress,
fatigue and, in extreme cases, with seizures, coma, hyperreflexia and opisthotonus.
28. For frostbite injuries, the best Tx is rapid re-warming with warm water. Whenever
frostbite or cold injuries are diagnosed, no attempt should be made to debridge any tissue
initially. Rapid re-warming with dry heat (like a fan) is not effective for frostbite.
29. Fibreoptic laryngoscopy establishes the Dx of epiglottitis but it must be performed in
the OR with preparations already made to perform endotracheal intubation.
30. Pressure sores are common over the sacrum, heels and hips. Frequent turning of the
patient is the only best method to prevent these.
31. Heat stroke is a life threatening catastrophic medical emergency due to failure of
thermoregulatory center leading to severe hyperthermia with body temperature generally
greater than 105 F. Patients will have CNS symptoms.
32. Warfarin induced skin necrosis is a complication seen in patients with protein C or S
deficiency especially when it is started in high dose without heparin coverage.

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33. Vit B12 deficiency: subacute combined degeneration of the dorsal and lateral spinal
columns is the classic neurologic manifestation. Symmertrical neuropathy, ataxia with
loss of vibration and position sense are the clinical clues.
34. Aortic dissection is an acute emergency and its medical management includes prompt
BP lowering with IV nitroprusside and short-acting beta blocker.
35. Aortic dissection may cause impaired consciousness. Neurological deficits may
develop later in the course of disease.
36. Prolonged placement of central lines can lead to subclavian vein thrombosis and
result in arm swelling. Catheters should be removed and duplex ordered to document the
thrombus and for the need of anticoagulation.
37. Gentamicin causes vestibular toxicity (Rombergs sign +). Some of the drugs
(especially aminoglycosides) commonly associated with ototoxicity are as follows:
Streptomycin
Minocycline
Neomycin
Quinine
Kanamycin
Quinidine
Tobramycin
Salicylates
Amikacin
Cisplantin
Netilmicin
Ethacrynic acid
Vancomycin
Furosemide
Genitourinary
1. Renal transplant dysfunction in the early post-operative period can be explained by a
variety of causes, including ureteral obstruction, acute rejection, cyclosporine toxicity,
vascular obstruction, and acute tubular necrosis. Radiosotope scanning, renal ultrasound,
MRI, and renal biopsy can be employed in conducting a differential diagnosis. Acute
rejection is best treated with IV sterioids. (biopsy: heavy lymphocyte infiltration, and
vascular involvement with swelling of the intima)
2. Rule out bladder cancer in all elderly patients with irritative voiding symptoms and
have negative urine culture.
3. The major cause of anemia in patients with end stage renal disease is deficiency of
erythropoietin. The anemia is normocytic and normochromic. The Tx of choice is

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recombinant erythropoietin, which is started if the Hb is <10 g/dL. The MC side effects
are worsening of HTN (30% of patients), headaches (15% patients) and flu-like
symptoms (5% of patients)
4. Focal segmental glomerulosclerosis (FSGS) is the MCC of nephritic syndrome in
African American adults. It also occurs in patients with HIV and IV drug abuse.
5. The classic findings in patients with amyloidosis (eg. In RA patients) are renal amyloid
deposits that show apple-green birefringence under polarized light after staining with
congo red.
6. 70% of cases with interstitial nephritis are caused by drugs such as cephalosporins,
penicillins, sulfonamides, sulfonamide containing diuretics, NSAIDs, rifampin,
phenytoin, and allopurinol. Discontinuing the offending agent is the Tx of drug-induced
interstitial nephritis.
7. IgA nephropathy is the MCC of glomerulonephritis in adults. Patients have recurrent
episodes of gross hematuria, beginning 1-3 days after an upper respiratory infection.
Serum complement levels are normal.
8. Ultrasound of the kidney, ureter and bladder should be done in patients of benign
prostatic hyperplasia whose serum creatinine is elevated.
9. Memranoproliferative glomerulonephritis, type II, is a unique glomerulopathy that is
caused by persistent activation of the alternative complement pathway. (IgG and C3
deposit at basement membrane)
10. Pulmonary-renal syndrome include a variety of disorders with simultaneous
involvement of the lung and kidney. Quick DD is important because the management
differs per disease. Emergency plasmapheresis is required in patients with Goodpastures
syndrome. Wegeners granulomatosis is treated with a combination of cyclophophamide
and steroids.
11. Routine urine cultures are not indicated in women with uncomplicated cystitis. Oral
trimethoprim-sulfamethoxazole is the preferred empiric Tx.
12. When isolated proteinuria occurs, the evaluation of the patient should begin by testing
the urine on at least two other occasions. (transient proteinuria is a common cause of
isolated proteinuria and can occure during stress or any febrile illness.
13. Acute allergic interstitial nephropathy is a drug-induced hypersensitivity reaction
characterized by rash, renal failure, eosinophilia, and eosinophiluria (Hansel stain). The
common medications:
Antibiotics (MC is methicillin group)
NSAIDs (often cause heavy proteinuria)
Thiazides

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Phenytoin
Allopurinol
14. Cholesterol embolization usually follows surgical or interventional manipulation of
the arterial tree. Renal failure, livedo reticularis, systemic eosinophilia, and low
complement levels should make you think of cholesterol embolism. (HY Q)
15. Suspect Alports syndrome in patients with recurrent episodes of hematuria,
sensorineural deafness and a family history of renal failure.
16. The Tx of choice for fibromuscular dysplasia: percutaneous angioplasty with stent
placement. (The usual cause of renal artery stenosis in young adults is fibromuscular
dysplasia: headache, elevated BP, renal bruit)
17. Collapsing focal and segmental glomerulosclerosis is the most common form of
glomerulopathy associated with HIV. Typical presentation of focal segmental
glomerulosclerosis includes nephritis range proteinuria, azotemia, and normal sized
kidneys. (HY Q)
18. Drug induced interstitial nephritis is usually caused by cephalosporins, penicillins,
sulfonamides, NSAIDs, rifampim, phenytoin and allopurinol. Patients present with
arthralgias, rash, renal failure and the urinalysis will show eosinophiluria.
19. Suspect medullary cystic disease in adults with recurrent UTI or renal stones and
contrast filled cysts demonstrated by IVP.
20. Acute post-streptococcal glomerulonephritis occurs 10-20 days after streptococcal
throat or skin infections. It presents with hematuria, HTN, red cell casts, and mild
proteinuria.
21. Tamsulosin is alpha-1a receptor blocker and it has the least side effects of all the
alpha-1 blocker used for the tx of BPH.
22. Several medications can cause hyperkalemia. Examples of these are: ACEIs,
NSAIDs, and potassium-sparing diuretics, such as spironolactone and amiloride.
23. Calcium gluconate is the most appropriate initial Tx for hyperkaliemic patients with
significant EKG abnormalities.
24. Patients with prostatodynia are afecrile and have irritative voiding symptoms.
Expressed prostatic secretions show a normal number of leukocytes and culture of these
secretions is negative for bacteria.
25. Simple renal cysts are almost always benign and do not require further evaluation.
Know how to recognize these on a CT scan.

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26. Allergic interstitial nephritis is a type 4 hypersensitivity reaction commonly seen

following the ingestion of nephrotoxic drugs. The triad of fever, petechial, rash, and
peripheral eosinophilia in an azotemic patient is highly suggestive of the Dx.
27. Patients with acute pyelonephritis usually present with fever, chills, nausea, vomiting
and flank or suprapubic pain. Physical examination shows costovertebral angle
tenderness. Hospitalization and intravenous antibiotics are indicated in complicated acute
pyelonephritis.
28. Finasteride acts on epithelium and alpha-1 blockers act on smooth muscles of prostate
and bladder base.
29. Acyclovir can cause crystalluria with renal tubular obstruction during high-dose
parenteral therapy, especially in inadequately hydrated patients.
30. Rifampin causes red to orange discoloration of body fluid. Red urine in a patient
taking rifapin is usually a benign drug effect.
31. Autonomic neuropathy may lead to a denervated bladder, resulting in overflow
incontinence. This condition is characterized by a high post-void residual volume.
32. Struvite stones almost always occur in the presence of alkaline urine that is
persistently infected with urease-producing bacteria.
33. Renal stones are predominantly of 4 types:
Calcium oxalate/phosphate (75%)
Uric acid (10-15%)
Struvite/triple phosphate (10-15%)
Cysteine (<1%)
34. Platelet dysfunction is the MCC of abnormal hemostasis in patient with CRF,PT,
PTT, and platelet count are normal. BT is prolonged. DDAVP (desmopressin) is usually
the Tx of choice, if needed. DDAVP increases the release of factor VIII: von Willebrand
factor multimers from endothelial storage sites. Platelet transfusion is not indicated
because the transfused platelets quickly become inactive. (HY Q)
35. The symptoms of BPH are weak urinary stream, urgency, frequency, and sensation of
incomplete voiding. Unlike prostate cancer, BPH starts in the center of the prostate.
Placement of a Foley catheter is the most appropriate initial step in patients who present
with acute renal failure. The obstruction should be reversed within the first two weeks to
prevent permanent kidney damage.
36. Autosomal dominant polycystic kidney disease (ADPKD) is a potential cause of
HTN. Hepatic cysts are the MC extrarenal manifestations. Intracranial berry aneurysms
are seen in 5 to 7% of the cases. Although such aneurysms are common and dangerous
when coupled with HTN, routine screening for intracranial aneurysms is not

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recommended.
37. The other major extra-renal complication of ADPKD are:
Hepatic cysts-MC common extrarenal manifestations of ADPKD
Valvular heart disease-most often mitral valve prolapse and aortic regurgitation
Colonic diverticula
Abdominal wall and inguinal hernia
38. Patients with recurrent hypercalciuric renal stones should be treated with increased
fluid intake, sodium restriction, and a thiazide diuretic. Calcium restriction is not advised.
The Tx of a first uncomplicated calcium stone is hydration and observation.
39. The MCC of calcium stones are:
Idiopathic hypercalciuria
Hypercalciuria due to systemic disorders (e.g., primary hyperparathyroidism,
sarcoidosis, etc.)
Hyperuricosuria
Hyperoxaluria: The cause may be hereditary, dietary (i.e. due to ingestion of a large
amount of vit. C or green leafy vegetables), or secondary to IBD or short bowel
syndrome.
Decreased urinary citrate
Renal tubular acidosis: typically, nephrocalcinosis is seen
Chronic decrease in urine output: this helps the precipitation of calcium salts.
40. The dietary recommendations for patients with renal calculi are:
Decreased dietary protein and oxalate
Decreased sodium intake
Increased fluid intake
Increased dietary calcium
41. Elderly patients are particularly predisposed to dehydration after even minor insults
(e.g., a minor febrile illness). Know the classic signs of dehydration (i.e., dry mucosa,
marginally high values for hematocrit and serum electrolytes, BUN/creatinine ratio >20).
The Tx is administration of intravenous sodium-containing crystalloid solutions (usually
0.9% NaCl= normal saline).
42. Hydration is the cornerstone of therapy for renal stone disease. A detailed metabolic
evaluation is not needed when a patient presents with his first renal stone.
43. In hyperkalemia, removal of K+ from the body can be achieved with dialysis, cation
exchange resins (Kayexalate) or diuretics.
44. Dx criteria of ATN:
Urine osmolality of 300-350 mOsm/L (but never <300)
Urine Na of >20 mEq/L

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FENa >2%
Prolonged hypotension from any cause can lead to ATN.
Hallmark findings on urinalysis: muddy brown granular casts consisting of renal tubular
epithelial cells.
45. Educational Objective: (extremely HY Q)
Muddy brown granular-Acute tubular necrosis (ATN)
RBC casts- Glomerulonephritis
WBC casts- Interstitial nephritis and pyelonephritis
Fatty casts- Nephrotic syndrome
Broad and waxy casts- Chronic renal failure
48. Acute pyelonephritis can potentially result in gram-negative sepsis. Urine and blood
cultures should be routinely obtained prior to administering antibiotics.
49. Presence of hematuria in a patient with irritative or obstructive voiding should alert
the physician to the possibility of bladder cancer.
50. in elderly patients, E.coli is the MC causative organism of acute bacterial prostatitis.
Prostatic massage and urethral catheterization are contraindicated due to the risk of
septicemia.
51. Any elderly patient with bone pain, renal failure, and hypercalcemia has multiple
myeloma until proven otherwise. Approximately 50% of multiple myeloma patients
develop some degree of renal insufficiency; this is most likely due to obstruction of the
distal and collecting tubules by large laminated casts containing paraproteins (mainly
Bence Jones protein).
52. Membranous glomerulonephritis is the most likely Dx in patients with both hepatitis
B infection and nephritic syndrome.
53. Acute epididymitis in younger patients is usually caused by sexually transmitted
organisms such as C. trachomatis or N. gonorrhea. In older men it is usually non-sexually
transmitted and is caused by gram-negative rods.
54. Rhabdomyolysis should be suspected in the following situation:
Presence of risk factors such as alcoholism, cocaine use, and electrolyte abnormalities
(e.g. hypokalemia, hypophosphatemia)
Disproportionate elevation of creatinine as compared with BUN.
Urine dipstick positive for blood but no RBC on microscopic examination.
The underlying pathology is acute tubular necrosis. Serum CK should be measure in
suspected patients. The Tx is aggressive intravenous hydration and alkalinazaion of urine.
In some cases, forced diuresis with mannitol may be required.
55. Uric acid stones are highly soluble in alkaline urine; therefore, alkalinization of urine
to pH >6.5 with oral sodium bicarbonate or sodium citrate is the treatment of choice.

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56. Consider three possibilities when a flat film of the abdomen and pelvis does not show
a stone in a patient with typical renal colic:
Radiolucent stone disease (uric acid stones)
Calcium stones less than 1 to 3 mm in diameter
Non-stone causes (e.g., obstruction by a blood clot or tumor)
OBGYN
1. Vasa previa or fetal vessel rupture necessitates immediate C. section.
2. Meigs syndrome: ovarian fibroma + ascites + right hydrothorax.
3. Krukenbergs tumor: metastasis of stomach cancer to both ovaries.
4. Advanced stage of premature labor should be managed more aggressively and
tocolysis has to be institute at once. Magnesium sulfate is the DOC for tocolysis. (bed
rest, cervical cultures, antibiotics, steroid, Magnesium)
5. HCG is a hormone secreted by the syncytiotrophoblast and is responsible for
maintenance of progesterone secretion by preservation of the corpus luteum until the
placenta starts producing progesterone on its own.
6. Toxoplasmosis in pregnancy:
DOC in first trimester: spiramycin
DOC in 2nd -3rd trimester: pyrimethamine and sulfadiazine.
Elective termination of pregnancy is an option in 1st trimester.
7. Hypotension is a common side effect of epidural anesthesia. The cause of hypotension
is blood redistribution to the lower extremities and venous pooling.
8. HELLP: combination of thrombocytopenia, microangiopathic hemolytic anemia and
increased liver enzymes in a patient with preeclampsia is defined as HELLP syndrome.
9. Severe preeclampsia is defined as a BP> or = 160/110, and / or the presence of one or
more of the following signs:
Oliguria (<500 mL/day)
Altered consciousness, headache, scotoma or blurred vision
Pulmonary edema or cyanosis
Epigastric or right upper quadrant pain
Microangiopathic hemolysis
Altered liver function tests
Elevated serum creatinine levels
IUGR, or oligohydramnios
10. In which patients with DUB do you perform endometrial biopsy to rule out

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endometrial carcinoma? When the patient is older than 35 yo, obese, diabetic or has
chronic HTN.
11. DUB is the MCC of abnormal uterine bleeding. Due to its benign nature, it is a Dx of
exclusion. The MCC of DUB in adolescent women is anovulation. IV estrogen is the
DOC for uncontrolled bleeding.
12. All patients with positive PPD should undergo a chest Xray. Should be given INH for
a period of 9 months.
13. Endometritis: typically occurs on the 2nd -3rd day postpartum. Predisposing risk
factors:
Prolonged labor
Prolonged and premature rupture of membranes
Manual removal of the placenta
Repeated pelvic examinations
More frequent after C section or operative vaginal delivery (episiotomy)
Tx: antibiotics ASAP: covering the aerobic and anaerobic ------clindamycin +
aminoglycoside/ ampicillin.
14. Fetal hydantoin syndrome presents with a small body size with microephaly,
hypoplasia of the distal phalanx of the fingers and toes, nail hypoplasia, low nasal bridge,
hirsutism, cleft palate and rib anomalies. (due to fetal exposure to hydantoin
anticonvulsants, such as diphenylhydantoin, usually taken by epileptic mothers.)
15. Hypertrophic dystrophy of vulva is most commonly seen in postmenopausal women
and is treated with local 1% corticosteroid ointment 3 times a day for 6 weeks. DD:
biopsy to differentiate from vulva cancer.
16. Granuloma inguinale: is a STD caused by the bacterium Donovania granulomatis and
characterized by an initial papule, which rapidly evolves into a painless ulcer with
irregular borders and a beefy-red granular base. (microscopic exam reveals Donavan
bodies: Giemsa stain of tissue smears reveals reddish encapsulated bipolar staining
organisms that are found within large mononuclear cells.). Tx. tetracycline
17. The most appropriate next step in managing variable deceleration is mask oxygen and
change in maternal position.
18. Lithium is associated with the congenital anomalies, classically Ebsteins anomaly.
When a woman with isotretinoin, she should receive strict contraception. Inhaled steroid
are okay in pregnancy.
19. Idiopathic precocious puberty is managed with GnRH agonist therapy in order to
prevent premature fusion of the epiphyseal plates.
20. In pregnant patients, asymptomatic bacteriuria increases the risk of developing

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cystitis and pyelonephritis more than in the non-pregnant state. E.coli accounts for more
than 70% of cases. Tx in pregnancy consists of a 7-10 day courses of nitrofurantoin,
ampicillin or first generation cephalosporin.
21. Lichen sclerosis is usually seen in postmenopausal women but many develop at any
age. It present with pruritus, burning and dyspareunia and is treated with superpotent
topical corticosteroids such as clobetasol or halobetasol. *Itchy spot in a postmenopausal
women needs biopsy.
22. In a postmenopausal female who has vulvar itch and dryness, Lichen sclerosis must
be suspected. However, vulvar carcinoma in situ must also be in the DD and a biopsy
obtained if suspicion is high.
23. The chancre characterizes the primary stage of syphilis: painless, indurated ulceration
with a punched-out base and rolled edges. Serologic testing is not reliable at this stage
and includes a high rate of false-negatives, so Dx in the first stage is made via spirochete
identification on dard field microscopy.
24. Fetal distress (repetitive late decelerations) is an indication for emergency C. section.
25. Physicians have to maintain their obligation to a patients right to confidentiality,
even in the event of a pregnant minor wanting to withhold the Dx from her parents.
26. GnRH stiulation test serves to differentiate between true isosexual and
pseudoisosexual precocious puberty.
27. Presence of dysmenorrheal, heavy menses, and enlarged uterus is almost diagnostic
of either adenomyosis or fibroid uterus.
28. Hormone replacement therapy is now only recommended for the short-term use of
controlling menopausal symptoms. Large studies, such as the WHI, have shown that the
long-term use of combined HRT can slightly increase the risk of coronary heart disease
and stroke.
29. Abrupt onset of hyposia with respiratiory failure, cardiogenic shock and DIC when
doing amniocentesis or delivery, ---amniotic fluid embolism. Respiratory support is
always the 1st step of management.
30. The indicence of vertical transmission of HIV can be reduced from 25% to 8% by
admistrationg ZDV to pregnant women and their offspring. ZDV is administered orally
after 1st trimester, IV during labor, and orally to the neonate for the first 6 weeks of life.
31. Vulvar papillomatosis, or condylomata acuminate, are genital lesions caused by HPV
serotype 6 and 11. Condylomas present as exophytic lesions with a raised papillomatous
or spiked surface and may grow into large and cauliflower-like formations.

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32. Low back pain is a very common complaint in the 3rd trimester of pregnancy. It is
believed to be caused by the increase in lumbar lordosis and the relaxation of the
ligaments supporting the joints of the pelvic girdle.
33. The first step in a patient with secondary amenorrhea is to rule out common
situations; that is, pregnancy, then hypothyroidism (TRH increasesprolactin
increasesGnRH inhibited) and hyperprolactinemia. The subsequent step should be the
determination of the patientss estrogen status with progestin challenge test.
34. The MCC of mastitis: staph. Aureus.
35. Active phase arrest: occurs when dilation fails to progress in the active phase of labor
over a period of at least 2 hours. In the primigravida, cervical dilatation in the active
phase progresses at a speed of 1.2 cm/hr. So after 2 hours the patient (originally with
cervix dilated to 5 cm) must be at 7.4 cm. If less than that, Dx is made. Tx.: C-section
36. Prolonged latent phase: therapeutic rest.
37. In incomplete abortion, the cervix is dilated; there is an incomplete evacuation of the
conceptus with fragments retained in the uterine cavity.
38. Labor should be induced immediately in patients with intrauterine fetal demise who
develop coagulation abnormalities.
39. Patients with testicular ferminization syndrome present with amenorrhea, developed
breast (why? Because testes secret some estrogen, unopposed to testosterone), absent
pubic and axillary hair, absent internal reproductive organs, and a 46XY karyotype.
(lower part of vagina exists, sine it is from urogenital sinus, not from Mullerian tube:give
rise to uterus, tubes,upper part of vagina). Presence of MIF is the casue.
40. Tx of luteal phase defect is first attempted with progesterone supplements;
clomiphene citrate or hMG can be tried if progesterone gives no results.
41. Dx of luteal phase defect is confirmed by emdometrial biopsy.
42. beta-2 agonist may worsen the edema by decreased water clearance, tachycardia and
increased myocardial workload.
43. Pregnancy is associated with an increase in total T4 (normal free T4), an increase in
TBG, and a normal TSH. (extremely HY Q for USMLE)
44. Pseudocyesis is a rare condition in which a woman presents with nearly all signs and
symptoms of pregnancy; however, ultrasound reveals a normal endometrial stripe. All
patients with ~ need psychiatric evaluation.
45. Edema of the lower extremities in pregnancy is most commonly a benign problem.

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Pre-eclampsia should be suspected if the edema is associated with HTN or proteinuria, or

if it is located on the hands and/or face. Know when to order Duplex. (reassurance in
regular edema)
46. Bed rest and hydration are the first step in stopping uterine contractions in early
stages of preterm labor and if these measures fail, tocolytics are indicated.
47. Total abodominal hysterectomy is the Tx of choice for uterine rupture. However,
debridement and closure of the site of rupture can be considered in women with low
parity or who desire more children.
48. Even though ACEIs /ARBs retard the progression of diabetic nephropathy, they are
strictly contraindicated in pregnant women. Labetalol is a perfect substitute for enalapril
in pregnant women with diabetic nephropathy. The goal is to bring the protein excretion
to less than 500-1000 mg/day and blood pressure to less than 130/80 mmHg.
49. In chlamydial infection, empiric Tx of gonorrhea is not recommended. But in
Gonococcal infections empiric Tx of Chlamydia is recommended. A single dose of
azithromycin is Tx of choice for genital Chlamydia infections. 7 days of doxycycline can
also be used for Chlamydia but because of the compliance issues single dose
azithromycin is preferred. (treat patient and partner)
50. Clotrimazole cream is an effective Tx for Candidal vaginitis, and partner need not be
treated.
51. In the ovulatory phase of the menstrual cycle, cervical mucus is profuse, clear and
thin.
52. Neuroblastomas have been shown to be associated with exposure to phenytoin and
other hydantoins in utero.
53. Think of trichotillomania in patients with uncontrollable urges to pull out their hair,
resulting in alopecic patches.
54. The most appropriate test to confirm the Dx of intra uterine fetal demise (IUFD) is
real time ultrasonography.
55. Reassurance and outpatient follow up is the std of care for threatened abortion.
56. In severe preeclampsia, the patient has to be evaluated and stabilized before
management decisions are made. Bed rest and salt reduced diet are mandatory; patients
with BP >160/110 mmHg necessitate antiHTN therapy. If the response to Tx is prompt
and the patient is stabilized, the decision will then depend on the term: if the patient is at
term or fetal lungs are mature, delivery must be done. In the opposite case, delivery can
be delayed until 34 weeks gestation or until fetal lungs become mature.

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57. Diabetes screening is performed between 24 and 28 weeks of gestation. The

screening test is the 1 hour 50 gram oral glucose tolerance test. After 1 hour, if the blood
glucose value is less than 140 mg/dL, the gestational diabetes is ruled out. If the blood
glucose value is >140mg/dL, the 3 hour OGTT is used for confirmation.
58. Patients with Kallmanns syndrome have a normal karyotype, and present with
hypogonadotropic hypogonadism, eunuchoid stature and anosmia (cant smell).
59. Down syndrome: a decrease in MSAFP and Estriol, and an increase in beta-hCG level
is typical.
60. Asymmetrical IUGR is a result of a late exposition to the insult past 28 weeks and is
characterized by a normal or almost normal head size and a reduced abdominal
circumference. It is usually caused by maternal factors such as HTN, preeclampsia and
chronic renal disease.
61. Abdominal circumference is the most effective parameter for estimation of fetal
weight in cases of suspected IUGR.
62. In cases of IUGR, presence of oligohydramnios (amniotic fluid index:<7) is an
indication for delivery.
63. MRKH (Mayer-Rokitansky-Kuster-Hauser syndrome) is the result of a mullerian
agenesis. Patients have normal secondary sexual characteristics, amenorrhea, absent or
rudimentary uterus, and a 46 XX karyotype.
64. Physical exercise can be beneficial during pregnancy and is helpful in maintaining a
feeling of well being. It is usually recommended to keep it at the same level as before
pregnancy.
65. OHSS (ovarian hyperstimulation syndrome) is a complication that occurs in 1-3% of
patients under ovulation induction. OHSS may be complicated with ovarian torsion,
ovarian rupture, thrombophlebitis and renal insufficiency.
66. Labor:
active phase (considered prolonged First stage: latent phase(2-3CM) if exceeds 20
hours in the primiparous, and 14 hours in the multiparous.) Normal dilating rate:
primiparous: 1 cm/hr, multiparous: 1.2cm/hr.
Second stage:
Third stage: starts with the delivery of the baby, and ends with the delivery of the
placenta.
Fourth stage: from delivery of the placenta until 6 hours postpartum. (the mother should
be closely observed during this stage because of the risk of postpartum hemorrhage.
67. Screening cultures for GBS should be performed at 36-37 weeks gestation, and
positive cases should be treated with penicillin G during labor, even in the absence of

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frank chorioamnionitis, thus reducing the risk of neonatal infections.

68. Epicural anesthesia may cause overflow incontinence as a transient side effect. It is
best treated with intermittent catheterization.
69. PID Tx: inpatient Tx with cefotetan plus doxycycline.
70. Penicillin desensitization is considered to be the Tx of choice for the pregnant
patients with syphilis and having penicillin allergy.
71. Asymptomatic bacteriuria occurs when the urine culture grows>100,000 CFU per ml
of a single organism in an asymptomatic patient. It is important to promptly treat the
infection to prevent progression to pyelonephritis in the pregnant patient.
72. Suction curettage is the Tx of choice for inevitable abortion.
73. Most of the breech presentations assume cephalic presentation by 34-weeks gestation.
External cephalic version should not be tried unless the fetus has not assumed the
cephalic presentation past 37 wks.
74. Once the Dx of missed abortion is confirmed, surgical evacuation (dilation and
curettage) of the uterus has to be performed to avoid serious complications, such as DIC
and sepsis and to minimize the extent of the hemorrhage.
75. In cases of post-term pregnancy (42-43 weeks), the NST and biophysical profile
should be performed twice weekly and if there is oligohydramnios or if spontaneous
decelerations are noted, delivery has to be accomplished.
76. Biophysical profile (BPP) is a scoring system designed to evaluate fetal well being. It
is indicated in high risk pregnancies, or in case of maternal or physician concern,
decreased fetal movements, or an NST. It includes the NST in addition to four parameters
assessed by ultrasonography: 1/fetal tone; 2/fetal movements (3/10 min); 3/fetal breathing
(30/10min); 4/amniotic fluid index, (5-20). Each of these five variables is given a score of
two when present, and a score of 0 when absent or abnormal. A total of score of 8-10 is
considered normal, and should only be repeated once or twice weekly until term for high
risk pregnancies.
77. Primary dysmenorrheal: due to increased prostaglandins level. Tx: NSAIDs are
highly effective, oral contraceptive pills inhibit ovulation and are also effective.
78. Candida vaginitis is not considered a STD and occurs in presence of risk factors such
as DM, oral contraceptive pills, pregnancy and immunosuppressive therapy.
79. Atrophic vaginitis is treated with estrogen, this latter should be balanced with
medroxyprogesterone (provera) if the uterus is still present. If the patient is not willing to
use oral hormones, premarin (estrogen) cream twice daily may be used.

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80. Septic abortion is managed with cervical and blood sampling, IV antibiotics and
gentle suction curettage.
81. The increased in BP that appears before 20 weeks gestation is either chronic HTN or
hydatiform mole.
82. Midplevic contraction which is indicated by prominent ischial spines is an important
cause of arrest disorder of dilation (cervical dilation has been the same for over 2 hours,
or the descent has not progressed for more than 1 hour). Causes of arrest disorder:
hypotonic contractions, conduction anesthesia, excessive sedation, cephalopelvic
disproportion or malpresentation.
83. In the presence of decreased fetal movements, fetal compromise should be suspected,
and the best next step in management in such case is the performance of a non-stress test
(NST).
84. An antepartum hemorrhage with fetal heart changes, progressing from tachycardia, to
bradycardia, to a sinusoidal pattern occurring suddenly after rupture of membranes
suggests the diagnosis of vasa previa.
85. Transvaginal ultrasonogram is more accurate than transabdominal one in diagnosing
ectopic pregnancy, and should be performed when beta-hCG levels are below 1500-2000
mIU/mL.
86. Graves disease is the MCC of maternal hyperthyroidism. New onset, significant
arrhythmias (not premature beats) in a pregnant patient could be from hyperthyroidism.
TSH should be ordered as the next step.
87. Increased HCG seen with hyperemesis gravidarum, H. mole, and choriocarcinoma
can cause hyperthyroidism during pregnancy too.
88. CVS (chorionic villus sampling) is the best test for detection of fetal chromosomal
abnormalities in the first trimester of pregnancy (earliest)
89. Primary dysmenorrheal usually appears 6-12 months after menarche. NSAIDs are
highly effective for Tx; OCPs inhibit ovulation and are also effective. They have high
levels of prostaglandins than normal women.
90. Tx for superficial thrombophlebitis postpartum: local heat, bed rest, and NSIDs.
Anticoagulants are indicated only when clot extends into the deep vein system.
91. Thrombophlebitis: a condition predisposed by the pelvic venous stasis usually present
after delivery and occurs when there is a large inoculum of anaerobic pathogen on that
level. It is suspected in the setting of a persistent spiking fever for 7 to 10 days
postpartum, which fails to respond to antibiotic therapy. When suspected, heparin should

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be added promptly to antibiotics and maintained for 2 to 3 wks.

92. Patients with placental abruption in labor have to be managed aggressively to insure a
rapid vaginal delivery. C. section is used only when there are obstetrical indications, or
when there is a rapid deterioration of the state of either the mother or the fetus, and labor
is in an early stage.
93. All patients with primary amenorrhea and high FSH levels need to have a karyotype
determination.
94. If maternal serum AFP levels are found to be abnormal in a pregnant patient, the next
step is ultrasonography.
95. Clomiphene citrate acts by binding to hypothalamic estrogen receptors and
suppressing the inhibitory effect estrogen has on GnRH production.
96. Variable decelerations are secondary to umbilical cord compression.
97. OCP are first line agents in the Tx of endometriosis in young women desiring future
fertility.
98. The risk factors for osteoporosis include: thin body habitus, smoking, alcohol intake,
steroid use, menopause, malnutrition, family history of osteoporosis, and Asian or
Caucasian race.
99. Laparoscopy is the gold std for the Dx of endometriosis
100. Lupus anticoagulant, seen in SLE patients, leads to recurrent abortions and
thromboembolic disease. (antiphospholipid AB, such as lupus anticoagulant and
anticardiolipin Ab, cause placental infarction leading to fetal growth restriction or death.)
These Ab are also associated with thromboembolic disease.
101. NST: a test is considered reactive (good), and therefore normal, if in 20 minutes, 2
accelerations of fetal heart rate of at least 15 beats per minute above the baseline, lasting
at least 15 seconds each, are noted. If less than 2 accelerations are noted in 20 mins, the
test is said to be non-reactive (bad) and further assessment is required. The MCC of non
reactive NST is sleeping baby; If acceleration (>15bpm for >15 sec) is noted after
exposure to the vibroacoustic stimulus, the test is considered positive, and reassuring. If
the NST is abnormal either BPP or CST should be considered.
102. Standard of care for threathened abortion: reassurance and outpatient follow ups.
103. OCPs have been shown to decrease the risk of ovarian and endometrial carcinoma.
Breast cancer risk does not seem to change with their use. Besides HTN, OCP may be
associated with other complications including thromboembolism, cerebrovascular
disease, MI, gallbladder disease and benign hepatic tumors.

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104. The initial tests to assess the ovulatory function are BBT and midluteal progesterone
level.
105. Patients with severe placental abruption in labor have to be managed aggressively to
insure a rapid vaginal delivery.
Risk factors of abruption placenta include:
Maternal HTN
Placental abruption in a previous pregnancy
Trauma
Rapid decompression of a hydramnios
Short umbilical cord
Tobacco use and cocaine abuse
Folate deficiency
106. Secondary amenorrhea is relatively common in elite female athletes and results from
estrogen deficiency. (excessive exercises, excessive weight loss)
107. Endometiral hyperplasia: cyclic progestins
108. Major complication of ovulation induction are multiple gestation and OHSS
109. Pap smear schedule: from 18 yo on, or onset of sexual activity: annually. After 3
normal results 1 year apart, perform the screening every 2-3 yrs.
110. Granulosa cell tumors produce excessive amounts of estrogen, and can present with
precocious puberty in younger children and postmenopausal bleeding in elderly patients.
This has to be differentiated from heterosexual precocious puberty or virilizing symptoms
which are usually produced by excessive androgens.
111. In the presence antepartum hemorrhage, pelvic examination must not be done before
ruling out placenta previa (ruled out by ultrasound). Placenta previa presents with
painless third trimester vaginal bleeding.
112. Arrest disorder resulting from midpelvic contraction is treated with C. section. (lowtransverese C. section)
113. The chancre characterizeds the primary stage of syphilis: it is a painless, indurated
ulceration with a punched-out base and rolled edges. Serologic testing is not reliable at
this stage and includes a high rate of false-negative, so Dx in the first stage is made via
spirochete identification on dark field microscopy.
114. Behcets disease is a rare multisystem disorder with an autoimmune etiology and
manifests with recurrent ulceration in the mouth and genital area associated with uveitis.
115. Metronidazole is the Tx of choice for Trichomonas vaginitis and should be given to

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both the patients and the partners.

116. Bacterial Vaginosis: Tx of choice is metronidazole cream or clindamycin cream (not
orally). An STD caused by the bacteria Gardnerella vaginalis. Presents with a profuse
ivory to gray malodorous discharge with a pH of 5 -6.5. When add KOHfishy odor.
Itching and burning are not usual, Identifying clue cells on a wet mount preparation of
the discharge makes the Dx.
117. Clue cells: characteristic epithelial cells diffusely coated with the organism.
118. The MCC of abnormal AFP is gestational age error.
119. The major cause of death in eclampsia is hemorrhagic stroke.
120. Adenomyosis occurs most frequently in women above 40 and typically presents
with severe dysmenorrheal and menorrhagia. The physical exam reveals an enlarged and
generally symmetrical uterus.
121. Excessive use of oxytocin may cause water retention, hyponatremia and seizures
(water intoxication).
122. A young woman who presents with a breast lump can be asked to return after her
menstrual period for reexamination (which may reveal regression of the mass) if no
obvious signs of malignancy are present.
123. 1 ovarian failure results in decreased estrogen, and increased FSH and LH (loss of
negative feedback of estrogen).FSH elevation > LH, diagnostic
124. Metformin is indicated in PCO patients with impaired glucose tolerance. It helps in
preventing Type 2 DM and correcting obesity, hirsutism, menstrual irregularity, and
infertility.
125. Patients with PCO are at risk of developing type II DM and the best next step in the
management once Dx ed is oral glucose tolerance test.
126. PCO patient usually have elevated DHEA levels. Although ACTH levels are normal
in these women, ACTH stimulation test produces an exaggerated response of DHEA
because of increased sensitivity of the adrenal gland to ACTH.
127. The MCC of mucopurulent cervicitis is : Chlamydia trachomatis. Besides, cervical
ectopy created by OCPs may preferentially predisposed to colonization with C.
trachomatis.
128. Tubo-ovarian abscesses are usually managed with triple antibiotic therapy. Drainage
is indicated if there is no response to antibiotic therapy after 24 to 48 hours.

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129. Raloxifene is a mixed agonist/antagonist of estrogen receptor. In breast tissue and

vaginal tissue, it is an antagonist, whereas in bone tissue, it is an agonist and may be used
to treat osteoporosis. It increases the risk of DVP.
130. Retinal hemorrhage is considered to be an extremely ominous sign of preeclampsia.
131. The most effective agent used for the Tx and prevention of seizures in eclampsia is:
magnesium sulfate.
132. Depressed deep tendon reflexes is the earliest sign of magnesium sulfate toxicity
which requires stopping of the magnesium sulfate infusion and administration of calcium
gluconate.
133. Before 37 weeks of gestation, fetuses in breech presentation need no intervention as
they may convert to vertex automatically.
134. Magnesium sulfate is the DOC of tocolysis.
135. Ovarian solid tumors discovered incidentally in a multiparous African-American
pregnant woman: think of pregnancy luteoma. If in non pregnant woman, it is almost
always malignant and demand immediate and aggressive evalution and Tx in all age
groups.
136. In pregnant lady with toxoplasmosis (recognize contact with cats), Spiramycin is
DOC in first trimester, however combination of pyrimethmine and sulfadiazine is
preferred in second and third trimester. Elective termination of pregnancy is an option in
1st trimester.
137. In a pregnant lady in her first trimester, who presents with severe and persistent
vomiting, one has to think of hyperemesis gravidarum. (measure HCG)
138. Voiding after intercourse has been shown to decrease the risk of UTI in sexually
active females.
139. If Pap smear reveals a dysplasia, perform colposcopy. If it reveals an inflammatory
atypia, repeat after 4-6 months.
140. Radiation levels used for Dx exams are not associated with teratogenicity.
141. Suppression of lactation: tight fitting bra and ice packs. (testosterone + estrogen will
do it too. No bromocriptine for lactation suppression anymore
142. BUN, serum creatinine, and hematocrit are often decreased in pregnant women, and
it is due to dilutional effect.
143. ABO antibodies: IgM, dont cross the placenta

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Rh antibodies: Ig G, do cross the placenta.

144. Emergency contraception: up to 72 hours after coitus. Ethinyl estradiol (estrogen)
and levonorgestrol -progesterone(now and after 12 hours).
145. Testosterone level increased in female: androgen comes from ovary
DHEAs level increased in female: androgen comes from adrenal.
146. Maternal risk factors:
Infection (Rubella virus, Listeria, CMV, and Treponema)
Environmental factors: alcohol consumption, cigarette smoking can increase up to 4
times the risk. Advanced maternal age and low socioeconomic status. Women above 40
yo exceeds 10%, and can be as high as 50% in women above 45
Systemic disorders: DM, hypothyroidism, SLE. Up to 40% of pregnancies in patients
suffering from SLE are lost.
Local maternal factors: cervical incompetence, uterine anomalies
Fetal factors:
Genetic abnormalities (MCC)
147. Diseases improve in pregnancy:
Graves disease (due to the relative immunotolerance of pregnancy)
Migraine (especially during 2nd trimester, avoid -blockers, it decreases placental blood
flow and cause growth retardation. In the 3rd trimester, imitriptyline or doxepin may be
used in low dose)
Peptic ulcer (pregnancy associated with increased prostaglandins which protect the
gastric mucosal barrier.)
Multiple sclerosis
148. Puerperal fever: is defined as an increase in temperature 38C for more than 2
consecutive days in the first 10 days of postpartum. It occurs in approximately 6-7% of
women after vaginal delivery but its incidence is twice as high after a C. section. When
thrombophlebitis is suspected, heparin is required.
149. Risk factors of gynecologic cancers:
Endometrial cancer-HTN and DM
Breast cancer- late childbirth and pauciparity
Cervical cancer-smoking, HPV
OCPs reduce the risk of ovarian and endometrial cancers, as well as benign breast
disease
Hepatology
1. Liver founctions can be divided into three distinct categories:
Synthetic (clotting factors, cholesterol, proteins)
Metabolic (of drugs and steroids, including detoxification)

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Excretory (bile excretion)

2. All chronic hepatitis C patients with elevated ALT, detectable HCV RNA and
histologic evidence of chronic hepatitis of at least moderate grade are candidates for
antiviral therapy with interferon and ribavirin.
3. Tx for Chronic hepatitis B with persistently elevated ALT levels, detectable serum
HBsAg, and HBV DNA: interferon or lamivudine.
4. HyperTG>1000 mg/dL can cause acute pancreatitis.
5. Characteristic of alcoholic hepatitis: AST: ALT>2 It is thought that this transaminase
imbalance occurs in alcoholics secondary to a heptic deficiency of pyfidoxal-6-phosphate
(a cofactor for ALT enzymatic activity). The absolute values of serum AST and ALT are
almost always less than 500 IU/L in alcoholic liver disease. (Mallory bodies are often
observed in severe cases, but are not specific for the Dx of alcoholic hepatitis)
6. Jaundice in the 3rd trimester of pregnancy should be evaluated specifically for those
hepatic disorders associated with pregnancy. Marked pruritis and elevated of total bile
acids are suggestive of intrahepatic cholestasis of pregnancy.
7. Benign intrahepatic cholestasis can develop after a major surgery in which hypotesion,
extensive blood loss into tissues and massive blood replacement are notable.
8. Hydatid cysts in the liver are due to infection with Echinococcus granulosus.
9. Dubin-Johnson and Rotor syndrome are two familial disorders of hepatic bile system
that result in conjugated hyperbilirubinemia. A dark granular pigment is present in the
hepatocytes of patients with Dubin-Johnson syndrome, but is not seen in association with
Rotor syndrome.
10. Acute pancreatitis is one of the conditions causing acute abdomen, which is managed
conservatively (analgesics, IV fluids, nothing by mouth)
11. Cigarette smoking is the most consistent reversible risk factor for pancreatic cancer.
12. Risk factors for pancreatic cancers are:
Male sex
Increasing age (50yo)
Black race
Cigarette smoking
Chronic pancreatitis
Long-standing diabetes
Obesity
Familial pancreatitis
Pancreatic cancer in a close relative

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13. The following are not risk factors for pancreatic cancer:
Alcohol consumption
Gall stones
Coffee intake
14. Tx for coagulopathy in patients with liver failure: fresh frozen plasma
15. Emphysematous cholecystitis is a common form of acute cholecystitis in elderly
diabetic males. It arises due to infection of the gallbladder wall with gas-forming
bacteria.
16. Conjugated hyperbilirubinemia is mainly because of intrahepatic or extrahepatic
obstruction or congenital impaired hepatic excretion of bilirubin.(ultrasonogram will
help)
17. Abdominal CT scan is a very sensitive and specific tool used in the Dx of pancreatic
carcinoma.
18. Cholecystectomy is indicated in all patients with symptomatic gallstones who are
medically stable enough to undergo surgery.
19. Asymptomatic gallstones should not be treated. Laparoscopic cholecystectomy is the
Tx of choice for symptomactic gallstone disease.
20. Abdominal ultrasound is the best tool for the initial investigation of gallbladder
pathology. While asymptomatic patients typically do not require Tx, laparoscopic
cholecystectomy (not open cholecystectomy) is the Tx of choice for those with
symptomatic gallbladder disease.
21. Acute acalculous cholecystitis is an acute inflammation of the gallbladder in the
absence of gallstones, most commonly seen in hospitalized and severely ill patients.
22. Fatty liver (steatosis), alcoholic hepatitis and early fibrosis of the liver can be
reversible with the cessation of alcohol intake. True cirrhosis (with regenerative nodules)
is irreversible, regardless of alcohol abstinence.
23. Cholangiocarcinoma can complicate primary sclerosing cholangitis, especially in
patients who smoke and have ulcerative colitis.
24. Ursodeoxycholic acid is a medication used to dissolve small radiolucent gallstones in
patients with normal, functional gallbladders who are poor surgical candidates. However,
this medication is very costly and associated with a high risk of relapse when therapy is
halted.
25. Ursodeoxycholic acid is the most commonly used drug for primary biliary cirrhosis as

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it relieves symptoms and improves the transplant free survival time.

26. Post cholecystectomy pain most commonly occurs due to one of three reasons:
common bile duct stone, sphincter of Oddi dysfunction, or functional causes.
27. PSC (primary sclerosing cholangitis) is caused by inflammation and fibrosis of the
intrahepatic and extrahepatic biliary ducts. It is frequently associated with ulcerative
colitis.
28. Insuline resistence plays a central role in the pathophysiology of non-alcoholic fatty
liver disease by increasing the rate of lipolysis and elevation the circulating insulin levels.
29. Predominantly found in children who were given aspirin for virus-induced fever,
Reye syndrome can lead to fulminant hepatic failure. Elevation of ammonia levels and
transaminases, vomiting, and mental status changes are the more common clinical
manifestations of this syndrome (extensive fatty vacuolization of liver)
30. Paracentesis can be used for both diagnostic and therapeutic purposes in patients with
ascites.
31. Individuals who received blood transfusions before 1992 should be screened for
hepatitis C. Those who received blood transfusion before 1986 should be screened for
hepatitis B.
32. Wilsons disease is Dx by decreased serum ceruloplamin, increased urinary copper,
and Kayser-Fleischer rings seen on slit lamp examination of the eye.
33. Gallbladder carcinoma is a rare malignancy that most often arises in Hispanic and
Southwestern Native American females who have a history of gallstones. It is typically
Dx during or after cholecystectomy. No more Tx other than cholecystectomy is needed.
34. Hepatic adenoma is a benign tumor most often seen in young and middle-aged
women who are taking OCPs. Severe intra-tumor hemorrhage and malignant
transformation are the most dreaded complications.
35. Pain management in patients with chronic pancreatitis: perform an ERCP with
removal of the stone and stent insertion.
36. ERCP is the investigation of choice for patients with recurrent pancreatitis with no
obvious cause.
37. Studies have shown that patients with chronic hepatitis C who show persistently
normal liver enzymes on multiple occasions have minimal histological abnormalities,
therefore they do not need to be treated with interferon or antiviral drugs at this stage.
38. Non-selective beta blockers are used for the primary and secondary prevention of

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variceal bleeding in cirrhotic patients who have portal HTN with esophageal varices.
39. Choledochal cysts are congenital abnormalities of the biliary tree characterized by
dilation of the intra and/or extra hepatic biliary ducts.
40. Alpha-1 antitrypsin deficiency is associated with panacinar emphysema and cirrhosis.
41. Most reliable way to distinguish chronic active from chronic persistent hepatitis: liver
biopsy.
42. Lab tests in the evaluation of liver disease either assess liver functionality (eg, PT,
bilirubin, albumin, cholesterol) or structural integrity and cellular intactness (eg, AST,
ALT, gamma glutaryl transferase, alkaline phosphatase). A progressive decrease in
transaminase levels signals either recovery from liver injury or that few hepatocytes are
functional. (progression to fulminant hepatitis).
43. HCV RNA is the single most sensitive serological marker used in screening for HCV
infection.
44. Orthotopic liver transplantation remains the only effective mode of Tx of fulminant
hepatic failure and should be considered in any patient presenting with fulminant hepatic
failure, regardless of the etiology.
45. In U.S.A., acute liver failure and fulminant hepatitis are most commonly due to
acetaminophen toxicity. Remember that acute hepatic failure is defined as the
development of liver failure within 8 weeks of hepatocellular injury onset. If hepatic
encephalopathy is also seen, then the syndrome is described as fulminant hepatic failure.
46. Porcelain gall bladder is an entity usually diagnosed on an abdominal X-ray. The
condition predisposes individuals to gall bladder carcinoma and requires resection.
47. Sudden onset right upper quadrant abdominal pain, fever, vomiting, and leukocytosis
are highly suggestive of acute cholecystitis.(impaction of gallstone in cystic duct).
48. In evaluating the asymptomatic evaluation of aminotransferases, the first step is to
take a thorough history to rule out the more common hepatitis risk factors (eg. Alcohol or
drug use, travel outside of the country, blood transfusion, high risk sexual practices)
49. Hepatitis A vaccine or serum immune globulin should be given to all non-immunized
travelers to endemic countries. If travel will occur in less than 4 weeks, serum immune
globulin should be given. If travel will occur in greater than four weeks, hepatitis A
vaccine should be given instead as it offers long-term protection.
50. Known risk factors for the development of pancreatic cancer include:
family history
chronic pancreatitis

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smoking
DM
Obesity
Diet high in fat
(Alcoholism is not a risk factor for pancreatic cancer)
51. Checking for urinary excretion of bilirubin is an easy and effective way of determing
wheter the cause of jaundice is conjugated or unconjugated bilirubin. The presence of
biirubin in urine is indicative of conjugated hyperbilirubinemia. A more precise way is to
do the Vandenberg test.
52. 95% of blood bilirubin is due to unconjugated fraction.
The unconjugated fraction of bilirubin is insoluble as it is bound to the albumin and
therefore cannot be filtered by the glomerulus and is not excreted in urine.
The conjugated fraction is soluble in plasma, can be filtered by the glomerulus and
excreted in the urine.
53. Anti-mitochondrial Ab are present in 90% of patients with primary biliary cirrhosis, a
chronic liver disease characterized by autoimmune destruction of the intrahepatic bile
ducts and cholestasis.
54. Alcoholism is the MCC of cirrhosis in the United States. Infection with HCV is the
second MCC of cirrhosis in the U.S.
55. Tx for acute cholangitis:
Supportive care
Broad-spectrum antibiotics
Biliary drainage with an ERCP
56. Budd Chiari syndrome or hepatic vein occlusion is most commonly associated with
polycythemia vera and other myeloproliferative diseases.
57. Spironolactone is the diuretic of choice in treating cirrhotic ascites.
58. Common indications for TIPS:transjugular intrahepatic portalsystemic shunt
Refractory cirrhotic hydrothorax.
Refratory ascites (defined as diurectic resistant or diuretic refractory ascites)
Recurrent variceal bleed not controlled by other minimal invasive means.
Patients waiting for liver transplantation and needing portocaval shunts.
59. Tx of cirrhotic ascites:
Diagnostic paracentesis, with examination for cell count and culture and ascetic
albumin level. The latter allows calculation of the serum-ascites albumin gradient (serum
albumin minus ascetic albumin) SAAG level >1.1 suggest portal HTN
Salt-restricted diet, which may allow for complet resolution of the ascites without
additional therapy in a subset of patients.

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Spironolactone, generally in conjunction with furosemide, for patients who do not

improve with salt restriction. Spironolactone is an aldosterone-receptor antagonist and is
the diurectic of choice in ascites secondary to cirrhosis
Patients with massive ascites, regractory ascites, or respiratory compromise may benefit
from early larg-volume paracentesis
Recalcitrant ascites may require a transjugular intrahepatic portosystemic shunt (TIPS)
procedure
60. Patients with cirrhosis develop ascites as a result of multiple mechanisms:
Portal HTN
Hypoalbuminemia
Peripharl vasodilation
Limited hepatic inactivation of aldosterone
Increased aldosterone secretion (due to renin production)-this 2 hyperaldosteronism
is considered most responsible for cirrhotic ascites)
61. Hepatic venogram or a liver biopsy is the diagnostic test of choic for the evaluation of
congestive hepatomegaly secondary to hepatic vei occlusion (Budd Chiari syndrome)
62. Spotaneous bacterial peritoneal (SBP) should be suspected immediately in cirrhotic
patients with ascites who develop fever or abdominal pain. The diagnosis of SBP is
confirmed by a positive ascetic bacterial culture and an elevated ascetic fluid absolute
neutrophil (PML) count of more than 250 cells/mm3
63. ERCP with sphincterotomy is the Tx of choice for sphincter of oddi dysfunction.
64. Endoscopy is the preferred screening tool for esophageal varices in patients with
cirrhosis.
65. Entamoeba histolytica is a protozoan, which can cause amebic liver abscess.
Remember the Mexico trip. Amebic abscess is characterized by an anchovy paste
collection in the liver. Tx is with oral metronidazole.
66. Gallstones and alcoholism are the two most common causes of acute pancreatitis in
the United States. Abdominal ultrasound should be used to search for gallstones in all
patients experiencing a first attack of acute pancreatitis. Abdominal CT scan is used to
confirm the Dx. of acute pancreatitis.
67. The first step in the Tx. of acute variceal bleeding is to establish vascular access with
two large bore intravenous needles or a central line.
68. Chronic liver disease or cirrhosis from almost any cause is a risk factor for
hepatocellular cancer. Hepatocellular cancer is responsible for 30% of deaths in patients
with hemochromatosis
69. Hemochromatosis is an autosomal recessive disorder characterized by increased skin

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pigmentation, diabetes, cirrhosis and arthralgia in the later stages.

70. About 10% of patients on INH (isoniazid) develop a mild elevation of
aminotranserases within first few weeks of the Tx. However, this elevation of
aminotranserases returns to normal despite continued use of INH in most of the patients.
(so do nothing except for regular follow ups).
71. Uncomplicated pseudopancreatic cysts < 5 cm should be observed for 6 weeks before
any further therapeutic intervention.
72. Hepatic encephalopathy is a central nervous system complication of liver failure
secondary to accumulation of ammonia in blood because of inability of liver to detoxify
ammonia into urea.
Pathogenic factors involved in the development of hepatic encephalopathy
Accumulation of ammonia in blood
Production of false neurotransmitters
Increased sensitivity of the CNS to inhibitory neurotransmitters like GABA.
Zinc deficiency
Some of the precipitating factors for hepatic encephalopathy:
High protein diet
Alkalosis
Diuretic therapy
Extensive gastro intestinal bleeding
Narcotics, hypnotics, and sedatives
Medication containing ammonium or amino compounds
High volume paracentesis
Hepatic or systemic infection
Portocaval shunts
Hepatic encephalopathy is characterized by
reversal of sleep cycle,
asterixis,
progressive coma,
characteristic delta waves on EEG.
73. Tx for acute hepatic encephalopathy: protein free diet, lactulose, neomycin
Hepatic encephalopathy is a reversible condition. Tx principles:
During acute attack all the dietary protein should be withheld. Later on patient should
be started on low protein diet of 20g/day.
Give oral or rectal lactulose. Bacterial action on lactulose results in acidification of the
colon contents, which converts the absorbable ammonia into nonabsorbable ammonium
ion (ammonia trap)
Oral neomycin a nonabsorbable antibacterial agent kills the colonic bacteria producing
ammonia

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liver biopsy 74. Risk factors for non-alcoholic steatohepatitis include reveals
macrovesicular steatosis, polymorphonuclear cellular infiltrates,necrosis)
Obesity
DM
Hyperlipidemia
Total parenteral nutrition
The usage of certain medications
75. One of the known complications of ERCP is an iatrogenic biliary enteric fistula
characterized by the presence of air in the biliary tree. Other complications include
Iatrogenic biliary enteric fistula
pancreatitis,
biliary peritonitis,
sepsis,
hemorrhage,
adverse effects from the contrast, sedative, or anticholinergic agents.
76. Hyperestrogen in cirrhosis leads to (due to decreased its metabolites)
Gynecomastia
Testicular atrophy,
Decreased body hair,
Spider angiomas
Palmar erythema
77. Progression of liver disease in patients with chronic hepatitis C is relatively more
rapid in following conditions:
Male sex
Acquiring infection after age of 40
Longer duration of infection
Co infection with HBC or HIV
Immunosuppression
Liver co mobidiities like alcoholic liver disease, hemochromatosis, alpha-1 anti
trypsinase deficiency
Factors in chronic hepatitis C patients associated with high rates of liver fibrosis:
Male gender
Acquiring infection after age 40
Alcohol intake: in any amount can hasten the progression of fibrosis in patients with
chronic hepatitis C
78. Vitiligo is characterized by skin depigmentation of unknown etiology. Associated
with other autoimmune conditions such as pernicious anemia, hypothyroidism, Addisons
disease, type I DM. Patients often have Ab to melanin, parietal cells, thyroid, or other
factors.
79. Chronic hepatitis C is associated with number of extra hepatic complications like:

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Cryoglobulinemia
B cell lymphomas
Plasmacytomas
Autoimmune disease like Sjogrens syndrome and thyroiditis
Lichen planus
Porphyria cutanear Tarda
Idiopathic thrombodytopenic purpura (ITP)
Membranous glomerulonephritis
80. The decision to treat a patient of chronic hepatitis C depends on :
Natural history of disease
Findings of liver biopsy
Stage of the disease
The levels of liver enzymes
Presence of HCV RNA
Efficacy and adverse effects of the drugs in the patient
Psychiatry
1. When child abuse is suspected, the following steps should be performed:
Complete physical examination
Radiographic skeletal survey, if needed
Coagulation profile ( if multiple bruise are present)
Report to child protective services
Admit to hospital if necessary
Consult psychiatrist and evaluate family dynamics
2. Patients who are extremely agitated, psychotic, or manic should be initially managed
with haloperidol.
3. Lithium exposure in the 1st trimester of pregnancy causes a twenty-fold increase in the
risk of Ebsteins anomaly, a cardiac malformation. In the later trimester, goiter and
transient neonatal neuromuscular dysfunction are of concern.
4. Always have a high index of suspicion for physical/sexual abuse in children (especially
females) with sudden behavioral problems, families with unstable economic
backgrounds, or parents with a history of drug/alcohol abuse.
5. Altered levels of the neurotransmitter serotonin play an important role in the
development of obsessive-compulsive disorder.
6. The Tx for bulimia nervosa include
pharmacotherapy (SSRI antidepressants),
cognitive therapy,
interpersonal psychotherapy,
family therapy,

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Group therapy.
7. For the general population, the lifetime risk of developing bipolar disorder is 1%.
However, an individual with a first-degree relative who suffers from bipolar disorder has
a 5-10% risk of developing the condition in his lifetime.
8. Always rule out hypothyroidism in patients who present with symptoms of depression.
(order blood test for TSH)
9. Pyromania is characterized by intentional, repeated fire setting with no obvious
motive. Although a history of arson may be documented in individuals with conduct
disorder, other features will be present as well. (e.g. lying, theft, cruelty).
10. Clozapines serious side effect: agranulocytosis.
11. In severely depressed patients with active suicidal thoughts, antidepressants should be
started immediately. This is also true for depressed patients suffering from terminal
illnesses.
12. Marijuana ((Cannabis) abuse causes behavioral changes and 2 or more of the
following symptoms: dry mouth, tachycardia, increased appetite, or conjunctival
injection.
13. Tx of choice for social phobia: assertiveness training, which is a component of
cognitive-behavioral psychotherapy (CBT). SSRI drugs are the 1st line drugs in the
management of these patients, either alone or in combination with CBT.
14. Odd behavior, magical thinking, and a lack of close friends are common features of
schizotypal personality disorder. While individuals with schizoid personality disorder
also lack close friends and have a restricted range of emotional expression, they do not
have eccentric behavior or odd thinking. Those with avoidant personality disorder want
friends but fear ridicule.
15. All depressed patients should be screened for suicidal ideation. Suicidal patients who
cant contract for safety should be hospitalized for stabilization.
16. Patients with somatization disorder benefit from regularly scheduled appointments
intended to reduce the underlying psychological distress.
17. Cocaine and amphetamine intoxication present in a similar manner, but psychosis is
more commonly associated with amphetamine use. Common symptoms of stimulant
intoxication include dilated pupils, HTN, and tachycardia.
18. Cocaine abuse should be suspected in an individual presenting with weight loss,
behavioral changes, and erytham of the turbinate and nasal septum (hallmark).

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19. Sleep terror disorder is characterized by multiple episodes of sudden, fearful waking
at night that cause the patient to be highly agitated and inconsolable. Later, the details of
the event cant be recalled. The disorder typically occurs in children ages 3 to 8 years,
and is more common in boys than girls.
20. Patients with sleep terror disorder report complete amnesia for the event. In contrast,
patients with nightmare disorder can provide detailed descriptions of their dreams.
21. Unlike patients with anorexia nervosa, patients with bulimina nervosa maintain a
normal body weight and are not amenorrheic.
22. The antidepressant of choice in depressed patients suffering from sexual dysfunction
(whether as a side effect of medication or as a pre-existing condition) is bupropion.
23. Bupropion has been found to be effective in treating major depression, attention
deficit disorder, and the craving and withdrawal symptoms associated with smoking
cessation. Bupropion may be used in conjunction with nicotine replacement agents, but
such a combination necessitates frequent monitoring of BP because of the risk of
developing emergent HTN.
24. In most states, adolescents do not require parental consent when they seek a
physicians care for:
Contraception
Pregenancy
STD Tx
Drug abuse
Mental health concerns
If a rape is suspected, the doctor is obliged to report his findings to
local law enforcement and child protective services.
25. Hirschsprung disease is considered life-threatening in a neonate. Abdominal
radiograph and barium emema are necessary.
26. Large ears, long face with a prominent jaw, voice is high pitched, mental retardation-------Fragile X syndrome.can be taught some basic self-care skills and perform simple
tasks with close supervision.
27. Propranolol is the DOC for treating performance-related anxiety.
28. Childhood disintegrative disorder is a rare pervasive developmental disorder that
occurs more commonly in males. It is characterized by a period of normal development
for at least two years, followed by a loss of previously acquired skills in at least two of
the following areas: expressive or receptive language, social skills, bowel or bladder
control, or play and motor skills.
29. Schizophrenic patients have increased ventricular size as shown on CT scan of the

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brain.
30. Circadian rhythm sleep disorder is a likely diagnosis in a patient with insomnia who
often travels between different time zones.
31. Benzodiazepines are used for the acute Tx of panic attacks. An SSRI or TCA should
be substituted for long-term symptom relief. (Diazepam, lorazepam, triazolam,
oxazepam, midazolam, chlordiazepoxide, valium) Facilitate GABAA action by Clchannel opening. Contraindicated in patients with breath-related sleep disorders. (panic
attack-hyperventilation-respiratory alkalosis-numbness and tingling of the lips)
32. Benzodiazepines may cause sudden onset memory disturbance or other cognitive
impairment in the elderly and should therefore be used with extreme caution in this
patient population.
33. Olanzapine, an atypical antipsychotic, has been demonstrated to lead to weight gain
in many patients with schizophrenia. It affects the 5HT2 serotonin receptor in the brain,
which is also thought to control satiety, in addition to decreasing auditory hallucinations
and controlling mood symptoms.
34. The likelihood a schizophrenic patient will relapse is decrease if conflicts and
stressors in the home environment are kept to a minimum.
35. A physician is authorized to provide emergent life-saving Tx to the unconscious
patient. This remains true even if the patients spouse requests that the Tx not be given
because it contraindicts a belif system.
36. The extrapyramidal symptoms (EPS) frequently seen with typical antipsychotics
include dystonia, Parkinsonism, tardive-dyskinesia, akathisia, and neuroleptic malignant
syndrome. The atypical antipsychotic medication most likely to cause EPS is risperidone.
TD is characterized by involuntary perioral movements such as biting, chewing,
grimacing, and tongue protrusions.
37. Patients who develop dystonia from the use of antipsychotics should be treated with
benztropine or diphenhydramine.
38. A phobia is a fear related to a specific object or experience, and is best treated with
cognitive behavioral therapy that includes repeated exposure to the object or experience.
39. Low doses of TCAs such as imipramine or desmopressin can be used to treat
enuresis.
40. When breaking bad news, physicians should begin with exploratory general
statements such as How are you feeling right now? to help the patient feel at ease.
41. If a patient presents with refractory mania despite therapy with a mood stabilizer

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(liuthium, for example), a urine toxicology screen and mood stabilizer drug levels should
be obtained in the initial evaluation.
42. Older individuals may frequently awaken from sleep and spend less time sleeping
overall. These changes are considered a normal part of aging.
43. Bereavement is the normal reaction to the loss of a loved one. Symptoms are similar
to those seen with major depression but are less intense and usually significantly taper
within two months.
44. First-line therapy for major depression is prescription of a SSRI (eg. Sertraline).
45. When treating a single episode of major depression, Tx should be continued for
another 6 months following the patients response. If multiple episodes occur,
maintainece Tx should be continued for a longer period of time.
46. Side effect of olanzapine: weight gain
47. Vaginismus is a voluntary spasm of the perineal musculature that interferes with
sexual intercourse.
48. Bispirone is the DOC for generalized anxiety disorder.
49. Pathological gambling is an individual with a chronic history of gambling and a
seeming inability to stop. Significant financial losses or damaged relationships are
common consequences of this behavior.
50. Contraindication to the use of bupropion: a history of seizure disorder. (epilepsy)
51. The dissociative disorders are characterzed by forgetfulness and dissociation.
Dissociative fugue is the only condition within this group that is associated with travel.
52. The most concerning MAOI side effects include hypertensive crisis and serotonin
syndrome. The HTN crisis is a malignant HTN caused when food rich in tyramine (wine
or cheese) are ingested by an individual taking an MAOI. Serotonin syndrome is caused
by the interaction of an MAOI with an SSRI, pseudoephendrine, or meperidine. The
syndrome is characterized by hyperthermia, muscle rigidity, and altered mental status.
Therefore fluoxetine is a contraindicated medication for MAOI (eg. Phenelzine).
53. If a patients family disagrees with his living will and demands care that contradicts
the patients written wishes, the best initial step is to discuss the matter with the family. If
a discussion fails to resolve the situation, then the hospitals ethics committee should be
consulted.
54. Lithium should not be given to patients with renal dysfunction. Valproate or
carbamazepine are suitable alternatives for the long-term Tx of bipolar disorder in this

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patient group.
55. Lithium and valproic acid are first-line tx of bipolar disorder. Carbamazepine is an
occasionally used alternative.
56. Borderline personality disorder is characterized by splitting, unstable relationships,
and impulsivity. Angry outbursts and suicidal gestures are common.
57. A pregnant woman has the right to refuse Tx, even if it places her unborn child at
risk.
58. Somatization disorder is characterized by multiple recurrent somatic complaints that
have persisted for several years and that have been evaluated by healthcare providers to
no avail. The condition presents before the age of 30 and most frequently occurs in
females.
59. Methylphenidate (a mild CNS stimulant) is frequently used to treat ADHD. Common
side effects include nervousness, decreased appetite, weight loss, insomnia, and
abdominal pain.
60. Altruism: involves minimizing internal fears by serving others.
61. Severe symptoms of Tourette syndrome are best treated with typical antipsychotics
such as haloperidol or pimozide.
62. Adjustment disorder results in marked distress in excess of what is expected from
exposure to the triggering stressor. (usually within 3 months, rarely lasts 6 months)
63. PCP (phencyclidine) and LSD (Lysergic acid) intoxication present similarly, but
agitation and aggression occur more often in patients using PCP. Visual hallucinations
and intensified perceptions are hallmarks of LSD use.
64. One of the MC side effects of electroconvulsive therapy (ECT) is amnesia.
65. The Tx of choice for adjustment disorder is cognitive or psychodynamic
psychotherapy.
66. Kleptomania is characterized by an inability to resist the impulse to steal objects that
either are of low monetary value or are not needed for personal use. The condition is
more prevalent in females and is occasionally associated with bulimia nervosa.
67. Most antidepressants must be taken for 4-6 weeks before they provide symptomatic
relief.
68. Abrupt cessation of alprazolam, a short-acting benzodiazepine, is associated with
significant withdrawal symptoms such as generalized seizures and confusion.

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69.
70. Differentiation of Delirium and Dementia:
Onset: Acute in delirium vs. gradual in dementia
Consciousness: impaired in delirium vs intact in dementia
Course: fluctuating symptoms in delirium vs. progressive decline in dementia
Prognosis: reversible symptoms in delirium vs. irreversible in dementia
Memory impairment: global in delirium vs remote memory spared in dementia.
71. Individuals with schizoid personality disorder are socially detached and aloof but do
not have bizarre cognition. Those with schizotypal personality disorder are also socially
detached but typically demonstrate magical thinking and a more eccentric thought
process. Individuals with shcizophreniform disorder have full-blown schizophrenic
symptoms (eg. Hallucinations, delusions) that have been present for one to six months.
72. Atypical antipsychotics such as risperidone are particularly effective in the Tx of
negative symptoms of schizophrenia.
73. Sertraline is an SSRI used for treating depression.
74. Chlordiazepoxide is predominantly used for the Tx. of alcohol withdrawal.
75. Vascular dementia (also called multi-infarct dementia) is a Dx to consider in patients
given old age and the finding of a carotid bruit. However, the absence of any focal
neurological signs should also be present.
76. Suspect herorin withdrawal in patients with papillary dilation, rhinorrhea, muscle and
joint aches, abdominal cramping, nausea, and diarrhea. The symptoms are severe and out
of proportion to physical findings. Tx. clonidine.
77. Fantasy is an immature defense mechanism that substitutes a less disturbing view of
the world in place of reality as a means of resolving conflict.
78. Antisocial personality disorder is diagnosed in those aged 18 or older who engage in
illegal activities and disregard the rights of others. These individuals display evidence of
conduct disorder as minors.
79. Patients have the legal right to obtain copies of their medical records.
80. Acute distress disorder and post-traumatic stress disorder present with identical
symptoms (recurrent nightmares and flashbacks, potential memory loss, and exaggerated
startle response). Acute distress can last no more than 4 weeks, however, while PTSD
lasts longer than 4 weeks.
81. Avoid benzodiazepine use in patients with PTSD. Tx of PTSD is best accomplished

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with a combination of SSRIs and exposure or cognitive therapy.

82. Alcohol withdrawal is best treated with long-acting benzodiazepines such as
chlodiazepoxide (Librium). Withdrawal symptoms should be correlated with the time of
the last alcoholic drink
83. . Manic episode (mnemonic: DIGFAST)
Distractibility
Insomnia
Grandiosity
Flight of ideas
Activity increased
Speech (extremely talkative)
Thoughlessness (high risk behavior)
84. Remember the common findings in anorexic patients (important):
Osteoporosis
Elevated cholesterol and carotene levels
Cardiac arrhythmias (prolonged QT interval)
Euthyroid sick syndrome
Hypothalamic-pituitary axis dysfunction resulting in anovulation, amenorrhea, and
estrogen deficieny
Hyponatremia secondary to excess water drinking is often the only electrolyte
abnormality, but the presence of other electrolyte abnormalities indicates purging
behavior.
85. Physical abuse should be suspected in a woman with multiple bruises and frequent
injuries. In these cases, the following steps should be carried out:
Confront the patient gently, in a non-judgmental way.
Assure her about confidentiality.
Emphasize that she should not allow abuse to happen to her
Ensure safety of the patient and children, if any.
Ask her if she has a plan to escape.
Suggest talking to a womens group dealing with these problems.
Assure her of your continuing support.
86. The following signs and symptoms are indications that psychiatric hospitalization is
necessary:
Homicidal ideation
Suicidal ideation
Grave disability
Gross disorganization
Agitated
Threatening behavior
Severe symptoms of substance intoxication or withdrawal

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87. Tx options for narcolepsy include:

Scheduled daytime naps
Psychostimulants (eg. Modafinil, methylphenidate), or
A combination of antidepressant and psychostimulant
Surgery
1. Hypotension not responsive to fluid administration is suggestive of ongoing blood loss
and such patients with abdominal trauma need an immediate exploratory laparotomy.
2. Vital signs, hemodynamic stability, and need for blood transfusion are important
determinant for surgical v/s non-surgical management of patient with splenic trauma.
3. Choledocholithiasis symptomatic of biliary colic and without any systemic toxicity is
treated with analgesic and spasmolytics and elective surgery is done at a later date.
4. Tetanus prophylaxis depends upon whether the patient had his 3 doses or not. If yes, it
depends upon when did he have it. For any wound, clean or minor, patients should be
administered tetanus toxoid if the last dose was administered 5 years ago. However, if the
patient has clean wound & he has previously received 3 or more doses, but received the
last dose 10 years ago, then again he should receive the tetanus toxoid.
5. Transient submandibular gland swelling may occur during feeding due to partial
obastruction of its duct and further evaluation is required if swelling is persistent or
recurrent.
6. In a young individual who present with a fleshy immobile mass on his hard palate, the
most likely Dx is torus palatinus. No medical or surgical therapy is required.
7. Technetium pertechnetate scintigraphy is the best diagnostic test for Meckels
diverticulum.
8. Colonoscopy is difficult and rarely performed in settings of active bleeding. If the
bleeding stops, however, it should be done.
9. Angiodysplasia may be seen as cherry-red spots that may be coagulated.
10. Labeled erythrocyte scintigraphy, although not a very precise study, could be helpful
to define the site of bleeding.
11. The diaphragmatic rupture is more common on the left side, since the right side is
protected by the liver. The leakage of intraabdominal contents into the chest causes
compression of the lungs and mediastinal deviation. Elevation of the hemidiaphragn on

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the chest X-ray may be the only abnormal finding. Sometimes, there may be evidence of
small bowel in the thoracic cavity.
12. Approximately 5-10% of unconscious patients who present to the ED as result of a
motor vehicle accident or fall, have a major injury to the cervical spine. One third of
injuries occur at the level of C2, and one half of the rest occur at the level of C6 or C7.
Most fatal cervical spine injuries occur in upper cervical levels, either at craniocervical
junction, C1 or C2.
13. It is important to rule out a fracture or dislocation of cervical spine as the first priority
because of grave consequences of missing a cervical spine injury.
14. Cast immobilization is recommended in the tx of all non-displaced scaphoid fractures
(fractures < 2mm displacement and no angulation).
15. Varicose veins with incompetent perforators may present with non-pitting edema,
medial leg ulcers, fatigue, and a brown discoloration at the ankles. The MC symptoms
from varicose veins are fatigue, tiredness in the leg, aching, swelling and occasional
cramps at night.
16. History of a traumatic event and presence of crunching are compatible with fracture
of metatarsal.
17. Anterior cord syndrome is commonly associated with burst fracture of the vertebra
and is characterized by total loss of motor function below the level of lesion with loss of
pain and temperature on both sides below the lesion and with intact proprioception.
18. Central cord syndrome is characterized by burning pain and paralysis in upper
extremities with relative sparing of lower extremities. It is commonly seen in elderly
secondary to forced hyperextension type of injury to the neck. (rear end collision)
19. central cord syndrome may result from hyperextension injuries and is characterized
by weakness that is more pronounced in the upper extremities than in the lower
extremities.
20. Brown Sequard syndrome is acute hemisection of cord and is characterized by
ipsilateral motor and proprioception loss and contra lateral pain loss below the level of
lesion. (should be suspected when there is unilateral paralysis.
21. Posterior cord syndrome: is usually associated with signs and symptoms of posterior
columns.
22. Patients with mild head injury can be discharged with a head sheet if they have a
normal CT scan.
23. Axillary nerve is the most commonly injuried nerve in anterior dislocation of

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shoulder. (symptoms:numbness over the lateral aspect of the right shoulder).

24. Acute disk prolapse will be characterized by severe radicular pain with positive
straight leg raising test.
25. Cauda equine syndrome is characterized by paraplegia, variable sensory loss, urinary
and fecal incontinence.
26. With posterior dislocation of the shoulder (Tonic clonic seizures may result in
posterior dislocation of the shoulder joint), patient shows internally rotated arm, inability
for external rotation and intact sensations and reflexes.
27. The 2nd part of the duodenum is the most commonly injured portion of the duodenum
and needs a high degree of suspicion for Dx, especially in the presence of retroperitoneal
air or blunting of the right psoas shadow on X-ray. (*Remember the bicycle injury*)
the 2nd portion of the duodenum, being retroperitoneal and the least mobile, is most
commonly injured.
28. Duodenal injuries are best diagnosed with CT scan of the abdomen with oral contrast
or an upper GI study with gastrograffin, followed by barium, if necessary.
29. Muffled heart sounds are common in severe hypovolemia and do not necessarily
indicate pericardial fluid. Moreover, cardia tamponade is unlike without distention of the
neck veins.
30. Whenever a patient is in decompensated hemorrhagic shock most probably from
rupture abdominal organ bleeding, next step is diagnostic peritoneal lavage or abdominal
ultrasound once the resuscitative efforts are begun.
31. Bee and hymenoptera stings account for more deaths in the U.S. than any other
envenomation. Anaphylactic shock should be promptly treated with subcutaneous
epinephrine. Then remove the bee stinger ASAP.
32. Acalulous cholecystitis occurs in critically ill patients and imaging studies show
diagnostic findings of thickening of the gall bladder wall and presence of pericholecystic
fluid.
33. Diverticulosis is the MCC of bleeding in an elderly patient. Chronic constipation is
the single most predisposing factor to develop diverticulosis.
34. Whenever an open wound fails to heal after a prolonged period, biopsies have to be
obtained to ensure that the ulcer has not degenerated into a squamous cell carcinoma.
These ulcers are known as Marjolins ulcers.
35. A long-standing cycle of repeated healing and breaking down my eventually give rise
to a squamous cell carcinoma of the skin, know as Marjolins ulcer. Biopsy is need for

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diagnosis.
36. In stable patients with abdominal trauma, CT scan with contrast is the single best
study to evaluate solid organ damage.
37. Nosocomial infections are defined as infections acquired as a result of hospitalization,
and they manifest at least 48 hours after hospitalization. A urinary tract infection is the
MC type of nosocomial infection; however, it is easy to treat and has the best prognosis.
*The case didnt specify the source or cause of infection. That means you have to select
the MC nosocomial infection.*
38. Widening of the mediastinum: Mediastinittis, hemorrhage, large pericardial effusion.
39. Recognize the mediastinitis, a post CABG (coronary artery bypass grafting)
complication by systemic signs of inflammation, chest pain, breathlessness and
mediastinal widening on chest X-ray; it is a serious condition and it requires thoracotomy
for debridement and drainage + antibiotics.
40. Mastitis associated with breast-feeding is treated with antibiotics and continuation of
breast-feeding from the affected breast is recommended.
41. When blunt chest trauma occurs with a widened mediastinum on chest x-ray, aortic
injury must be suspected. Either a CT scan or ECHO will be diagnostic.
42. Ludwigs angina (rapidly spreading bilateral cellulites to the submaxillary and
sublingual glands) is infection of the submaxillary and sublingual glands. The source of
the infection is from an infected tooth.
43. Recognize the classic presentation of a tension pneumothorax. Remember the
hypotension, shortness of breath, jugular venous distension and decreased breath sound.
44. Absent bowel sounds with gaseous distention of both small and large bowel indicates
paralytic ileus. (secondary to retroperitoneal hematoma, dropped hematocrit, that affects
paraspinal ganglia.)
45. Dumping syndrome is common postgastrectomy complication. The symptoms usually
diminish over time and dietary changes are helpful to control the symptoms. In resistant
cases, octreotide should be tried. Reconstructive surgery is reserved for intractable cases.
46. Pneumomediastinum: may accompany a spontaneous pneumothorax: the air from
ruptured alveoli or bulla dissects along the vessels into the hilum and mediastinum.
Pneumomediastinum associated with tension pneumothorax usually responds to chest
tube drainage and it does not usually require surgical decompression. (Tx: chest tube +
observation)
47. Heroin overdose: deep coma, bradypnea, hypotension.

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48. Clavicle is one of the most commonly fractured bones and is treated with figure of
eight bandage.
49. After an AAA repair (abdominal arterial aneurysm), diarrhea with blood in the stools
should raise the suspicion of ischemic colitis. If the CT scan is inconclusive a
sigmoidoscopy/colonoscopy is recommended.
50. Oratracheal intubation and surgical cricothyroidectomy are preferred way to establish
an airway in apneic patient with head injury (who is unconscious).
51. If tachyneic conscious patient, to secure the air way, chin lift with face mask.
52. Aortic rupture should be ruled out in all the chest trauma patients with hypotension.
Screening for aortic trauma can best be done with a chest X-ray. Confirmation test is
angiography or spiral CT scan.
53. Pain on passive extension of fingers is the most sensitive physical sign of
compartment syndrome.
54. After placement of a central line, a chest x-ray must be obtained to ensure proper line
placement. A central line is an intravenous catheter or IV placed into a large vein.
55. Where is a central line placed:
Subclavian vein (chest)
Femoral vein (groin)
Jugular vein (neck)
56. Percutaneus drainage is the standard Tx approach for pelvic abscess.
57. Penile fracture is a medical emergency and needs prompt surgical repair. But should
be always be preceded by a retrograde urethrogram to rule out a urethral injury which is
very common with penile fracture.
58. Circumcision is the treatment of choice for paraphimosis.
59. Atelectasis is not uncommon after abdominal surgery and can be responsible for early
postoperative fever.
60. Fever occurring in the first 1-2 days after surgery is usually due to atelectasis.
61. Treatment of acute subdural hematoma is essentially conservative if no midline shift
is present on CT scan.
62. The direction of force that produces a fracture often predicts the possibility of other
less obvious injuries. The vertical fall depicted in this vignette classically results in

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compression fractures of thoracic and lumbar vertebral bodies. (Do X-ray films of
thoracic and lumbar spine)
63. Acute epidural hematoma has a classic presentation of unconsciousness followed by a
lucid interval followed by gradual deterioration of consciousness. CT scan is diagnostic
and it show a biconvex hematoma.
64. Hypoventilation is a frequent occurrence after abdominal hernia repair and early
physiotherapy and respiratory exercises are mandatory.
65. Neutralization of gastric pH should be considered for severely ill patients to prevent
gastric stress erosions. Gastric pH measured through nasogastric tube should be 5 or
above.
66. Patients with head injury should be triaged according to the Glasgow Coma Scale
(GCS): cant tell if there is ICP by GCS.
Eye opening:
Spontaneous 4
To verbal command 3
To pain (or shout) 2
None 1
Verbal response:
Oriented 5
Confused 4
Inappropriate 3
Incomprehensible sounds 2
None 1
Motor response:
Obeys 6
Localization 5
Flexion 4
Abnormal flexion (Decorticate) 3
Extension (Decerebrate) 2
None 1
Total:15
67. Clinical signs of increased intracranial pressure (ICP) include:
Papillary findings like bilaterally dilated pupils, anisocoria, or non-reactivity of one or
both pupils.
Flaccidity or decerebrate or decorticate motor posturing, or progressing neurological
deterioration not attributable to other causes.
papilledema
67. Intubation with mechanical ventilation and administration of IV fluid, analgesics and

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sedatives should be done in all the patients with severe head trauma as indicated by GCS.
68. The most rapid method available to lower ICP is hyperventilation to lower PaCO2,
which leads to decreased cerebral blood flow and ICP
69. When suspecting pulmonary embolism, order an arterial blood gas first. Confirmation
is by ventilation-perfusion scan.
70. The rule of abdominal gunshot wounds is simple: an exploratory laparotomy should
be done in every case, before there are obvious signs of either bleeding or peritonitis.
71. A crescent-shaped hematoma: seen in acute subdural hematoma
72. A biconvex, lens-shaped hematoma: seen in acute epidural hematoma.
73. Radial nerve is the MC injured nerve in association with fracture of midshaft
humerus.
74. Child abuse is very likely in following conditions:
Scalds and burns on feet or buttocks indicative of forceful immersion.
Circular burn marks indicative of cigarette burns.
Incoherent story of the event.
Delay in seeking care after the injury.
Torsional fracture of lower limbs
Bruises and fractures in various stage of healing. Bruising on normally non bruised
areas like thighs, abdomen, cheeks and genitalia.
Subdural hematoma and retinal hemorrhages in very young infant
What to do in a suspected child abuse?
Admit the patient to ensure further safety
Skeletal survey is mandatory in children less than 2 yo
For children older 2 yo a decision is to be made depending on the strength of suspicion.
A thorough physical examination to look for other associated injuries should also be
done.
Report to child safety services.
75. Mesenteric thrombosis (arterial or venous) or non-occlusive ischemia can lead to
massive fluid sequestration in the bowels. Hypovolemic shock and hemoconcentration
usually ensue. The extreme elevation of CK suggesting massive ischemia is
characteristic. The intensive abdominal pain out of proportion to the physical findings
and diarrhea, which may contain occult blood, further support the Dx. Poor neurologic
condition in this patient is probably due to brain hypoperfusion as a consequence of
shock.
76. Recognize the clinical presentation of mesenteric thrombosis. Severe abdominal pain
out of proportion to the physical findings along with bloody diarrhea should make you

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think about this.

77. Colles fracture is the MC fracture of distal radius characterized by dorsal
displacement and dorsal angulation. Tx: closed reduction and casting. Also can be
associated with a fracture of the ulnar styloid.
78. Smith fracture: is reverse Colles fracture and is characterized by fracture of distal
radius metaphysic with dorsal angulation of distal radius and hand, and the wrist
displaced volarly with respect to the foremarm.
79. Bartons fracture: is a fracture of radial styloid process and is commonly seen in
persons operating automobiles that require cranking to start.
80. In patients who present with ulcers on the soles of the foot, neuropathic ulcer from
diabetes should be suspected.
81. Scoliosis:
Idiopathic scoliosis: no cause is determined. MC type, and right thoracic curve is most
commonly seen. It can be further classified as:
-infantile type: age<3
-juvenile type: 3-10
-adolescent type: >10
Neuromuscular scoliosis: secondary to neuromuscular disturbance or muscle disease.
Congenital scoliosis: secondary to structural bony deformities.
82. Highest detection rate of prostatic carcinoma in early stages---PSA+digital rectal
examination
83. Kidney stones:
Oxalate stones: in a patient who undergoes bowel resection and then develops kidney
stones, one should always suspect oxalate.
Cystine stones: rare and occurs as part of a rare inherited disorder of defective renal
transport resulting in over-excretion of cystine. Sone formation begins in childhood and
are a rare cause of staghorn calculi.
Uric acid stones: occur when urine is saturated with uric acid in the presence of an
acidic urine and dehydration. Seen in gout, myeloproliferative disorders and diarrhea. Tx:
fluid, alkalinization of urine, allopurinol.
Struvite stones: form in the collecting system and become infected with urea splitting
organisms. Condicitons required for formation of struvite stones are presence of high
urine pH, magnesium, ammonium and carbonate levels.
Calciu phosphate stones: associated with hypercalciuria (sarcoidosis, immobilization,
Cushings syndrome, renal tubular acidosis.) std Tx: fluid, thiazide.(note Furosemide in
CI).
84. Acute appendicitis: Rovsings sign +. Requires immediate surgery.

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85. Acute appendicitis may be complicated by pelvic abscess that presents with lower
abdominal pain, malaise, low-grade fever and tender pelvic mass on rectal examination.
(most of the pelvic abscesses are due to perforation of appendix. Tx. Drainage of the
abscess).
86. Laxatives should not be given in the setting of intestional obstruction.
87. Intestinal obstruction with metabolic acidosis and shock indicates serious disease and
it requires laparotomy. (suggesting bowel ischemia or necrosis).
88. In case of simple mechanical obstruction, there would be metabolic alkalosis.
89. Patients who present more than 5 days after the onset of symptoms of appendicitis,
and have localized right lower quadrant findings, should be treated with IV hydration,
antibiotic and bowel rest. Antibiotics should cover enteric gram-negative organisms and
anaerobes (cefotetan)
90. Cefotetan: has a good coverage of gram-negative organisms and anaerobes; therefore,
this can be used as monotherapy in complicated appendicitis.
91. Erythromycin and vancomycin are effective against gram-positive organisms, they do
not cover gram-negative organisms or anaerobes.
92. Persistent symptoms (e.g. mechanical symptoms) in patients with probable meniscal
injury should be further evaluated by MRI or arthroscopy. Surgery (arthroscopic or open)
is often necessary to correct the problem.
93. Boerhaaves syndrome is esophageal perforation due to severe vomiting and it
produces pneumomediastinum.
94. Saphenous vein cut down or percutaneous femoral vein catheterization are
alternatives to have an intravenous access in trauma patients with collapsed veins.
95. Interosseous membrane cannulation is an alternative route in children <4 yo but not in
adults.
96. Cardiac contusion can be associated with various arrhythmias and is best monitored
by continous ECG monitoring. ECHO is used only if murmurs are detected on
auscultation.
97. Pulmonary contusion: is not uncommon after high-speed car accidents. The
symptoms usually develop in the first 24 hours and a patchy alveolar infiltrate on chest
X-ray is typical.
98. Necrotized surgical infection: characterized by intensive pain in the wound, decreased
sensitivity at the edges of the wound, cloudy-gray discharge, and sometimes crepitus.

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Early surgical exploration is essential.

99. Enterolysis: is used to diagnose small bowel tumors and other pathology, which can
cause intestinal obstruction.
100. Colonoscopy: is not indicated for the right-sided pathology and shoul not be
performed in acute pathology of the bowel wall because of the risk of perforation.
101. Ileus: sometimes is due to a vagal reaction due to ureteral colic. Needle shaped
crystals on urinalysis indicate uric acid stones. Uric acid stones, which are radiolucent,
have to be evaluated by either CT of the abdomen or intravenous pyelography. CT of the
abdomen is also useful to diagnose other pathology such as appendicular abscess etc.
102. Isolated duodenal hematoma: is treated conservatively with nasogastric tube and
parenteral nutrition.
103. Stress fracture or March fracture or insufficiency fracture: is commonly seen in
young active adults (like a dancer) involved in vigorous and excessive exercise.
104. Osgood schlatter disease: is an epiphysitis of the tibia tubercle and is characterized
by pain over tibial tubercle, which is exacerbated by contraction of quadriceps muscle.
Almost exclusively seen in young men and women of less than 19 years age whose
growth centers are still active. The typical patients is a 13-14 yo boy or 11-12 yo girl who
has had recent rapid growth spurt.
105. The characteristic findings of tear of patellar tendon: proximal displacement of
patella.
106. Intraductal papilloma: a benign tumor of major lactiferous ducts and clinically
manifests as serous or bloody discharge. Mammogram does not show papilloma, as they
are too small. Mammogram is not useful for young women, since their breast tissue is
dense. Resection has to be done to provide relief and is guided by a galactogram.
107. Esophageal perforation due to iatrogenic cause is very frequent and radiography
with water-soluble contrast is the best way to diagnose esophageal perforation.
108. The presence of pulses does not rule out compartment syndrome and suspicion
should be high hence fasciotomy is the Tx and must be done urgently. (surgical
emergency)
109. 10% of calcaneal (heel, most commonly fractured tarsal bone) fractures secondary to
fall from height is associated with compression fracture of thoracic or lumber vertebra.
110. Pain relief should be the prime objective in management of rib fracture in elderly.
Local nerve block can be used if oral or systemic analgesics are not useful. (intercostals
nerver blocks provide pain relief without affecting respiratory function, although it

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carries some risk of pneumothorax.

111. Brown recluse spider bite causes deep necrotic ulcer at the bite site.
112. Breast mass that produces non-bloody aspirate and disappears completely on
aspiration does not need any further evaluation other than observation. (cyst)
113. In acute pancreatitis patient who is septic, the cystic lesion must be regarded as
abscess, until proven otherwise. An abscess anywhere in the body of the pancrease needs
to be drained and external drainage is preferred for pancreatic abscess.
114. Pseudocyst engaging tail of the pancreas could be resected.
115. Galactogram guide resection is the Tx of choice for intraductal papilloma which
presents with serous or bloody nipple discharge.
116. In right ventricular infarction, consider IV normal saline and do not give diuretics or
nitrate.
117. The usual sequence of management of injury to bone, artery and nerve is to stabilize
the bone followed by repair of vasculature followed by the nerve repair. (B-A-N)
118. CT scan is the investigation of choice to diagnosis intraabdominal abscess
119. Ulcers on the medial aspect of the leg are generally from venous disease. Venous
HTN may be due to vein varicostities and incompetent perforators.
120. Bladder rupture can be classified into the following types:
Type 1: bladder contusion
Type 2: extra peritoneal rupture is more common than intra peritoneal rupture and
usually occurs at lateral border or base
Type 3: intraperitoneal rupture is less common but is commonly seen in patients with
full bladder at accident due to rupture of dome of bladder.
Type 4: combined intra and extra peritoneal rupture: it accounts for 10% of bladder
injury.
118. Fixation:
Closed intramedullary nailing: preferred over open nailing in closed femoral shaft
fractures (associated with less chances of infection, less soft tissue disruption and do not
compromise periosteal circulation)
External fixation: indicated in certain cases of open fracture but not in closed fracture.
Plate and screw fixation: needs soft tissue dissection and would disrupt fracture
hematoma. It may be used in cases of fracture of femoral neck.
Most of fractures of shaft of femur can be managed with closed intramedullary fixation
of fracture.
Lower limb skin traction would significantly increase the immobilization duration and

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its complications. Also the fracture union is not satisfactory in most cases. It can be used
as a Tx. option in pediatric patients.
121. Preoperative DVT prophylaxis is dependent on the patients individual risk factors
and the type of surgery being performed. The best DVT prophylaxis for high-risk surgical
patients who are undergoing an orthopedic operation includes either oral warfarin or
LMWH.
122. Risk of DVT in surgical patients:
Low risk: minor surgery in a patient <40 yo with no additional risk factors present.
Without prophylaxis, the risk of DVT <2%
Moderate risk: patients >40 yo, one or more additional risk factors, minor/non-major
surgery. The risk of DVT is 2-10%.
High risk: patients > 40 yo, additional risk factors, major operation (e.g. orthopedic
procedures of the lower extremity). The risk of DVT in these patients is between 10-20%.
123. Bucket handle tear of medial meniscus is the MC meniscus injury at knee and leads
to locking of the knee joint during terminal extension.
124. Lachmans test is the most sensitive physical test for Dx of anterior cruciate
ligament injury. (A popping or snapping sensation is commonly felt at the time of ACL
injury, ACL prevents anterior gliding of the tibia under the femoral condyles). Patients
complain of instability of the knee. Commonly associated with injury to medial meniscus
and medial collateral ligament of the knee (terrible triad). Lachmans test: is done with
knee flexed at 20 degrees, and pulling the proximal tibia with one hand while stabilizing
the femur with the other hand.
125. Anterior cruciate ligament: prevents anterior glinding of the tibia under the femoral
condyles. Isolated injury is seen after hyperextension of the knee. A popping or
sanpping sensation is commonly felt at the time of injury. Patients complain of
instability of the knee (giving out, looseness etc.) It is commonly associated with injury
to medial meniscus and medial collateral ligament of the knee. (terrible triad)
126. Osgood Schlatter disease: is an apopysitis of tibial tubercle seen in young teenager
due to overuse. (swelling and marked tenderness over the tibial tubercle. Pain increases
on contraction of quadriceps muscle.)
127. Slipped femoral capitis: is an emergency condition and should be promptly
corrected with external screws. (Dx is made by a high degree of clinical suspicion in
presence of limited range of hip movements. Loss of abduction and internal rotation are
very characteristic and external rotation of thigh is seen when hip is flexed. Frog-leg
lateral view X-ray of hip joint is the imaging technique of choice for Dx.)
128. Lateral collateral ligament injury: tackled while playing football, knee pain, swollen,
direct palpation over the lateral aspect of the knee elicit pain. Anterior drawer and
posterior drawer test, and Lachman test are all negative.

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129. Anterior drawer test: is also used for Dx of ACL injury but is less sensitive. It is
done in supine position with the knee flexed at 90 degrees and hips flexed at 45 degrees,
while tibia is pulled forward over femur to note the degree of displacement.
130. Posterior drawer test: is used for Dx of posterior cruciate ligament injury. It is
similar to anterior drawer test except that posterior pressure is exerted on tibia to note
posterior displacement.
131. McMurrays test: is used for Dx of meniscus injury. In case of meniscus injury a
click is heard on forced flexion and rotation of the knee. (popping sound on passive
flexion/extenstion of the joint)specific for meniscal injury.
132. Valgus stress test: is used for Dx of medial collateral ligament injury in which case
valgus stress leads to marked angulation of knee joint as compared to the normal knee.
133. The immediate management of splenic trauma caused by blunt abdominal injury
depends on the patients hemodynamic status and response to IV fluids. If the patient is
initially hemodynamically unstable but improves with fluid administration, the best next
step is to obtain an abdominal CT scan. If the patient is initially hemodynamically
unstable and is unresponsive to fluid administration, then emergent exploratory
laparotomy is required.
134. Intermittent claudication is best treated with aspirin and an exercise program.
135. MRI is now the investigation of choice for ligamentous injuries of the knee with an
accuracy rate of 95%. Surgery is rarely necessary for MCL tear.
136. Non-communicating hydrocele disappears spontaneously by 12 months of age and it
is therefore managed expectantly.
137. CT scan of a diffuse axonal injury shows numerous minute punctuate hemorrhages
with blurring of grey-white interface. It is the most significant cause of morbidity in
patients with traumatic brain injuries.
138. A sternal fracture is very likely to be complicated by myocardial contusion, serial
ECG is needed.
139. Pagets disease of the nipple: Dxmammogram and punch biopsy.
140. Tx. of Mitral stenosis: cardiovascular surgeons prefer to repair the patients own
mitral valve, rather than replacing it. Stenosis is due to fusion at the commissures--commissurotomy can correct.
141. As a rule: internal hemorrhoids bleed but do not hurt, wherears external hemorrhoids
hurt but do not bleed. (discomfort could be pain, or itchy)

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142. Brain examinations:

CT scan is our best tool when intracranial bleeding is suspected.
MRI is our choice when brain tumor is suspected..
Duplex scanning is our choice if transient ischemic attack is suspected.
143. Fogarty balloon tipped catheters: an embolectomy used in treating embolic
occlusion of the artery. Heparin etc anticoagulants are an adjunct to vascular procedures,
but are not the primary Tx for a clot that has already traveled from the atrial appendage to
the lower extremity. Anticoagulants cannot dissolve existing clots.
144. The urinary retention is extremely common in the immediate postoperative period
after lower abdominal inguinal or perineal surgery. Tx: in and out bladder catheterization.
(dont use indwelling Foley catheter unless in and out fails twice to resolve the urinary
retention.)
145. If a scaphoid fracture is suspected, even without a visible fracture on X-ray, it must
be treated as if there was a fracture. (long arm cast)---fall on an outstretched hand. Pain
with wrist movement, tenderness in the anatomical snuffbox. 10% go on to develop
avascular necrosis due to tx error.
146. Spinal cord ischemia with lower spastic paraplegia is a rare complication of
abdominal aneurism surgery.
147. Acute adrenal insufficiency is a potentially lethal postoperative complication.
Preoperative steroid use is the main cause. A high index of suspicion is required.
Commonly, they present with nausea, vomiting, abdominal pain, hypoglycemia, and
hypotension.
148. Burns:
1st degree: superficial burns, confined to the epidermis with minimal skin damage. The
skin is mildly erythematous and pain is the chief complaint. (such as sunburn, heals
without scaring.)
2nd degree: partial thickness burnsinvolves the entire epidermis and various layers of
the dermis. Skin is painful, red, edematous and blistered.
3rd degree: full thickness burnsno dermal appendages remain, all epidermis and
dermis is completely destroyed. (flame burn)
149. Patients have obvious signs of hemorrhagic shock (loss of about 25-30%, 1500 mL
blood), can only occur with intraabdominal bleeding, intrathoracic bleeding, and fracture
of femur, pelvic, extremities or bleeding in neck. USG and DPL are the procedure of
choice to diagnose intra abdominal bleeding in an unstable trauma patient.
(ultrasonogram, diagnostic peritoneal lavage).
150. In case of amputation injury, amputated parts should be retrieved and brought to the
ED. The amputated part should be wrapped in a saline-moistened gauze sponge placed in

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a plastic bag. The plastic bag should be sealed and placed on ice.
151. Cirrhotic patients with ascites may develop spontaneous primary bacterial
peritonitis, which gives a mild picture of acute abdomen, Dx: culture of the ascetic
fluid.
152. Sigmoid volvulus, a common condition in elderly patients. The endoscopic
instrument (proctosigmoidoscopy) can untwist the bowel from the inside, relieve the
obstruction, and allow placement of a long rectal tube.
153. Nerves of the lower extremities:
Femoral N.:innervated the muscles of the anterior compartment of the thigh, and is
therefore responsible for knee extension and hip flexion. It provides sensation to the
anterior thigh and medial leg via the saphenous branch.
Tibial nerve: supplies the muscles of the posterior compartment of the thigh, posterior
compartment of the leg, and plantar muscles of the foot. The tibial nerve provides
sensation to the leg (except medial side) and plantar foot.
The obturator nerve: innervated the medial compartment of the thigh (ie, gracilis
adductor longus, adductor brevis, anterior portion of adductor magnus), and controls
adduction of the thigh. It provides sensation over the medial thigh.
The common peroneal nerve: gives rise to the superficial and deep peroneal nerves.
These two nerves supply the muscle of the anterior and lateral leg. These nerves provide
sensation to the anterolateral leg and dorsum of the foot.
154. Current Tx. to full thickness burn: immediate excistion, grafting
155. DDH:
Ultrasound is the most sensitive investigation for DDH (developmental dysplasia of the
hip) for infants less than 6 months of age.
X-ray of hip is not useful in young infants, as the cartilage and epiphysis are not ossified.
However, in older infants and children, plain radiography is the preferred modality of
investigation.
MRI of hip joint though sensitive is reserved for complicated cases
CT though sensitive is not the first investigation of choice. It is particularly used for
evaluating complicated dislocations and for postoperative evaluation of the hip.
156. After rhinoplasty, if there is whistling noise during respiration, one should suspect
nasal septal perforation.
157. Unless strangulation or perforation is suspected, bowel obstruction is treated
conservatively with fluids, nasogastric suction and enemas.
158. Retrograde cystogram with post void film is the investigation of choice for patients
with suspected bladder trauma.
159. Retrograde urethrogram should be the first step in management of suspected
posterior urethral injury. (inability to void, trauma history, high riding prostate)

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160. Anterior urethral injury due to injury to urethra anterior to the perineal memebrane.
Anterior urethral injuries are most commonly due to blunt trauma to the perimeum
(straddle injuries), and many have delayed manifestation.
161. Posterior urethra consists of the prostatic urethra and memebranous urethra.
Posterior urethral injuries are most commonly associated with pelvic fracture. (presents
with blood at meatus, high riding prostate, scrotal hematoma and inability to void in spite
of sensation to void).
162. When suspecting a urethral injury, do a retrograde urethrogram, inject the dye
directly into the urethra. Inserting a Foley catheter is absolutely contraindicated in
suspected urethral injury, you may change a partial urethral disruption into a complete
transaction.
163. Retrograde ejaculation occurs in up to 90% patients undergoing transurethral
resection of the prostate (TURP).
164. TUIP (transurethral incision of the prostate) involves incision of the periurethral
prostate without resection of any tissue. This procedure is minimally invasive and can be
performed on an outpatient basis. It frequently results in symptomatic relief without the
adverse effects of TRP.
165. The disease with the highest incidence of perioperative death or cardiac event is a
recent myocardial infarction. (other causes: coronary disease, worsened or poor baseline
exercise tolerance, recent infarction)
166. Postoperative period, patient has persistent difficulty swallowing solids and even
more difficulty swallowing liquids. Any attempts to do so results in violent coughing ans
aspiration.Lesion: ----------sensory fibers of the 9th (glossopharyngeal) nerve.
167. When a patient presents with a pulsatile abdominal mass and hypotension, a
presumptive Dx of ruptured abdominal aortic aneurysm must be entertained and the
patient should be taken straight to the operating room.
168. Aortic aneurysm rupture, best diagnostic exam: Spiral CT scan or MRI angiogram.
169. Ureteropelvic junction obstruction and profuse diuresis: a congenital narrowing at
the ureteropelvic junction allows normal passage of urine at a normal flow rate, but the
lumen cant accomadate a suddenly increased flow rate. (remember, beer is a wonderful
diuretic.)
170. Most common nontraumatic casue for SAH is: berry aneurysm in the anterior
portion of the circle of Willis.
171. Any gunshot wound of the abdomen requires exploratory laparotomy. Any gunshot

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wound below the 4th intercostals space (level of nipple) is considered to involve the
abdomen.
172. Subluxation of radial head is a common condition in preschool children and needs
closed reduction by flexion and supination of forearm.
173. Small amount of intraperitoneal bleed that is not visible on abdominal ultrasound
can be detected by diagnostic peritoneal lavage.
174. Consider bowel ischemia and infarction as an early complication of operation on the
abdominal aorta.
175. Hallmark triad of urethral injury is:
Blood at urethral meatus
Inability to void
Distended bladder
176. For carcinoid tumors located at the tip of the appendix, appendectomy is sufficient
Tx. Carcinoids do not have the tendency to spread and have a good prognosis. When
carcinoid spreads to the liver, it may produce the carcinoid syndrome, which is
characterized by flushing, diarrhea, cramping, and valvular heart lesions.
177. Rule out vascular injuries in case of penetrating wound near the site of important
vessels. (arteriogram)
178. Monteggia fracture: an isolated fracture of proximal third of ulna, with anterior
dislocation of radial head. May be associated with injury to radial nerve, so careful
neurovascular examination at the time of evaluation is mandatory. Tx: open reduction
and internal fixation in adults, closed reduction and casting are optimal for children.
179. Galeazzi fracture: an isolated radial shaft fracture, associated with disruption of
distal radio ulnar joint also need open reduction and internal fixation.
180. Osteogenic sarcoma usually presents with painful swelling around the knee without
any systemic signs and radiographic findings are osteolytic lesions with periosteal
reaction.
181. Hyperventilation helps to prevent and treat intracranial hypertension by causing
cerebral vasoconstriction and thus decresing cerebral blood flow. (goal: to have pCO2 in
the range of 30-35 mmHg.)
182. Harvesting teamd evaluate any dying patient as a potential donor.
183. Typical history for fracture of the posterior lateral talar tubercle: standing on a chair
and falls backward, a cracking sound develop pain and swelling behind the ankle. Pain
is exacerbated by plantar flexion and dorsiflexion of the hallus (big toe).Tx: with

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immobilization in a cast for 4-6 weeks. Dx: lateral x-ray film of the ankle.
184. After rectal surgery, patient experience impotence, cause?erectile nerve damage.
185. In cirrhotic patient with hepaticencephalopathy, porto-systemic shunt may worsen
the encephalopathy.
186. Patient with cirrhosis may have upper GI bleeding due to:
Erosive gastritis
Varices
PUD (peptic ulcer disease)
Mallory-Weiss tears.
187. In cases of bleeding esophageal varices, need for 5 or more units of blood
transfusion in a period of 24 hours is considered an indication for surgery and
transjugular intrahepatic portosystemic shunt is the best choice in emergency situations.
188. When clavicle injuries occur and a bruit is present, an anterial injury must be ruled
out with an angiogram.
189. Atelectasis on chest X-ray can be confused with pneumonia and pleural effusion.
However, it is more common after surgery in smoker and requires bronchoscopy to
remove the mucus plug.
190. Fever on the first postoperative day is almost invariably from atelectasis, the Tx of
which requires active participation and cooperation from the patient. If atelectasis does
not resolve, it leads to the development of pneumonia, which can be identified in chest xray and confirmed with sputum cultures.
191. Sclerotherapy and surgery are indicated after first variceal bleeding, but not
prophylactically. (sclerotherapy may have complications such as perforation, stenosis,
and bleeding.)
192. Pelvic X-ray should be routinely done in all patients with trauma to screen for pelvic
injury.
193. Fibrocystic disease: (mammary dysplasia) typically seen in women aged 20-40. It is
characterized by painful breasts and recurrent formation of cysts.
194. Malrotation: 3 week old infant, protracted bilious vomiting. With double bubble sign
with a little gas beyong is highly suggestive. Dx must be promptly confirmed by barium
enema or contrast study from above. Tx: emergency surgery.
195. A patient must be left with at least 800mL in FEV1 to live a semi-decent life.
196. Even being left with at least 800 mL in FEV1, a patient with SCC in lung still needs

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to do a CT scan of the chest and upper abdomen to rule out lymph metastasis before a
pneumonectomy can be done.
197. The best initial therapy for rhabdomyolysis is infusion of copious amounts of
alkalinized saline to assist the kidneys in clearing the myoglobin from the blood.
Alkalinizing the urine allows the renal tubules to retain the myoglobin and excrete it in
the urine. (saline+bicarbonate)
198. Percutaneous lithotomy: used for large renal sontes located within the pelvicaliceal
system. Smaller stones located in this position are best treated with ESWL.
199. Extracorporeal shock wave lithotripsy (ESWL): particularly effective on stones
impacted in the distal ureter that have failed to pass spontaneously with conservative
management.
200. Testicular torsion needs immediate de-torsion if the testis is to be saved. No time
should be wasted doing further studies.
201. In patients sustaining trauma, there is a chance of bony cervical spine injurylateral
cervical spine x-ray can rule it out.
202. A COPD patient with a 1100 mL in FEV1, suffers from a SCC at the hilar. What to
do? ---only radiation + chemotherapy. If surgery and have the bad lung removed, then
only leave him 40% FEV1 (440 mL).
203. Expectant therapy is a rule for all patients with uncomplicated basilar skull fracture.
Clinical signs of basilar skull fracture includes rhinorrhea, raccoon eyes (black eyes), and
ecchymosis behind the ears and otorrhea. Patients head should be elevated and fluid
intake should be restricted to 1200 mL/day. Patient should also be cautioned against the
maneuvers that increase the intracranial pressure like blowing the nose.
204. Legg calve Perthes disease (avascular necrosis) is serious but self-limiting condition
of young children characterized by avascular necrosis of femoral head. Can be painless.
But hip pathology can present as referred knee pain. Also named: avascular necrosis of
the capital femoral epiphysis.
205. The Tx of choice for isolated diaphyseal humeral fracture is by closed methods.
206. Scaphoid fracture: nonunion and avascular necrosis are common complications. The
proximal third of the scaphoid is prone to avascular necrosis in fractures involving the
wrist or proximal pole.
207. Gentle traction to attempt alignment of the fragments of a fractured long bone is
important to prevent further vascular and neurological damage and it should be attempted
immediately.

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208. Nasopharyngeal cancer usually presents initially as a painless neck mass. (other
symptoms: epistaxis, hearing loss, nasal blockage)
209. Warfarin treated patients should be given fresh frozen plasma instead of vitamin K
when emergency surgical procedure is to be performed.
210. Intravenous pyelography is very useful for the Dx of renal stones.
211. Open fractures should not be closed primarily because of the associated increased
risk of infection and subsequent osteomyelitis.
212. Rhabdomyolysis can occur with severe crush injuries and should be managed with
IV fluids, osmotic diuretics and alkalinization of urine.
213. Hyperkalemia due to crush injuries needs IV calcium gluconate (acts as a
membrane-stabilizing agent to balance against the imminent hyperkalemia-induced
global depolarization of the myocardium.
214. Elderly patients with displaced femoral neck fractures should be treated with
primary arthroplasty.
215. Tx of choic for intertrochanteric fracture: internal fixation with sliding screw and
plate and early mobilization.
216. Patients treated with high-dose methylprednisolone within eight hours of spinal cord
injury have significant and sustained neurological improvement, thus its use is warranted
as the first priority after stabilizing the patient. *important Q.!!!*
213. Garden classification for femoral neck fracture:
Type 1: valgus impaction of femoral head commonly seen with stress fracture
Type 2: complete but non-displaced femoral neck fracture.
Type 3: complete fracture with displacement <50%
Type 4: complete fracture with displacement >50%
217. Delayed emergency from anesthesia is characterized by hypotension, which is
evident by decreased in respiratory rate, HTN progressing to hypotension, tachycardia
progressing to bradycardia, restlessness and pallor/cyanosis.
218. After blunt trauma to the chest, if an x-ray shows a deviated mediastinum with a
mass in the left lower chest, one should suspect a diaphragmatic perforation.(Dx. barium
swallow)
219. Patient with head injury can never have hemorrhagic shock due to intracranial
bleeding.
220. Becks triad of hypotension, elevated JVP, and muffled heart sounds confirms the

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Dx of pericardial tamponade.
221. Volkmanns ischemic contracture is the final sequel of compartment syndrome in
which the dead muscle has been replaced with fibrous tissue. Tx: immediate fasciotomy.
222. Displaced anterior fat pad is a radiographic sign of supracondylar fracture, which
may be complicated by Volkmanns ischemic contracture.
223. Presence of brachial pulse on the fracture side cant rule out the possibility of
vascular compromise because of collateral flow.
224. Two locations in the body have the highest risk for development of the dreaded
compartment syndrome: the forearm and the lower leg.
225. Hirschsprungs disease in neonate presenting with obstruction: diverting ileostomy
+appendectomy (for Dx. of the disease). Definite repair can be done when the child is
older.
226. A known complication of ling-standing use of birth control pills is the development
of hepatic adenomas that may rupture and bleed. (acute onset of abmominal pain,
followed by a faint)
227. The MC site of ulnar nerve entrapment is the elbow where the ulnar nerve lies at the
medial epicondylar groove. *extremely HY Q for USMLE* (decreased sensation over the
4th and 5th fingers of the hand and a weaker grip compared to the normal side.)
Prolonged, inadvertent compression of the nerve by leaning on the elbows while working
at a desk or table is the typical scenario.
228. APKD (adult onset polycystic kidney disease) diagnosed, you should order an MRA
(magnetic resonance angiogram) of the brain to rule out berry aneurysms. (10%-20%
incidence of this in APKD).
229. Virtually all solid testicular masses are malignant tumors. The best way to avoid
dissemination is to open the inguinal canal, do a high ligation of the cord, and pull the
testicle out.(radical inguinal orchiectomy)
230. Mixed connective tissue disease represents the over lapping symptoms of SLE,
scleroderma and myositis. It is associated with autoantibody to ribonuclear protein.
231. The rule is that lymph nodes that progressively enlarge over several months are
malignant.
232. Lymph nodes which are in the supraclavicular area, typically harbor metastasis from
a primary tumor below the clavicles (i.e., not in the head and neck).
233. Inhalation injury is common in burns patients and may take several days to manifest.

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Diagnosis is best done with a bronchoscopy.

234. Body surface involved in burn injury is calculated with the rule of 9:
Each arm: 9%
Each lower extremity: 18%
Anteiror torso: 18%
Posterior torso: 18%
Face 9%
Perineum: 1%
235. Burns patients need 4 ml/kg/% of the body area involved of fluid in first 24 hours,
half of which is given in the first 8 hours. Plus 2000 mL dextrose 5% in water.
236. Infection is the MCC of death in burns patients.
237. Burns:
Superficial and erythematous burns while painful do not require any special wound care
(not even antibiotics)
Early excision therapy is indicated for extensive partial-thickness and full-thickness
burns, as they do not heal spontaneously. Also, it allows for early skin grafting and lesser
complications.
Prophylactic systemic antibiotic is not indicated in all the patients. However, topical
antibiotics should be used for burn wound care.
The most commonly used topical anti bacterial agent: silver sulphadiazine. Mafenide
sulphate is only used if deep penetration is required in case of wound with eschar.
Mafenide sulfate is associated with severe pain and acidosis.
Eschar is dead rigid tissue formed in burns wounds. The eschar restricts outward
expansion of the compartment as edema occurs in the injured extremity following the
burns. As a result, interstitial pressure rised to the point that vascular flow is
compromised. This can be relieved by performing an escharoctomy.
Tetanus prophylaxis should be considered in all the burns wound patients using std
guidelines as burn wounds are prone to tetanus infection.
238. Cholesteatoma is an epithelial cyst that contains desquamated keratin. Patients
generally present with chronic ear discharge and granulation tissue that are unresponsive
to antibiotic treatment. (This is not a tumor)
239. Carcinoids are most commonly found on the appendix; however, patients who
present with carcinoid syndrome usually have carcinoids located in the small bowel.
240. Dog bite:
May result in rabies (fatal disease)
Post exposure prophylaxis: active and passive immunization.
Capture the dog, if fails to do so, the dog is assued to be rabid and post exposure
prophylaxis is indicated.
If the dog is available and it does not show any features of rabies, observed it for the

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development of rabies (10 days). If it shows rabies, it is killed and its brain is examined
to confirm the presence of rabies and post exposure prophylaxis is given when rabies in
dog is confirmed by FA.(fluorescent antibody)
241. When isolated proteinuria occurs, the evaluation of the patient should begin by
testing the urine on at least two other occasions. (transient proteinuria is a common cause
of isolated proteinuria and can occur during stress or any febrile illness).
242. Glanzmanns thrombasthenia: an autosomal recessive disease that results in
deficient glycoproteins IIb-IIIa complex so fibrinogen will not cross-connect. The patient
presents with increased bleeding episodes for some time. Platelet counts may be normal,
but on the peripheral blood stream, platelets remain isolated and do not exhibit clumping
that is normally seen. BT is markedly increased. Epinephrine, collagen, ADP and
thrombin fail to induce aggregation. VWF is normal.
243. Chediak Higashi syndrome: is a storage granulocyte abnormality resulting in
hepatosplenomegaly, lymphadenopathy, anemia, thrombocytopenia, roentgenological
changes of bones, lungs and heart, skin andn psychomotor abnormalities, and
susceptibility to infection, usually resulting in death in childhood.
244. Bernard Soulier syndrome: is a bleeding disorder characterized by
thrombocytopenia, giant platelets, and a bleeding tendency, which is typically greater
than expected bleeding for the degree of thrombocytopenia.
245. skin pigmentation, polydypsia, polyuria, serume ferritin , transferring saturation ,
blood glucose , ALT and AST hemochromatosis. If left untreated, 30% of deaths in
patients will be due to hepatocellular cancer (hepatoma).
246. AlZheimers disease is the MCC of dementia in the western world. It is initially
characterized by memory loss, language difficulties and apraxia, followed by impaired
judgement and personality changes. CT scan shows generalized cortical atrophy.
247. Eczema herpeticum is a form of primary herpes simplex virus infection associated
with atopic dermatitis. Numerous vesicles over the area of atopic dermatitis are typical.
The infection can be life-threatening in infants; thus, prompt treatment with acyclovir
should be initiated.
248. Unrecognized bowel ischemia is one of the common causes of lactic acidosis in
patients with severe atherosclerotic disease.
249. Seborrheic keratosis: is commonly referred to as the barnacles of old age. Suspect
seborrheic keratosis in an elderly person with benign plaques that are 3-20 mm in size,
and have a greasy surface and stuck-on appearance.*extremely HY Q*
250. Churg Strauss syndrome (CSS): is a multisystem vasculitic disorder of unknown
etiology that affects the skin, kidney, nervous system, lungs, GI tract and heart. It is

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characterized by allergic rhinitis, asthma and prominent peripheral blood eosinophilia. Up

to 75% of CSS patients have evidence of peripheral neuropathy (mononeuritis multiplex).
Tx: glucocorticoid and sometimes immunosuppressant. (it is a severe disease)
251. Identify allergic granulomatosis of Churg-Strauss syndrome (CSS) and remember
that leukotreine antagonist (asthma agent) are known to cause CSS.
252. Job syndrome: is characterized by recurrent bacterial infections and markedly
elevated IgE levels. Bacterial infections in Job syndrome are usually caused by
staphylococci and the skin is the most frequent site of involvement. Neutrophils exhibit
impaired chemotaxis. Some patients have coarse features while others are fair. Other
allergic disorders like eczema, asthma, allergic rhinitis may be present. Tx: intermittent
or continuous antibiotics.
253. Indications for the Tx of Pagets disease include:
Bone pain
Hypercalcemia of immobilization
Neurological deficit
High output cardiac failure
Preparation for orthopedic surgery
Involvement of weight-bearing bones (to prevent deformities)
254. Asymptomatic patients with Pagets Disease generally do not require any Tx.
Symptomatic ones are best treated with oral or IV bisphosphonates.
255. Bisphophonates (Zoledronic acid) are the DOC for mild to moderate hypercalcemia
due to malignancy.
256. Excessive use of oxytocin may cause water retention, hyponatremia and seizure
(water intoxication). Oxytocin has ADH effect.
257. Intensive axillary freckling and caf-au-lait spots are suggestive of
neurofibromatosis type I. Optic glioma is a well-known complication of it. ( presenting as
pallor of the optic disk). Optic glioma occurs in 15% of patients with neurofibromatosis,
type 1.
258. Retinal hamartoma is typical for tuberous sclerosis, mulberry lesions.
259. Optic neuritis is frequently the early manifestation of multiple sclerosis.
260. Prophylactic allopurinol is the most effective method to prevent gout in patients at
risk for tumor lysis syndrome.(it is a competitive inhibitor of xanthine oxidase, prevents
the conversion of soluble hypoxanthine and xanthine to insoluble uric acid).
261. Loss to follow-up in prospective studies creates a potential for selection bias.

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262. Post-ictal (post seizure) lactic acidosis is transient and resolves without Tx within
60-90 minutes.
263. Primary hyperPTH is the MCC of hypercalcemia in ambulatory patients.
Hepercalcemia due to primary hyperPTH is associated with elevated or inappropriately
normal serum PTH level.
264. Retropharyngeal abscess presents with posterior pharyngeal edema, nuchal rigidity,
cervical adenopathy, and fever.
265. Palliative radiation, along with anti-androgen therapy, is the Tx. of choice for
metastatic prostate cancer. Anti-androgen therapy consists of Leuprolide. (LHRH
analogues) Flutamide is considered inferior to LHRH analogues.
266. Hydatid cysts in the liver are due to infection with Echinococcus granulosus.
(contact from the close and intimate contacts with dogs. Mostly asymptomatic and
generally diagnosed on screening for some other problem. Eggshell calcification of a
hepatic cyst on CT scan is highly suggestive of hydatid cyst.
267. Marfans features + mental retardation+ thromboembolic event + downward
dislocation of the lens= Homocystinuria. It is an autosomal recessive disease casued by
cystathionine synthase deficiency. Tx: mainly involves administration of high doses of vit
B6.
268. PCOD (polycystic ovarian disease) patients are at risk of developing type II DM. So
once diagnosed PCOD, do an oral glucose tolerance test.
269. Erosive joint disease in RA is a clear-cut indication for the use of diseases
modifying anti-rheumatic drugs (DMARD) and methotrexate is the initial DOC for this
purpose.
270. Nasal polyps: recurrent episodes of rhinitis, chronic nasal obstruction, altered taste
sensation, diminished sense of smell, and persistent postnasal drip.
271. Severe, excruciating pain should be treated with IV opioids (like morphine) even if
the patient has a history of drug abuse.
272. Tricuspid atresia is a cyanotic congenital heart disease characterized clinically by
cyanosis that appears early in life and left axis deviation. Most cases (90%) are associated
with VSD, and 30% are associated with TGA (transposition of the great arteries).
Interestingly, the associated heart defects (eg. ASD, VSD and PDA) are necessary for
survival. (presents as: cyanotic, holosystolic murmur at the left, lower sternal border, and
a single S2. No rales or rhonchi heard, decreased pulmonary vascular markings and a
normal sized heart)
273. VSD-holosystolic murmur.

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274. Anticholinergics are useful for PD patients younger than 70 years with disturbing
tremors and minimal bradykinesia. PD tremor is a resting tremor.
275. Progestin is chosen over estrogen as contraceptive method postpartum because it has
no effects on milk production and does not pass into the milk. (e.g. minipill)
276. Sodium bicarbonate is effective for the Tx of cardiac dysfunction induced by
thioridazine toxicity. (which presents with low BP, seizure, miosis, confused state, ataxia)
277. Patients with mild head injury can be discharged with a head sheet if they have a
normal CT scan.
278. Pneumococcal vaccine is recommended:
For adults over age 65
All individuals with immunosuppression and DMChronic alcoholics, and individuals in
chronic-care facilities, should also receive this
vaccination.
270. Pneumococcoal vaccine contains capsular polysaccharides and it
produces T cell independent B cell response. (only peptides can be
presented by macrophages/B cell to T cell in association with MHC II.
Polysaccharides and other antigens induce T cell independent response
By B cells.
271.Influenza immunization is recommended on annual bases for:
All individuals aged 65 years and older.
Individual of any age with chronic debilitating illnesses like: cardiovascular, renal or
pulmonary disorders, DM.
All immunocompromised adults.
Pregnant women in the second or third trimester during influenza season.
Nursing home residents
Other high-risk individuals such as physicians, nurses, employees of nursing homes,
and family members of patients infected with influenza.

272. HSV and VZV can cause severe, acute retinal necrosis associated with pain,
keratitis, uveritis, and funduscopic findings of peripheral pale lesions and central retinal
necrosis.In contrast, CMV is PAINLESS.(HSV, VZV painful)
273. MAOI (phenelzine) cant be taken with tyramine (cheese, wine etc.). Other side
effects include interaction with serotonergic drugs to produce serotonin syndrome, sexual
dysfunction, hypotension, and insomnia.
274. The antidepressant of choice in depressed patients suffering from sexual dysfunction

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(whether as a side effect of medication or as a pre-existing condition ) is bupropion.

(inhibits NE and DA reuptake)
279. Newer antipneumococcal quinolones, like levofloxacin or gatifloxacin, are the DOC
for in-patient Tx. of community-acquired pneumonia. For out-patient therapy, either
azithromycin or doxycycline can be used.
280. NG tube placements may lead to the loss of large amounts of acidic gastric fluid
leading to contraction alkalosis, even in patients with preexisting metabolic acidosis. This
phenomenon should not be confused with a normalization of the acid base status.
281. Polymyositis and Dermatomyositis: are inflammatory myopathies, which are
characterized by proximal muscle weakness, and ultimately wasting. Dermatomyositis
involve typical skin changes: heliotrope rash around the eyes associated with periorbital
edema, and Gottrons papules, which are red scaly patches over the emtacarpophalangeal
joints. These conditions may occur along or in association with a variety of neoplasms
such as breast, ovary, lung, prostate, or colon cancer. Unlike myasthenia, facial or ocular
muscle weakness is uncommon. Unlike scleroderma, which affects the lower smooth
muscle of esophagus, it involves striated muscle of the upper pharynx and can make
deglutition difficult. Suspected patients should have measurement of serum CK and
aldolase levels. Specific Dx is usually made by muscle biopsy. Tx: oral corticosteroid.
282. Bactrim (trimethoprim-sulfamethoxazole) is the DOC for uncomplicated cystitis and
sinusitis.
283. Always consider thyroid abnormalities or fibromyalgia in a patient with diffuse
muscle aches and excessive fatigue with non-restorative sleep. (do a thyroid function test
and CK level)
284. Nasopharyngeal cancer usually presents initially as a painless neck mass.
285. In patients with hyperthyroidism-related tachysystolic atrial fibrillation, a betablocker is the DOC.
286. Hairy cell leukemia is characterized by lymphocytes with fine, hair-like irregular
projections and a TRAP stain (tartrate-resistant acid phosphatase). The bone marrow may
become fibrotic; thus leading to dry taps. DOC for hairy cell leukemia: cladribine.
287. DOC for CLL: chlorambucil and prednisone.
288. Acanthosis nigricans is characterized by symmetrical, hyperpigmented, velvety
plaques in the axilla, groin, and neck. It is associated with DM (insulin resistance) in
younger patients, and GI malignancy in older individual.
289. Amphotericin use is associated with hypokalemia. Potassium levels should routinely
be monitored when administrating this agent. The presence of U wave and flat T wave

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in the ECG indicates hypokalemia.

290. Bromocriptine is useful in neuroleptic malignant disorder, which is characterized by
marked hyperthermia, muscular rigidity, tremors, altered mental status, and diaphoresis.
291. Patients suffering from panic disorder have an increased incidence of depression,
agoraphobia, generalized anxiety and substance abuse. (extremely important).
292. Immediate anticoagulation with heparin and surgical intervention (ie, embolectomy)
are crucial to prevent tissue death in a patient with ongoing ischemia of the limb.
293. Cholesterol embolization usually follows surgical or interventional manipulation of
the arterial tree. Renal failure, livedo reticularis, systemic eosinophilia, and low
competent levels should make you think of cholesterol embolism. (extremely important
for USMLE)
294. Patients with osteomalacia have low-normal serum calcium, low serum phosphate
and increased serum PTH level. (after surgery of inflammatory bowel diseaseVit D
deficiencyosteomalacia)
295. Acute allergic interstitial nephropathy is a drug-induced hypersensitivity reaction
characterized by rash, renal failure (eosinophilia in urine), eosinophilia. Common
offending drugs:
Methicillin (penicillin, etc)
NSAIDs
Thiazides
Phenytoin
Allopurinol
296. Suspect aortic dissection as a cause of tearing chest pain in the setting of HTN and
BP difference in the 2 arms.
297. Suspect optic neuritis in a patient with central scotoma, afferent papillary defect,
changes in color perception (colors like washed out) and decreased visual acuity.
Remember the association between optic neuritis and multiple sclerosis (The USMLE
love this topic!)
298. CHD (coronary heart disease) equivalents, which are the risk factors that place the
patient at similar risk for CHD events as a history of CHD itself include:
DM
Symptomatic carotid artery disease
Abdominal aortic aneurysm
Multiple risk factors that confer a ten year risk of CHD of more than 20%
295. Major CHD risk factors other than LDL are:
Age, male >=45 yo and female >=55 yo

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HTN (BP>140/90 mmHg or antihypertensive drugs)

Smoking
Low HDL (<40 mg/dL)
Family history of premature CHD (males<55 yo, females<65 yo)
299. Infective endocarditis is common among IV drug abusers. It can be fatal if Tx. is
delayed so IV vancomycin + gentamycin is empiric Tx.
300. Angioedema is characterized by the rapid onset of non-inflammatory edema. It is
due to deficiency in C1 esterase inhibitor, which results in elevated levels of the edemaproducing factors, C2b and bradykinin. Episodes of angiodedema usually follow an
infection, dental procedure, or trauma.
301. Sympathetic ophthalmia is characterized by damage of one eye (the sympathetic
eye) after a penetrating injury to the other eye. It is due to an immunologic mechanism
involving the recognition of hidden antigens.
302. Laryngomalacia or congenital flaccid larynx is the MCC of chronic inspiratory noise
in infants. It is a self-limiting condition in most cases, and generally subsides by 18
months of age. Hold the baby in an upright position for half an hour after feeding, and
never feed the baby when he is lying down.
303. Condylomata acuminate are skin colored or pink, verrucous and papilliform skin
lesions present around the anus and podophyllin is one of the available Tx.
304. Diammond-Blackfan anemia: a macrocytic pure red aplasia associated with several
congenital anomalies such as short stature, webbed neck, cleft lip, shielded chest and
triphalangeal thumbs.
305. Always suspect sickle cell trait in a young black male who presents with painless
hematuria. (due to papillary ischemia, which is due to the relatively low local oxygen
partial pressure, and which predisposes the diseased RBCs to sickling.)
306. Pharyngoesophageal (Zenkers) diverticulum develops immediately above the upper
esophageal sphincter by herniating posteriorly between the fibers of cricopharyngeal
muscle. Motor dysfunction and incoordination are responsible for the problem. *The
surgical Tx of the disorder includes excision and frequently cricopharyngeal myotomy.*
*extremely HY Q for USMLE*
307. Therapeutic INR ( international normalized ratio) for most clinical indications of
warfarin is 2-3 .
Thromboembolism
Valvular heart disease
Atrial fib
A higher INR of 3-4 is required only in certain clinical settings like prosthetic heart
valves.

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308. The risk of bleeding in patients treated with warfarin correlateds with the degree of
anticoagulation and it increases substantially when INR is greater than 4.
309. Due to high incidence of lung cancer among smokers, it should be suspected in any
smoker presenting with recurrent pneumonia. (admit the patient and order a high
resolution CT of the chest)
310. Mast cell stabilizers are the DOC for asthmatic patients who also have other allergic
disorders. (inhale sodium cromolyn)
311. Pinpoint pupils and respiratory depression are the hallmark features of acute opioid
toxicity for which naloxone is the DOC.
312. Sialolithiasis presents as post-prandial pain and swelling in a patient with history of
recurrent sialadenitis.
313. Reversible acetylcholinesterase inhibitors such as donepezil, rivastigmine,
galantamine, and tacrine are of benefit in slowing the cognitive decline associated with
Alzheimers disease.
314. Contraindications of triptans are as follows:
Familial hemiplegic migraine
Uncontrolled HTN
CAD
Prinzmetal angina
Pregnancy
Ischemic stroke
Basilar migraine
315. Pregnancy testing should be performed in women of child-bearing age before
starting Tx. with sumatriptan (serotonin agonists)
316. Neutralization of gastric pH should be considered for severely ill patients of
pancreatitis to prevent gastric stress erosions.
317. Turcots syndrome: refers to an association between brain tumors (primarily
medulloblastomas and gliomas) and FAP (familial adenomatous polyposis) or HNPCC.
318. Catatonic schizophrenia: best treated with benzodiazepines or ECT. (lorazepam, not
clozapine).
319. Antidote for acute benzodiazepine intoxication: flumazenil, a benzo antagonist.
(presents with drowsy, slurred speech)hint: elderly patients on sleeping pills.
320. Fibromuscular dysplasia: can present as new onset HTN in children (renal HTN).

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Bruit or venous hum may be heard at the costovertebral angle. Angiogram reveals the
string of beads sign of the renal artery.
321. Tx of choice for fibromuscular dysplasia: percutaneous angioplasty with stent
placement.
322. Patients with a leukocyte adhesion defect suffer from recurrent bacterial infections.
Delayed separation of the umbilical cord and necrotic periodontal infections are
characteristic.
323. A history of seizure disorder is an absolute contraindication to the use of bupropion.
324. Patients with chronic liver disease most commonly have respiratory
alkalosis.(progesterone accumulationstimulatory effect on the respiratory center
leads to tachypnea causing respirary alkalosis.
325. Primary polydypsia (psychogenic polydypsia) is characterized by primary increase
in water intake. Patients taking phenothiazines have this problem due to dry mouth
caused by anticholinergic action of phenothiazines.
326. Lithium exposure in the 1st trimester of pregnancy causes a 20 fold increase in the
risk of Ebsteins anomaly, a cardiac malformation. In later trimesters, goiter and transient
neonatal neuromuscular dysfunctions are of concern.
327. Central retinal artery occlusion is emergency treated with an ocular massage and
high-flow oxygen administration. (thrombolytic is effective if initiated within 4-6 hours
of visual loss, but always perform the former ones first)
328. Idiopathic pulmonary fibrosis is best treated with steroids. Most patients will have a
positive response in the first 6 months but they fail to have sustained response.
329. All patients with unstable angina should be hospitalized and treated with aspirin, IV
heparin, and IV nitroglycerin. Once the patient is free of chest pain, an angiography can
be performed non-emergently.
330. HIV-infected patients have lower than normal immunity for diphtheria. These
individuals should receive the tetanus and diphtheria vaccine as per the routine
recommendations. (Td vaccine.)
331. Leukopalkia presents as hard to remove whitish patches in the oral mucosa and may
lead to squamous cell carcinoma.
332. Toxic epidermal necrolysis is a severe mucocutaneous exfoliative disease. It is
characterized by an erythematous morbilliform eruption that rapidly evolves into
exfoliation of the skin.

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333. Always suspect X-linked hypophosphatemic rickets in patients of rickets who has
normal serum calcium, normal serum alkaline phosphatase and normal 25-OH vit D.
334. In type II vit D dependent rickets, there is mutation of vit D receptor. Therefore
these patients have normal serum levels of calcitriol but it is ineffective and as a result
osteomalacia occurs.
335. MCC of toxic megacolon: ulcerative colitis. This is medical emergency. Tx: prompt
administration of IV steroids, nasogastric decompression and fluid management are
required.
336. Delirium tremens: presents with seizures, headache, confusion and tremors. Due to
alcohol withdrawal. Usually occur 2-4 days after the last drink. Hallucinations,
autonomic instability (tachycardia and fever)
337. Alcohol withdrawal: is best treated with long-acting benzodiazepines such as
chlordiazepoxide, diazempam. Withdrawal symptoms should be correlated with the time
of the last alcohol drink. It is important to rule out other medical conditions that could be
responsible (electrolyte abnormalities, infection, or hypoxia) before making a Dx.
338. Lithium toxicity: tremulousness, headache, confusion, GI distress, fatigue, in
extreme cases, with seizures, coma, hyperreflexia and opisthotonus.
339. Tricyclic antidepressant intoxication: includes sodium bicarbonate. This drug not
only helps to correct the acidosis, but also helps to narrow the QRS complex
prolongation. Benzodiazepine (eg. Diazepam) is given when the patient presents with
seizures that require treatment.*Extremely HY Q for USMLE*
340. Riley-Day syndrome: (familial dysautonomia), is an autosomal-recessive diseae
seen predominantly in children of Ashkenazi Jewish ancestry. It is characterized by gross
dysfunction of the autonomic nervous system with severe orthostatic hypotension.
341. The management of diabetic gastroparesis includes: secondary to diabetic GI
automomic neuropathy.
Improved glycemic control
Small, frequent meals
A dopamine antagonist (eg. Metoclopromide, domperidone) before meals
Bethanechol
Erythromycin: this drug interacts with motilin receptors and can promote gastric
emptying
Cisapride: is effective, but it is currently available only through the manufacturer. It is
issued only after providing adequate documentation of the need for the drug, and after a
thorough assessment of the individuals risk factors for cardiac arrhythmias.
338. Cryoglobulinemia:

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Palpable purpura
Glomerulanephritis
Non-specifi systemic symptoms
Arthralgias
Hepatosplenomegaly
Peripheral neuropathy
Hypocomplementemia
Most patients also have hepatitis C
339. Whipples disease: is a multi-systemic illness characterized by arthralgias, weight
loss, fever, diarrhea and abdominal pain. PAS-positive material in the lamina propria of
the small intestine is a classical biopsy finding of Whipples disease. PAS positive
material in the lamina propria of the small intestine is a classical biopsy finding.
340. Whipples disease: D-xylose absorption is abnormal both in bacterial overgrowth
and whipples disease. However, with the bacterial overgrowth, the test becomes normal
after antibiotic treatment.
341. Dxylose: is a simple sugar. It does not need to undergo any digestive process before
it can be absorbed. Its absorption requires an intact mucosa only.
342. Sensory distribution of dermatomes:
A lesion in the upper thoracic spinal cord results in paraplegia, bladder and fecal
incontinency, and absent sensation from the nipple downwards.
A lesion in the cerebellum causes posterior fossa sympotoms (nausea, vomiting, ataxia).
A lesion in the lower thoracic spinal cord causes absent sensation from the umbilicus
downwards.
A lesion located supratentorially produces partial or complete hemiparesis.
343. The main substrate of gluconeogenesis are: alanine, lactate and G-3-P. Pyruvate is
an intermediate of alanine during the process of gluconeogenesis.
344. Painless jaundice in an elderly patient should make you think about pancreatic head
carcinoma.
345. Bladder rupture can be classified into the following types:
Type 1-Bladder contusion
Type 2-Extra peritoneal rupture is more common than intra peritoneal rupture and
usually occurs at lateral border or base.
Type 3- Intraperitoneal rupture is less common but is commonly seen in patients with
full bladder at accident due to rupture of dome of bladder.
Type 4- Combined intra and extra peritoneal rupture: it accounts for 10% of bladder
inuries.
346. Intraperitoneal bladder rupture can occur in trauma patient with full bladder.

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1. NIPPV (non-invasive positive pressure ventilation) is an excellent option for patients

with COPD exacerbation. It should be tried before intubation and mechanical ventilation
in COPD patients with CO2 retention.
2. Amoxicillin is used for Tx of pregnant/lactating patients with early-localized Lyme
disease.
3. Tx. of limb-threatening infections in Diabetic: IV cefotetan, ampicillin/sulbactam, or
the combination of clindamycin and a fluoroquinolone is the appropriate empirical
method. Mild or non-limb-threatening infections can be treated with oral antibiotics like
cephalosporin, clindamycin, amoxicillin/calvalanate and fluoroquinolones.
4. Cholangiocarcinoma can complicate primary sclerosing cholangitis, especially in
patients who smoke and have ulcerative colitis. (order biopsy of the prominent stricture)
5. Mastoiditis: is the MC complication of otitis media. It presents as erythema, edema,
and tenderness over the mastoid area (the area behind the ear). Examination of the
involved ear reveals a protruded auricle. CT imaging may be used to confirm the clinical
Dx.
6. Suspect Creutzfeldt-Jacob disease in an old patient (50-70 yo) with rapidly progressive
dementia, myoclonus and periodic synchronous bi or triphasic sharp wave complexes on
EEG.
7. Trachoma presents with follicular conjunctivitis and pannus (neovascularization)
formation in the cornea.
8. Pagets disease is characterized by excessive bone resorption and repair. Its features
are normal serum calcium and an elevated alkaline phosphatase. A small number of
patients will develop sarcomatous changes over 10 yrs and third will present as a new
lytic lesion and a sudden increase in alkaline phosphatase.
9. The earliest ECG finding in acute MI is peaked T waves (hyperacute), followed by ST
segment elevation, followed by the inversion of T waves, followed by the appearance of
Q waves (this do not occur in 20-50% cases of acute infarcts)
10. Delayed emergency from anesthesia is characterized by hypoventilation, which is
evident by decrease in respiratory rate, HTN progressing to hypotension, tachycardia
progressing to bradycardia, restlessness and pallor/cyanosis.
11. Triad of renal faiure, microangiopathic hemolytic anemia and thrombocytopenia
occurs in hemolytic uremic syndrome.
12. Elderly patients with dehydrationhypernatremia, common in nursing home

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altered mental status.

13. Recognized the common causes of altered mental status in elderly patients. The major
causes include:
Hyponatremia and hypernatremia
Hypocalcemia and hypercalcemia
Hypomagnesemia
Hypophosphatemia
Hypoglycemia
Stroke
Cardiac events
Infections (chest x ray and urinalysis is routine)
*Since altered mental status is one of the common cuases of
hospitalization in the U.S. USMLE expects you to know everything
possible)
14. Pyloric stenosis presents with non-bilious vomiting in a 4 to 8 week old infant, and an
abdominal ultrasound confirms the Dx.
15. The blood supply of the brain can be expained as follows:
Anterior vasculature-comprised of the internal carotid artery and its branches, especially
the paired anterior and middle cerebral arteries.
Posterior circulation- comprised of paired vertebral arteries, which unite to form the
basilar artery, which further divides into the paired posterior cerebral arteries.
16. Internal carotid artery dissection is a potential cause of strokes in children. The
history of a fall on a pencil in a childs mouth within 24 hours of the onset of symptoms
is typical. (The injury produces a tear in the intima of the internal carotid A. and
dissection and thrombosis may followhemiplegia of sudden onset, hemianesthesia,
mild motor aphasia)
17. Most definite way to Dx iron deficiency anemia: bone marrow iron stain.
18. Patients with hemochromatosis and cirrhosis are vulnerable to listeria monocytogenes
and some other bacterial infections.
19. Iron overload is also a risk factor for infection with Yersina enterocolitica and
septicemian from Vibrio vulnificus both of which are iron-loving bacteria.
20. Duchenne muscular dystrophy : CK levels are used for screening the muscular
dystrophies. Muscle biopsy can confirm the Dx in most cases. The gold std is genetic
studies, which is required in atypical cases.
21. Dx. of Whipples disease: can be confirmed with upper GI endoscopy and biopsy of
the small intestine, followed by PAS staining of the sample.

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22. Multiple myeloma Tx: melphalan, prednisone, interferon, combination chemotherapy

and autologous bone marrow transplantation.
23. Most specific test for Sjogrens syndrome: lip biopsy. (shows lymphoid foci in
accessory salivary glands)
24. Unless strangulation or perforation is suspected, bowel obstruction is treated
conservatively with fluids, nasogastric suction and enemas.
25. Monoclonal gammopathy of undetermined significance (MGUS): characterized by
lab findings of an M component (IgA, or IgG, or IgM)<3000 mg/dL, and fewer than 10%
plasma cells in the bone marrow. Patients initially do not require any Tx, but proper
education and counseling are necessary. Regular follow-up visits are recommended, and
all patients are instructed to promptly obtain medical evaluation if any clinical symptoms
occur.
26. Rhabdomyolysis should be suspected in the following situations:
o Presence of risk factors such as alcoholism, cocaine use, and electrolyte abnormalities
(eg. Hypokalemia, hypophosphatemia)
o Disproportionate elevation of creatinine as compared with BUN
o Urine dipstick positive for blood but no RBC on microscopic examination.
o (The underlying pathology is acute tubular necrosis. Serum CK should be measured in
o suspected patients. The Tx is aggressive IV hydration and alkalinzation of urine. Forced
o diruesis with mannitol may be required.)
27. Moderation of alcohol intake to 1-2 drinks per day has been shown to have a
cardioprotective effect (BP reduction).
1. Manometry establishes the Dx of diffuse esophageal spasm. (esophageal motility
studies)
2. Alzheimers disease: A MMSE score of <24 is suggestive of dementia (total maximum
is 30). Alzheimers disease is the MCC of dementia in the western world. Etiology is
unknown, but the following mechanisms have been implicated:
Degeneration of the basal nucleus of Meynert (in the forebrain), which secretes
acetylcholine (Ach). (diffused cortical and subcortical atrophy on CT scan)
Deficiency of choline acetyltracnsferase and its product, Ach, in the brain.
Abnormal amyloid gene expression
3. Infectious mononucleosis is an infection caused by the EBV, and is sometimes
detected only when the patient develops a characteristic polymorphous rash after taking
ampicillin for an apparent upper respiratory tract infection.
4. Orthotopic liver transplantation remains the only effective mode of Tx of fulminant
hepatic failure and should be considered in any patient presenting with fulminant hepatic
failure, regardless of the etiology.

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5. The Dx of PCP is likely if an HIV patient has a non-productive cough, exertional

dyspnea, fever, severe hypoxia, bilateral interstitial infiltrates on chest X-ray, and a
normal white count. TMP-SMX is DOC. Steroids have been shown to decrease the
mortality in patients with severe PCP.
6. Indication of steroid use in PCP includes:
o PaO2<70 mmHg
o A-a gradient >35; (A-a gradient= (150-(1.25xpCO2))-PO2)
7. PID tx: inpatient Tx with cefotetan + doxycycline
8. Aspirin intoxication in adults initially causes increased respiratory drive leading to
respiratory alkalosis and then uncouples oxidative phosphorylation leading to metabolic
acidosis.
9. Hairy leukoplakia is a white, painless lesion that appears hairy and is often found in
AIDS patient on the lateral aspect of tongue. It is caused by EBV.
10. CT of the chest should be done to look for a thymoma in all newly diagnosed
myasthenia gravis patients.
11. Reversible acetylcholinesterase inhibitors such as donepezil, rivastigmine,
galantamine, and tacrine are of benefit in slowing the cognitive decline associated with
Alzheimers disease.
12. Consider 3 possibilites when a flat film of the abdomen and pelvis doesnt show a
stone in a patient with typical renal colic:
o Radiolucent stone disease (uric acid stones)
o Calcium stones less than 1 to 3 mm in diameter
o Non-stone causes (eg. Obstruction by a blood clot or tumor)
13. Uric acid stones are highly soluble in alkaline urine; therefore alkalinzation of urine
to pH>6,5 with oral sodium bicarbonate or sodium citrate is the Tx of choice.
14. Clinical scenario describing a woman with chronic headaches who presents with
painless hematuria is typical for analgesic nephropathy. Papillary necrosis is the cause of
hematuria.(vasoconstriction of medullary blood vessels, vasa recta)
15. Hypercarotenemia is commonly seen in patients with anorexia, diabetes &
hypothyroidism.
16. Impaired ammonia ion (NH4+) excretion is the principal mechanism of metabolic
acidosis in chronic renal disease.
17. Situational syncope should be considered in the DD of syncopal episodes. The typical

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scenario would include a middle age or older male, who loses his consciousness
immediately after urination, or a man who loses his consciousness during coughing fits.
18. Primary pulmonary HTN can be seen in middle-aged patients, and it presents with
exertional breathlessness. Lungs will be clear to auscultation. Chest X-ray would show
enlargement of the pulmonary arteries with rapid tapering of the distal vessels (pruning)
and enlargement of the right ventricle.
19. Pyromania is characterized by intentional, repeated fire setting with no obvious
motive. Although a history of arson may be documented in individuals with conduct
disorder, other features will be present as well. (lying, theft, cruelty, etc.)
20. Tx for E. vermicularis infection (pinworm):
First line: Albendazole or mebendazole
Alternative: pyrantel palmate
21. Subcutaneous emphysema in an asthmatic is a benign disorder. A chest X-ray must be
ordered to ensure that there is no pneumothorax.
22. Dapsone is an effective Tx for dermatitis herpetifomis. Dermatitis herpetiform occurs
in association with celiac sprue. (will improve within hours after applying the drug)
23. The presence of dermatitis herpetiformis (erythematous vesicles symmetrically
distributed over the extensor surfaces for elbows and knees) and chronic non-bloody
diarrhea in a child of 12-15 months is suggestive of celiac disease. (microcytic anemia
too).
24. Rigid bronchoscopy is indicated in patients with massive hemoptysis as it allows
rapid visualization of the bleeding site and to control bleeding through cauterization or
other means.
25. Triad of juvenile angiofibroma: (a markedly vascular fibrous tumor in nasopharynx of
males, usually in the 2nd decade of life.)
Nasal obstruction
Nasopharyngeal mass
Recurrent epitaxis
26. Endoscopic retrograde cholangiopancreatography (ERCP) is the investigation of
choice for patients with recurrent pancreatitis with no obvious cause.
27. Rotator cuff tear:presents with shoulder pain aggravated by movements like pushing,
pulling and positioning the arm above the shoulder as well as weakness of shoulder
resulting in functional impairment. Dx: MRI of the shoulder, or arthrography.
28. Subacromial bursitis: injury to rotator cuff is a common casue of shoulder pain and
disability in athelets. Prolonged, repetitive overhead activity as in tennis, swimming,

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pitching or golf can compromise the space between the humeral head and coracoacromial
arch leading to impingement syndrome. Subacromial bursitis results from impingement
syndrome. It refers to inflammation of the subacromial bursa. Rotator cuff tendon tear
and supraspinatus tendonitis can also occur as a part of impeachment syndrome.
29. Normal pressure hydrocephalus: is characterized by the triad of gait disturbance,
dementia and urinary incontinence. Lumbar puncture reveals the normal CSF pressures,
and MRI shows the enlarged ventricles (not like in pseudotumor cerebri, the ventricles
shrink) Tx.: CSF shunting procedure.
30. Psedotumor cerebri: suspect this in a young obese female with a headache that is
suggestive of a brain tumor, but with normal neruoimaging and elevated CSF pressure
(papilledema). Tx: weight reduction, acetazolamide. Shunting or optic nerve sheath
fenestration may be performed to prevent blindness. (if left untreated-> blindness)
31. Membranous nephropathy is the MC nephropathy associated with carcinoma.
32. Nephrotic syndrome is a well-known complication of Hodgkins lymphoma, usually
casued by minimal change disease *extremely HY Q for the USMLE*
33. pressure sores are common over: (mostly parts below the waist)
hips
sacrum
heels
34. Hepatic venogram or a liver biopsy is the diagnostic test of choice for the evaluation
of congestive hepatomegaly secondary to hepatic vein occlusion (Budd Chiari
syndrome)-elevated hematocrit with organomegaly, polycythemia rubra vera (at risk of
hepatic vein occlusion)
35. Patients treated with high-dose methylprednisolone within 8 hours of spinal cord
injury have significant and sustained neurological improvement, thus its use is warranted
as the first priority after stabilizing the patient. *important Q!!!*
36. ECG manifestations of digitalis toxicity: atrial tachycardia with AV block.
37. Basal cell carcinoma presents as a slow-growing, pearly and indurated lesion. It is the
most common malignant tumor of the eyelid. (eyelid swelling, loss of lashes)
38. Cataract is the MCC of leukocoria (not retinoblastoma). The causes of cataract
include familial, congenital infection (rubella), metabolic conditions (eg, DM,
galactosemia), genetic disorders (eg. Downs syndrome, Turners syndrome), and longterm/high dose glucocorticoid use. (extremely HY Q!)
39. Effective in preventing pneumocystis carinii in transplant patients:
oral Trimethoprim-sulfamethoxazole.

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If sulfa allergic, use aerosolized pentamidine and Dapsone

40. Biophysical profile score of <2 is alarming and baby should be delivered
immediately.
41. Cat bites Tx: prophylactically with a 5-day course of amoxicillin/clavulanate.
42. Suspect rosacea in 30-60 yo patients with telangiectasia over the cheeks, nose, and
chin. Flushing of these areas is typically precipitated by hot drinks, heat, emotion, and
other causes of rapid body temperature changes. Topical antibiotic such as metronidazole
is the most frequrently prescribed initial therapy.
43. Lofgrens syndrome: is an acute form of sarcoidosis and consists of triad of bilateral
ankle arthritis(sometimes knees, wrists or elbow), erythema nodosum and bilateral hilar
adenopathy.
44. Erythema nodosum (EN): pink to reddish painful, subcutaneous, nodules that usually
develop in a pretibial location. Resolve without scarring over a 2-6 week period.
Histologically, this is a panniculitis involving inflammation of septa in the subcutaneous
fat tissue. EN is commonly associated with recent streptococcal infection.
45. Causes for painless hematuria:
Glomerulonephritis
Hb S trait
Kidney stones
Tumor
46. Intravenous pyelography (IVP) is very useful for the Dx of renal stones.
47. DOC for Variant angina: calcium channel blockers (eg. Diltiazem)
48. Chronic supraphysiological doses of glucocorticoids suppress CRH release, thereby
causing central adrenal insufficiency. Aldostorone secretion is relatively preserved. Lab
studies typically show low ACTH and low cortisol levels.
49. The most serious complication of bronchiectasis is: hemoptysis.
50. Oligoclonal bands are present in 85-90% of cases of multiple sclerosis. CSF pressure,
protein and cell counts are grossly normal. (may present as: paraplegia, urinary
incontinence, urgency. Trigenminal neuralgia, spasticity, hyperreflexia in the lower
extremities, impaired vibration and proprioception in one arm. (high immunoglobulin
levels, especially IgG)
51. Suspect pulmonary embolism in any patient who presents with sudden onset of
shortness of breath, pleuritic chest pain, normal lung exam, hypoxic, and have tachypnea,
tachycardia, and hypotention. New onset A fib (ECG: reveals irregular RR intervals, with

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no definite P waves and narrow QRS complexes) is seen in few patients with PE.
Pulmonary vascular disease includes PE.
52. Tumor burden is the single most important prognostic consideration in the Tx of
patients with breast cancer. It is based on TNM staging.
53. Early excision therapy is indicated for extensive partial-thickness and full-thickness
burns, as they do not heal spontaneously. Also, it allows for early skin grafting and lesser
complications.
54. Meningitis and empirical antibiotic regimens:
In children, Listeria monocytogenes: ampicillin + cefotaxime
In hospitalized patients, staph. Aureus and pseudomona: vancomycin (to cover Staph.)
and ceftazidime (3rd generation cephalosporins to cover pseudomonas)
Pneumococci: vancomycin + ceftrizxone (third generation cephalosporin)
55. Radial Tunnel syndrome: can be confused with lateral epicondylitis as both the
conditions can coexist. It is a compression neuropathy of radial nerve in radial tunnel
characterized by tenderness over mobile muscle mass distal to the radial head. Also, the
pain is reproduced by simultaneously extending the wrist and fingers while the long
finger is passively flexed by the examiner and also by resisted forearm supination.
56. Rupture of long head of biceps: commonly occurs in bicipital groove and would lead
to a bulging muscle mass in the middle arm
57. Lateral epicondylitis: also know as tennis elbow is epicondylitis about the origin of
extensors of forearm, know how to differentiate it from radial tunnel syndrome.
58. Transmission of HIV by breastfeeding is well documented; therefore, the presence of
maternal HIV infection is an absolute contraindication to breastfeeding.
59. Performance-related anxiety: prophylactic propanolol.
60. Generalized anxiety disorder (GAD): Buspirone is a first line drug. (it does not cause
the physical dependence and withdrawal symptoms associated with benzodiazepines)
61. Pericardial cysts are usually found in the middle mediastinum. Thyoma is usually
found in the anterior mediastinum. All neurogenic tumors (menigocele, enteric cysts,
lymphomas, diaphragmatic hernias, esophageal tumors and aortic aneurysms) are located
in the posterior mediastinum. It is benign, and can be aspirated and will shrink.
62. Middle mediastinal masses include:
Bronchogenic cysts
Lymphoma
Lymph node enlargement
Aortic aneurysms of the arch.

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Pericardial cysts
63. TCA (i.e. imipramine) intoxication: Sodium bicarbonate (single most effective
intervention). It prevents the development of arrhythmia in patients with TCA toxicity by
alleviating cardio-depressant action on sodium channels.
64. Antibiotic therapy is the most accepted and recommended management for the
eradication of H. pylori in patients with gastric MALT without any metastasis. (PPI,
clarithromycin, amoxicillin)
65. Drug-induced pancreatitis is mild and usually resolves with supportive care. CT scan
is diagnostic for pancreatitis. (presents as abdominal pain, nausea, vomiting, low-grade
fever, loss of appetite)
66. In patients presenting with significant peripheral vascular disease, calcium channel
blockers are preferred as anti-HTN agents. (such as amlodipine)
67. Granuloma inguinale is an STD caused by the bacterium Donovania granulomatis and
characterized by an initial papule, which rapidly evolves into a painless ulcer with
irregular borders and a beefy-red granular base. Tx: tetracycline 500 mg every 6 hours for
10-21 days
68. Children with occupational defiant disorder are disobedient and argumentative.
Although they may be hostile, they do not seriously violate the rights of others.
69. MCC of hypercalcemia in admitted patients: malignancy. Due to multiple reasons:
PTHrP secretion
Osteolytic metastasis
Increased formation of 1,25-dihydroxyvitamin D
Increased interleukin 6 levles
(normal calcium level: 8.4-10.2, thiazide will cause mild hypercalcemia, wont reach
14)
70. How to manage unstable angina in the setting of anemia due to a massive GI
hemorrhage?---blood transfusion.
71. When PEEP is increased, its major drawback is a decrease in cardiac output. Patients
who are maintained on PEEP should be monitored with a Swan-Ganz catheter. This Q is
based on simple physiology. It is expected in USMLE.
72. DOC for early syphilis: benzathine penicillin G and a single IM injection is required.
For those who are allergic to penicillin, doxycycline or tetracycline is given orally for 14
days.
73. DOC for patient with neurosyphilis: IV aqueous crystalline penicillin. IM procaine
penicillin is a good alternative.

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74. A complex partial seizure is characterized by brief episodes of impaired

consciousness, failure to respond to various stimuli during the episode, staring spells,
automatisms, and postictal confusion. The EEG pattern is usually normal or may show
brief discharges. *Remember the automatisms.*
75. Patients with a leukocyte adhesion defect suffer from recurrent bacterial infections.
Delayed separation of the umbilical cord and necrotic periodontal infections are
characeteristic. (normal NBT test, increased gamma globulin level)
76. In cases of intrauterine growth retardation, (IUGR), presence of oligohydraminos (
AFI < 5, amnionic fluid index) is an indication for delivery.
77. When hemorrhage occurs, the pulse pressure is the first physiological change.
78. Anserine bursitis presents with medial knee pain just below the joint line.history of
trauma, well-defined area of tenderness over the medial tibial plateau just below the joint
line. Valgus stress test doesnt aggravate the pain. X ray of tibia is normal.
79. Test of choice for lumbar spinal stenosis: MRI. Symptoms: associated with aging,
>60 yo. Narrowing of the spinal canal results from encroaching osteophytes at the facet
joints, hypertrophy of the ligamentum flavum and protrusion of intervertebral disks. Gait
disturbance can be so prominent that they complain of having spaghetti legs or walking
like a drunken sailor. The preservation of pedal pulses helps distinguish from vascular
claudication.
80. Decision of use of N-acetyl cysteine as an antidote for acetaminophen overdose is
generally based on 4 hour post-ingestion acetaminophen levels. (ingested >7.5 gm of
acetaminophen: give antidote)
81. Any elderly patient who presents with pneumonia, abdominal pain, confusion and
hyponatremia should be suspected for Legionellar pneumonia. This should also be
suspected in patitents who fail to respond to beta-lactam antibiotics and gram stain
showing many poly with few visible organisms. (they are intracellular ones). Tx. of
choice for Legionella pneumonia: high dose erythromycin or azithromycin.
82. Cholesterol embolization usually follows surgical or interventional manipulation of
the arterial tree. Renal failure, livedo reticularis, systemic esosinophilia, and low
complement levels should make you think of cholesterol embolism. *extremely HY Q*
83. Aortic dissection is an acute emergency and its medical management includes prompt
blood pressure lowering with IV nitroprusside and short-acting beta-blocker.
84. Unacceptability bias refers to participantss response with desirable answers which
leads to underestimation of the risk factors.(eg. Medical school students know the risk of
smoking and may not care to reveal their smoking status, especially to the public health

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department. Therefore a lower number of smoker may be reported, than actual.)

85. The MC esophageal anomaly is esophageal atresia with a tracheoesophageal fistula.
This is characterized by an atretic esophageal pouch that communicates distally with the
trachea just above the carina. Pneumonitis and atelectasis occur frequently.
86. The mechanism of action of antipsychotic drugs (such as haloperidol) is primarily
blockade of the dopamine-D2 receptors. The added serotonin antagonism of atypical
antipsychotic drugs (such as resperidone) reduces the likelihood of extrapyramidal side
effects.
87. Parinauds syndrome (paralysis of vertical gaze that may be associated with papillary
disturbances) and Colliers sign (eyelid retraction) usually indicate a lesion in the rostral
midbrain, most likely pinealoma or germinoma.
88. Fluid overload can lead to pulmonary edema and heart strain (elevated CVP, like 30
cmH2O and an S3 gallop).
89. Acute exacerbations of MS are treated with corticosteroids. Beta-interferon or
glatiramer acetate is used to decreased the frequency of exacerbations in patients with
relapsing-remitting or secondary progressive form of MS.
90. CT scan is the best test for the Dx of diverticulitis in acute setting.
91. Hyaline memebrane disease should be suspected in preterm infants with respiratory
distress and hypoxia not responding to oxygen therapy. The characteristic chest X-ray
findings of HMD demonstrates fine granularity of the lung parenchyma, and fine rales,
hypoxemia and metabolic acidosis. Tx includes early mechanical ventilation and
surfactant administration.
92. Magnesium is an effective Tx for torsade de pointes (i.e. side effect of quinidine)
93. Lidocaine: is a class 1 anti arrhythmic agent, used in the Tx of ventricular tachycardia
and fibrillation. Always given IV.
94. Hemodynamically unstable: low BP, patient not responding to commands, etc.
95. Common causes of Atrial flutter:
Mitrial valve stenosis
HTN
Pulmonary embolism
CAD (coronary artery disease)
Pericarditis
Post cardiac surgery
COPD

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123. Atrial flutter Tx:

Atrial flutter with unstable hemodynamics is best treated with cardioversion.
Acute atrial flutter with stable hemodynamics can be treated with cardioversion or can
be managed with rate control.
Chronic stable atrial flutter is best treated with rate control, which is best achieved with
either calcium channel blockers or beta-blockers.
96. Plain X-ray of the sarcroiliac joints is the next best step in a suspected patient of
ankylosing spondylitis.
97. Always suspect malignant HTN in patients with very high BP. Presence of
papilledema on ophthalmoscopy confirms the Dx. The pathologic change responsible for
end-organ damage in malignant HTN is fibrinoid necrosis of small arterioles.
98. Parathyroidectomy is the only effective Tx for primary hyperPTH.
99. Budd Chiari syndrome or hepatic vein occlusion is most commonly associated with
polycythemia vera and other myeloproliferative disease. (severe RUQ pain, icteric sclera,
hepatomegaly, splenomegaly, free fluid in abdomen. Centrilobular congestion)
100. Treatment for narcolepsy include:
Scheduled daytime naps.
Psychostimulants (eg modafinil)
Or a combination of antidepressants and psychostimulants (methylphenidate)
101. A nail puncture wound in an adult resulting in osteomyelitis is most likely due to
Pseudomonas aeruginosa.
102. Excessive use of vit C in patients with renal insufficiency can cause oxalate stones.
(radioopaque)
103. Elderly patients are particularly predisposed to dehydration after even minor insults
(e.g., a minor febrile illness). Know the classic signs of dehydration (ie. Dry mucosa,
marginally high values for hematocrit and serum electrolytes, BUN/creatinine ratio >20.)
The Tx is administration of IV sodium-containing crystalloid solutions (usually 0.9%
NaCl= normal saline).
104. Tinea versicolor is characterized by pale, velvety pink or whitish, hypopigmented
macules that do not tan and do not appear scaly, but scale on scraping. Topical Tx with
selenium sulfide lotion and ketoconazole shampoo is recommended. (extremely HY Q)
105. Any elderly patient with bone pain, renal failure, and hypercalcemia has multiple
myeloma until proven otherwise. 50% MM paitents develop some degree of renal
insufficiency; this is most likely due to obstruction of the distal and collecting tubules by
large laminated casts containing paraproteins (mainly Bence Jones protein).

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106. Anesthesia may reduce uterine activity if administered in the latent phase (too soon
to use anesthesia)
107. Anti-smith antibodies are present only in 30-40% SLE patients (but is very specific).
A case of SLE presents with: pain and swelling of joints of her right hand and wrist, lowgrade fever, malaise, difficult to rise from the chair. APTT slightly increased. Oral cavity
shows painless ulcer on the buccal mucosa. (+) ANA, (+) RA, (-) anti-smith Ab. Lupus
procoagulant (+)
108. Anti phospholipids antibody syndrome: may be either primary or associated with
other autoimmune disorders like SLE. Characterized by recurrent arterial or venous
thrombosis or recurrent fetal losses in the presence of anti phospholipids antibodies.
109. There are 3 types of anti phospholipids antibodies:
o The 1st is responsible for false-positive syphilis serology. (VRDL)
o The 2nd is responsible for lupus anticoagulant, which falsely elevated APTT.
o The 3rd is anticardiolipin antibody.
110. The Tx for an acute severe exacerbation of lung disease in a cystic fibrosis patients
is intravenous antibiotic therapy with coverage against Pseudomonas aeruginosa (usually
a combination of two drugs, such as penicillin/cephalosporin + aminoglycoside). The
example I met is :IV ceftazidime and gentamicin.
111. Thiazide (HCTZ) is the initial DOC for treating HTN in patients with chronic
persistent asthma.
112. Anti-thyroid peroxidase antibodies (namely antimicrosomal Ab) are present in more
than 90% of patients with Hashimotos thyroiditis.
113. Choanal atresia: It is the MC nasal malformation. It may be isolated or part of a
dysmorphic syndrome. Suspect choanal atresia in an infant who presents with cyanosis
that is aggravated by feeding and relieved by crying.
114. Choledochar cysts: are congenital abnormalities of the biliary tree characterized by
dilation of the intra and/or extra hepatic biliary ducts. ( abdominal pain, yellow urine,
icteric sclerase, abdominal tenderness with a mass palpable in RUQ. Mild elevated
amylase and lipase, ultrasonography: shows a cystic extra hepatic mass and a gall bladder
separated from the mass.
115. Migratory thrombophlebitis and atypical venous thromboses: are suggestive for
chronic DIC, most likely due to some visceral malignancy.
116. Seborrheic dermatitis: is characterized by dry scales, central face, presternal region,
interscapular areas, umbilicus and body folds. It may be associated with Parkinsonism,
acutely ill patients who have been hospitalized, and HIV positive individuals.

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117. Suspect an HIV infection in a young patient with seborrheic dermatitis.

118. Suspect hepatitis C infection in patients with lichen planus.
119. Atracurium is a neuromuscular blocking agent that is metabolized in plasma and
hydrolysed by serum esterases. Its use is safe in patients with renal and liver dysfunction.
120. Early deceleration: defined as a decrease in fetal heart rate by 15 beats/sec from
baseline for at least 15 sec, occurring at the same time as the uterine contraction.
121. Early deceleration is due to fetal head compression.
122. Fetal cord compression presents with variable decelerations.
123. Uteroplacental insufficiency presents with late decelerations. (most worrisome)
124. An epidural abscess presenting with neurologic symptoms of spinal compression
requires urgent surgery.
125. Be overly suspicious for an intraocular foreign body in patients with high-velocity
injuries (drilling, grinding, etc). If the initial pen light examination does not reveal any
conjunctival and corneal abrasions or foreign bodies, proceed with fluorescein
examination.
126. Know how to treat acute pulmonary edema in the setting of an acute MI. Loop
diuretics should be given to treat pulmonary edema.(furosemide)------symptoms
described for this case: sudden onset of severe substernal chest pain asoociated with
SOB, radiating to the left arm. Pain not respond to baby aspirin and nitroglycerine. EKG
has shown diffuse ST elevation in the inferior and lateral leads. JVD, 2+ pedal edema
bilaterally.
127. With posterior dislocation of the shoulder, patients shows internally rotated arm,
inability for external rotation and intact sensation and reflexes.
128. Local therapy (eg. Resection of metastases, local irradiation) is rarely curative in
paients with metastatic breast cancer, but it can be tried in patients with a respectable
solitary metastatic focus without signs of systemic involvement.
129. The MC locations of post aspiration lung abscess in recumbent position are apical
segment of right lower lobe and posterior segment of right upper lobe.
130. Lung abscess is commonly seen in patients with predisposition to aspiration and
those with periodontal disease. (seizure), Mouth anaerobes are responsible for most of the
lung abscesses.
131. DOC for variant angina: calcium channel blockers. Variant anginas are different

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from classic angina patients. They are younger, and do not exhibit the classic
cardiovascular risk factors. (due to vasospastic condition, they may also have other
related conditions like migraine headaches or Raynauds phenomena.)
132. Hemorrhage in HTN patients:
MC site of HTN hemorrhage: putamen (35%). The internal capsule lies to the putamen
and is almost always involved, thereby leading to hemiparesis. Other signs: hemi-sensory
loss, homonymous hemianopsia, stupor and coma. The eyes are deviated away from the
paralytic side.
Pontine hemorrhage accounts for 5-12%. Presents with deep coma, paraplegian that
developed within a few minutes. The pupils are pinpoint and reactive to light. There is
decerebrate rigidity. There are no horizontal eye movements.
Subarachnoid hemorrhage: sudden dramatic onset of severe headache, no focal
neurological signs. The MCC are saccular aneurysm and vascular malformations.
Cerebellar hemorrhage: ataxia, vomiting, occipital headache, gaze palsy, and facial
weakness. There is no hemiparesis. (emergency decompression may be life-saving in
such cases)
133. P value shows the probability of obtaining the result of a study by chance alone.
When the P value is less than 0.05, this is usually considered statistically significant. It is
very important to know the interpretation of the P value and its relationship with
confidence interval.
134. Many patients with influenza are treated with bed rest and simple analgesia (eg,
acetaminophen). Antiviral medications can reduce the duration of influenza symptoms by
2-3 days; however, these drugs are only effective if administered within 48 hours of the
onset of illness. Amantadine and rimantadine are only active against influenza A. The
neuraminidase inhibitor (ie, zanamivir and oseltamivir) are active against both influenza
A and influenza B. *extremely HY Q for the USMLE*
135. Chlamydial urethritis is suggested by mucopurulent urethral discharge, absent
bacteriuria, and history of multiple sexual partners.
136. Herpes mainly affects the temporal lobe of the brain and may present acutely (<1
week duration) with focal neurological findings. The characteristic CSF findings are
lymphocytic pleocytosis, increased number of erythrocytes, and elevated protein. HSV
PCR analysis is the gold standard.
137. Be ware of the potential for the development of metabolic alkalosis in patients
taking both Kayexalate and magnesium hydroxide. Kayexalate is a cation binding resin.
138. MC acid base disorder encountered in the hospitalized patient in the U.S.: metabolic
alkalosis.
139. DA-agnoist such as bromocriptine or cabergoline are the mainstays of Tx for most
patients with prolactinoma (for <10mm, over that size, surgery)

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140. Imatinib mesylate: has changed the prognosis of patients with chronic myelogenous
leukemia. (It is a tyrosine kinase inhibitor and works by blocking signals within cancer
cells and preventing a series of chemical reactions that cause the cancer cells to grow and
divide)
141. Infliximab, etanercept: TNF receptor inhibitors, used to treat RA.
142. Premenopausal women with simple or complex hyperplasia without atypia usually
respond to therapy with cyclic progestins. However, all patients should undergo repeat
biopsy after 3-6 months of Tx. Even if the patient does not want more children, a
hysterectomy is not warranted.
143. Hyper-IgM syndrome (HIM) is characterized by high levels of IgM with deficiency
of IgG, IgA and poor specific antibody response to immunizations.
144. Always rule out hypothyroidism in patients who present with symptoms of
depression. Once ruled out, prescribe fluoxetine. For severe, refractory depression, ECT
is helpful.(also helpful in pregnant women)
145. When treating patients with Pheochromocytoma: do not give beta-blockers without
alpha-blockers. Always give an alpha-blocker first, followed by a beta-blocker; doing this
in the wrong order can precipitate a very dangerous increase in BP. (-blocker first then
-blocker) i.e.: phentolamine, phenoxybenzamine.
146. Glucocorticoids are indicated in a case of infectious mononucleosis complicated by
upper airway obstruction, autoimmune hemolytic anemia, and thrombocytopenia.
147. Monospot test (+): is sufficient to Dx infectious mononucleosis.
148. Brain death is clinical Dx. The characteristic findings are absent cortical and brain
stem functions. The spinal cord may still be functioning; therefore deep tendon reflexes
may be present.
149. Secondary amenorrhea is relatively common in elite female athletes and results from
estrogen deficiency.
150. Spondylolisthesis is a developmental disorder characterized by a forward slip of
vertebrae (usually L5 over S1) that usually manifests in preadolescent children. In the
typical clinical scenario, back pain, neurologic dysfunction (eg. Urinary incontinence-bed
wetting), and a palpable step-off at the lumbosacral area are present if the disease is
severe.
151. Intermittent claudication is best treated with aspirin and an exercise program.
152. Controlling the rhythm or rate in patients with prolonged tachysystolic atrial

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fibrillation usually improves the LV function significantly, sometimes even dramatically.

153. Kallmann syndrome: hypogonadic hypogonadism, + decreased sense of smell.
(secondary hypogonadism, low LH, FSH). Tx: testosterone.
154. Klinefelter syndrome: 20 times higher risk for developing breast cancer. Mostly are
not mental retarded.
155. SLE pregnant women: treated with LMWH or aspirin to avoid spontaneous
abortions during the 2nd and 3rd trimester.
156. All SLE pregnant patients should be screened for SSA/anti-Ro antibodies. Since
they cross the placenta and cause neonatal lupus and rarely permanent heart block.
157. Anti-dsDNA Ab positive---very specific for the Dx of SLE, also increase the
likelihood of lupus nephritis, and when they are , they point to currently active SLE.
158. Schober test: a measure of lumbar spine motion in which parallel horizontal lines are
drawn 10 cm above and 5 cm below the lumbosacral junction in the erect subject; with
maximum forward flexion, the distance between the lines increases at least 5 cm in
normal patients but far less in patients with anklylosing spondylitis
159. Ankylosing spondylitis: stiffness in the morning >1 hr, improved as exercises. The
Dx of AS is based on clinical and X-ray findings (sacroiliitis, fusing of the sacroiliac
joint, bamboo spine and squaring of the vertebral bodies), not based on HLA-B27.
160. Septic arthritis:
In young man/women, consider gonorrhea, Tx: ceftriaxone (3rd generation
cephalosporin, to cover gonorrhea)
In older patients with RA, consider staph. Aureus, Tx. nafcillin or vancomycin
161. Capsaicin cream: used in Tx of osteoarthritis (OA). Depletes local sensory nerve
endings of substance P.
162. Prophylatic for malaria in pregnancy: combination of atovaquone & proguanil.
163. Smoking cessation: nicotine patches/gums, or the oral antidepressant bupropion.
164. Bupropion: is dopaminergic and adrenergic, it not only improves depression but also
improves cognitive funcitong related to OCD.
165. Nephrogenic DI: treated with thiazides. The mechanism is incompletely understood.
It is possible that the natriuretic action of thiazides and resulting depletion of extracellular
fluid volume plan an important role in the thiazide-induced antidiuresis. In this regard,
whenever ECF volume is reduced, compensatory meachnisms increase reabsorption of
NaCl in the proximal tubule, reducing the volume delivered to the distal tubule.(From

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Harrison online.)
166. Osteoarthritis: obesity is a major risk factor for osteoarthritis. Hence weight loss is
the most effective measure in osteoarthritis management.
167. Suspect peritonsillar abscess or quinsy in an ill-appearing patient with fever, sore
throat, dysphagia, trismus, pooling of saliva, and muffled voice. Management includes
needle drainage (patient should be in the Trendelenburg position), close monitoring, and
IV antibiotics. MCC- hemolytic streptococcus.(group A streptococcus)
168. Respiratory synscytial virus infection may increase the risk of asthma later in life.
169. Open angle glaucoma: usually asymptomatic in the earlier stages, more common in
African Americans, and has an prevalence in those with a family history of glaucoma
and diabetes. There is a gradual loss of peripheral vision over a period of years, and
eventual tunnel vision. (Intraocular pressure is high, cupping of the optic disc with loss of
peripheral vision.) Tx: beta-blockers, (timolol eye drops), laser trabeculopalsty, surgical
trabeculectomy.
170. Angle closure glaucoma: is characterized by a sudden onset of symptoms such as
blurred vision, severe eye pain, nausea, and vomiting. Examination reveals a red yee with
a hazy cornea and a fixed, dilated pupil.
171. Macular degeneration: affects central vision
172. Cataract: is a vision-impairing disease characterized by progressive thickening of the
lens. Oxidative damage of the lens occurs with aging and leads to cataract formation.
Patients usually complain of blurred vision, problems with nighttime driving, and glare.
Definitive Tx: lens extraction.
173. Acetaminophen intoxication:
4 hour post-ingestion acetaminophen levels are determined to decide whether the
patient will benefit from N acetyl cysteine, or not.
If patient (adult) has ingested >7.5 gm of acetaminophen and levels will not be available
within 8 hours after ingestion, he should be given the antidote.
Gut emptying procedures are best effective if carried out in the first hour.
174. Remember the following when Tx with phosphodiesterase inhibitors:
Sildenafil is contraindicated in patients on nitrates, and in those who are hypertensive to
dildenafil.
Sildenafil is used with precaution in conditions predisposing to priapism
Concurrent use of drugs which interfere with the metabolism of sildenafil (e.g.
erythromycin, cimetidine) may predispose to adverse reactions by prolonging its plasma
half life.
While combining with an alpha-blocker, it is important to give the drugs with at least 4
hour interval to reduce the risk of hypotension.

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175. Vasovagal syncope (common faint): neurally mediated or neurocardiogenic

syncope. Presents with prodome (lightheadness, weakness, and blurred vision),
provocation by an emotional situation, and rapid recovery of consciousness. Dx: upright
tilt table testing with or without pharmacologic provocation (isoproterenol) may be
indicated to confirm the Dx.
176. Sick sinus node syndrome: once diagnosed, the best Tx is placement of a permanent
ventricular pacemaker.
177. Porcelain gall bladder: is an entity usually diagnosed on an abdominal Xray. The
condition predisposes individuals to gall bladder carcinoma and requires resection.
178. The overall incidence of vertical transmission of HCV is approximately 2-5%. All
patients including pregnant patients, with chronic hepatitis C should receive vaccinations
against Hepatitis A and B if not already immuned. *extremely important Q for USMLE*
179. Tx of hepatitis C: interferon-alfa and ribavirin. But they are contraindicated in
pregnancy. Ribavirin is particularly highly teratogenic.
180. HCV sexual transmission incidence is extremely low, so no recommended barrier
precautions between stable monogamous sexual partners.
181. Suspect choriocarcinoma in any postpartum women who presents with shortness of
breath, chest pain and hemoptysis. The next step is chest X ray, pelvic exam, and -hCG.
182. Suspect hemoochromatosis in a patient with new-onset DM, arhtropathy, and
hepatomegaly.
183. Painless gross hematuria is the MC presentation of sickle cell trait (characterized by
a Hb S concentration ranging from 35-40%)
184. Dactylitis: is common in patients with sickle cell anemia. (hand-foot syndrome,
symmetric painful swelling of the feet and hands)
185. Frequent UTIs occur in pregnant individuals with sickle cell trait.
186. Type A personality: is characterized primarily by time pressure (ie. Feeling rushed
most of the time) and competitiveness. Patients of type A personality are not at special
risk for cardiovascular disease.
187. Insulin resistance plays a central role in the pathophysiology of non-alcoholic fatty
liver disease by increasing the rate of lipolysis and elevating the circulating insulin levels.
188. Arthrocentesis followed by empiric Tx with IV nafcillin are the most appropriate
measures for the management of suspected septic arthritis in a child.

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189. Osteomyelitis in DM patients that involves the bone adjacent to the foot ulcers is
explained by the contiguous spread of infection.
190. Tumor lysis syndrome: hyperphosphatemia, hypocalcemia, hyperkalemia,
hyperuricemia (increased phosphate binds to calcium and causes hypocalcemia)
191. Idiopathic precocious puberty is managed with GnRH agonist (Lupron, Synarel,
Busrelin) therapy in order to prevent premature fusion of the epiphyseal plates.
192. Factor V Leiden is the MC inherited disorder causing hypercoagulability and
predisposition to thromboses, especially DVT of lower extremities.
193. McCune-Albright syndrome: 3 Ps: precocious puberty, pigmentation (caf au lait
spots) and polystotic fibrous dysplasia.(Cushings syndrome can occur in patient). (lightbrown spots with irregular contours on the back of the shoulders and left side of the
neck.)
194. Amitriptyline and cyclobenzaprine have been shown to be effective in the Tx of
fibromyalgia
195. An airway is always patent (secure) in a patient who is conscious and able to speak.
Chin lift and oxygen by a face mask to clear the airway and cut down the RR.
196. Tumors that are metastatic to bone cause local osteolysis by production of cytokines,
such as IL-1 or TNF. The most frequent tumors that produce hypercalcemia by this
mechanism are lung cancer and breast cancer.
197. The MCC of hypercalcemia in patients with nonmetastatic solid tumors is
production of PTHrP. In such cases, PTH is typically low.
198. Hypercalcemia in Hodgkins disease is almost always produced by calcitriol (2nd
step in the biological conversion of Vit D3 to its active form, more potent than calcidiol).
199. Aplastic anemia should be suspected in any patient with pancytopenia following
drug intake, exposure to toxins or viral infections.
200. Peutz-Jeghers syndrome is characterized by GI polyposis and mucocutaneous
pigmentation. It may also involve the development of an estrogen-secreting tumor,
leading to precocious puberty.
201. Sturge-Weber disease: is a sproradic phakomatosis characterized by mental
retardation, seizures, visual impairment and a characteristic port-wine stain over the
territory of the trigeminal nerve.
202. Most thyroid nodules are benign colloid nodules.

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203. Fibromuscular dysplasia: can present as new onset HTN in children. Bruit or venous
hum (due to well-developed collaterals) may be heard at the costovertebral angle.
Angiogram reveals the string of beads sign. The right renal artery is more affected than
the left.
204. Mitral regurgitation is the MC valvular abnormality observed in patients with
infective endocarditis not related to IV drug abuse.
205. Non-communicating hydrocele disappears spontaneously by 12 months of age and it
is therefore managed expectantly.
206. Checking for urinary excretion of bilirubin is an easy and effective way of
determining whether the cause of jaundice is conjugated or unconjugated bilirubin.
207. A very simple and convenient method is to measure the urinary excretion of
bilirubin by urine dipstick method. Normally more than 95% of blood bilirubin is due to
unconjugated fraction. The unconjugated fraction of bilirubin is insoluble as it is bound to
the albumin and therefore cannot be filtered by the glomerulus and is not excreted in
urine. Thus normally urine has no detectable bilirubin. However, the conjugated fraction
is soluble in plasma, can be filtered by the glomerulus and excreted in the urine. Patients
with conjugated hyperbilirubinemia have >50% of bilirubin in form of conjugated
bilirubin so enough of it remains unbound to be filtered and excreted by kidney.A more
precise way is to do the Vandenbergh test.
208. The single MCC of asymptomatic isolated elevation of alkaline phosphatase in an
elderly patient is Pagets disease.
209. Glucocorticoid deficiency: weakness, fatigue, depression, irritability, hypotension,
lymphocytosis, eosinophilia and hypothyroidism (i.e., cold intolerance, constipation, dry
and rough pituitary skin, bradycardia), aldosterone production is intact. ---- tumor, low
ACTH ( no hyperpigmentation)
210. aton-Lambert syndrome is associated with small cell carcinoma of the lung, and
results from autoantibodies directed against the voltage-gated calcium channels in the
presynaptic motor nerve terminal.leads to defect release of Ach. Electrophysiological
studies confirm the Dx. Tx: plasmapheresis and immunosuppressive drug therapy.
211. Autoantibodies against postsynaptic receptors cause myasthenia gravis. Reduction
of postsynaptic acetylcholine receptors leads to muscle weakness. The muscle weakness
is provoked by repetitive or sustained use of the muscles involved, unlike myasthenic
syndrome. Deep tendon reflexes are usually preserved, and may be somewhat brisk in
clinically weak muscle.
212. Boerhaaves syndrome: is esophageal perforation due to severe vomiting and it
produce pneumomediastinum.

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213. Beckwith-Wiedemann syndrome: characterized by macrosomia, macroglossia,

visceromegaly (liver and kidneys), omphalocele, hypoglycemia and hyperinsulinemia.
214. Think of Cocaine intoxication in a young patient presenting with chest
pain/myocardial infarction or stroke. Features of cocaine intoxication are cocaine bugs,
agitation, decreased appetite, dilated pupils, elevated or decreased BP, tachycardia or
bradycardia, and sweating.
215. Acute lymphoblastic leukemia: is the MC leukemia in children. Dx is mainly based
on more than 25% lymphoblasts in the bone marrow. Dx is suggested by the presence of
anemia, thrombocytopenia and blast cells on a peripheral blood smear, but is confirmed
by examination of the BM. (history of viral infection, pallor, hepatosplenomegaly,
petechiae, and/or lymphadenopathy.
216. Multifocal leukoencephalopathy: suspect it in an HIV-infected patient with focal
neurological signs and multiple non-enhancing lesions with no mass effect on the CT
scan.
217. Primary CNS lymphoma: is the second MCC of mass lesion in HIV infected
patients. It also presents as a ring-enhancing lesion on MRI, but is usually solitary,
weakly enhancing and periventricular. The presence of EBV DNA in CSF is quite
specific for the Dx.
218. Most colon cancer develops from polyps: the risk factors for a polyp progressing
into malignancy are villous adenoma, sessile adenoma, and size >2.5 cm Only
adenomatous polyps are clearly premalignant, but <1% of such lesions progress to
malignancy. Hyperplastic polyps are non-neoplastic and do not require further work-up.
*extremely HY Q*
219. Cerebral toxoplasmosis: is the MCC of ring-enhancing mass lesion in HIV-infected
patients. MRI reveals lesions that are usually multiple, spherical, and located in the basal
ganglia. This is unlikely if the patient is receiving TMX-SMX. A positive Toxopalsma
serology is quite common in normal subjects in the U.S., and is therefore not specific for
this condition.
220. Indications for hemodialysis:
Refractory hyperkalemia
Prefractory metabolic acidosis (pH<7.2)
Uremic pericarditis
Uremic encephalopathy or neuropathy
Coagulopathy due to renal failure
221. HIV infected patients who develop esophagitis are first started on fluconazole
directed against candidiasis

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222. Oral acyclovir is used to treat HSV esophagitis

223. Oral famotidine is used in cases of GERD.
224. Metabolic alkalosis can occur in hemodialysis patients who receive citrate.
225. Elevated PT/INR levels in a patient with hepatic failure may be due to vit. K
deficiency or liver cirrhosis. Regardless of the cause, the first step in this setting is
empiric administration of vit. K, since there is usually an underlying vit. K deficiency due
to several comorbidities. Fresh frozen plasma is indicated if the patient is actively
bleeding, or if the patient needs immediate surgery or an invasive procedure.
226. Post-exposure prophylaxis for chicken pox can be provided with VZIG (varicella
Zoster immune globulin) or acyclovir. Post exposure prophylaxis with VZIG is preferred
and indicated in susceptible high-risk persons exposed to varicella within 96 hours
(preferably 72 hours) of exposure.
High risk persons:
Immunocompromised susceptible children
Immunocompetent susceptible adolescent (>15 yo) and adults, especially pregnant
women
Newborn of mother with onset of chicken pos <5 days before or <2 days after delivery
Hospitalized premature infants.
Exposure criteria---Exposed to a case by:
Continuous household contact
Palymate for >1 hour indoor
Hospital contact
Mother with onset of chicken pox <5 days before or <2 days after delivery
Time of administration:
Preferably within 72 hours of exposure (within 96 hours at most)
Efficacy after 96 hours is not known.
High risk persons might have a rash within a week or two.
227. A significant granulocytic leukocytosis may be seen in immediate postpartum period
(sweetish smelling). This patient has a normal Lochia rubra, which is characteristic of the
first few days postpartum. After 3-4 days, the color becomes paler and the discharge is
then named lochia serosa. It turns afterwards white or yellow and becomes lochia alba. If
a foul smelling odor is noted, endometritis should be suspected. (reassurance is all that
needed)
228. Blood smear with atypical lymphocytes should make you rank CMV higher on the
list in a patient with mononucleosis-like symptoms, but monospot test negative.(large
basophilic lymphocytes with vacuolated appearance are seen)

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229. Acalulous cholesystitis occurs in critically ill patients and imaging studies show
diagnostic findings of thickening of the gall bladder wall and presence of pericholecystic
fluid.
230. An ACEI is contraindicated in a patient with hyperkalemia.
231. The concept of latent period is an important issue in chronic disease epidemiology.
Exposure must be continuously present for a certain period of time (called latent period)
to influence the outcome.
232. Lactose intolerance is characterized by a + hydrogen breath test, a + clinitest of stool
for reducing substances, and an stool osmotic gap.
233. When to order endoscopy in GERD:
Nausea/vomiting
Weight loss, anemia or melena/blood in the stool
Long duration of symptoms (>1-2 yrs), especially in Caucasian males >45 yo
Failure to respond to proton pump inhibitors.
233. The Dx of achalasia is made by manometry, however, endoscopy is required to
ensure that there is no malignancy.
234. Currently, quantitative estimation of stool fat is the gold std for the Dx of
steatorrhea. (fat malabsorption).
235. Chronic mesenteric ischemia: is suspected in patients with unexplained chronic
abdominal pain, weight loss, and food aversion. Evidence of associated atherosclerotic
disease is usually present. Physical findings are usually nonspecific. Abdominal
examination may reveal a bruit.
236. Zollinger-Ellison syndrome: Dx is fasting serum gastrin level. Greater than 1000
pg/mL is diagnostic of the disorder. Patient with non-diagnostic fasting serum gastrin
level should have a secretin stimulation test done.
237. Bacterial overgrowth: is a malabsoption syndrome which can be associated with a
history of abdominal surgery.
238. In these cases, CHF (congestive heart failure) is most likely the cause of worsening
dyspnea in elderly patients: (BNP will be increased)
Orthopnea (breathlessness worse while lying flat)
Lower extremity edema
S3,
Bibasilar crackles
Jugular venous distention
hepatomegaly

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239. B-type natriuretic peptide (BNP) is a natriuretic hormone similar to ANP; however,
in contrast to ANP, which is released from the atria, BNP is released from the cardiac
ventricles in response to volume overload.
240. The measurement of serum BNP can help distinguish between CHF and other causes
of dyspnea. A value >100 pg/mL disgnoses CHF.
241. Depressed CO combined with elevated PCWP(normally <12) ( an indicator of left
atrial pressure, and most of the times left ventricular end diastolic pressure) is indicative
of left ventricular failure.
242. ACEIs improve prognosis in post-MI patients with subnormal EF by decreasing
ventricular remodeling.
243. -blockers decrease mortality after MI and the incidence of recurrent MI in post-MI
patients. They decrese the risk of ischemia and arrhythmic episodes by decreasing the
influence of the sympathetic nervous system on the heart.
244. Mediastinal hemorrhage due to coagulation abnormality caused by warfarin: The
blood accumulated in the mediastinum causes compression of the surrounding structures
leading to cardio-vascular compromise i.e. mediastinal tamponade. (lungs are clear, no
pericardiac fluid, heart sounds somewhat muffled, chest pain, dyspnea, ecchymoses,
PCWP), widening of the mediastinum.
245. Large cell carcinoma of the lung: may produce hCG resulting in gynecomastia,
milky discharge, and elevated levels of serum hCG. (false + pregnancy test).
246. Schizoaffective disorder: is characterized by the presence of schizophrenia and
mood symptoms.
247. connversion disorder: characterized by the sudden onset of pseudoneurologic
symptoms or deficits involving the sensory or voluntary motor systems. Common triggers
include relationship conflicts or other stressors with an intense emotional component, but
the symptoms are not feigned or purposefully produced. Patient with conversion disorder
may be hysterical or strangely indifferent (la belle indifference) to their symptoms.
Sodium amytal may show improvement. Tx. psycotherapy
248. Pityriasis rosea: usually starts out with the classic herald patch 1 week before the
generalized eruption that tends to affect the trunk. The scaly, erythematous patches are
classically in a Christmas tree pattern on the back, following the skin lines of Langerhans.
Usually remit spontaneously in about 1 month and supportive Tx (e.g. antihistamine for
itching) is all that usually is required.
249. Aztreonam: has a spectrum of antimicrobial activity limited to gram negative
organisms, which cause UTIs (e.g., E. coli, Serratia, Pseudomonas, Proteus, Klebsiella).

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It is not effective against anaerobic, atypical, or gram positive organisms.

250. Alternating pulse: mechanical alternation; a pulse regular in time but with alternate
beats stronger and weaker, often detectable only with the sphygmomanometer or other
pressure measurement and usually indicating serious myocardial disease. Syn: pulsus
alternans. It is because of severe left ventricular dysfunction. The right side of the heart
would not be expected to affect the pulse in this way.
251. Vit B12 is mainly from animal products. Strict vegan will have a deficiency of it.
252. Courvoisiers sign: a nontender, palpable gallbladder, usuallyu caused by pancreatic
cancer. (not in chronic cholecystitis, not in cholelithiasis, or acute cholecystitis, or
cholangitis.)
253. Factors increase the risk of transitional cell carcinoma of the bladder:
Smoking
Long-term exposure to cyclophosphamide
Chronic ingestion of phenacetin
Industrial exposure to aromatic amines.
254. Factors increase the risk of squamous cell carcinoma of the bladder: chornic
Schistosoma haematobium infestation.
255. Priapism: estrongen therapy sometimes is effective as prophylaxis in repeated
episodes. May be caused by trazodone, sickle cell disase etc. Prolonged cases lasting
more than several hours commonly result in impotence.
256. Stress incontinence: is the MC type of urinary incontinence in women and usually is
associated with aging, multiparity, and pelvic relaxation.
257. Blood transfusion: O is universal donor type, AB is universal receiver type. Rh
negative can only receive Rh negative blood; while Rh positive can receive from both
negative and positive.
258. IUD: is most suited for older, monogamous women. The risk of PID, infertility, and
ectopic pregnancy are increased with the use of this from of contraception, and most
physicians hesitate to use this from birth control in a young, mulliparous, promiscuours
woman with eventual plans to have children.
259. Hegars sign: softening and compressibility of the lower uterine segment and is
suggestive of pregnancy.
260. Chadwicks sign: is a dark discoloration of the vulva and vaginal walls and also is
suggestive of pregnancy.
261. Normal newborn heart rate: 95-180/min.

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262. Risks factors of premature delivery:

Maternal pelvic infection
Premature rupture of the membrane
Multiple gestation
Maternal smoking
263. Anencephaly is associated with prolonged gestation (>42 weeks) probably due to
lack of normal fetal hormone production because of abnormal CNS development in the
fetus.
264. Naloxone can reverse dramatically the effects of opioids on the central nervous
system and can precipitate acute withdrawal symptoms.
265. Urethroceles: located in the lower anterior vaginal wall
266. Rectoceles: located in the lower posterior vaginal wall
267. Cystoceles: located in the upper anterior vaginal wall
268. Enteroceles: located in the upper posterior vaginal wall
269. MC hernia: indirect hernias are the MC type of hernias in any age group and both
sexes. (hernia sac travels throught the inner and outer inguinal rings, protusion begins
lateral to the inferior epigastric vessels) and into the scrotum as result of a patent
processus vaginalis.
270. Restrictive cardiomyopathy : sarcoidosis, amyloidosis, hemochramatosis, cancer and
fibrosis.
271. Dilated cardiomyopathy:
Alcohol
Coronary artery disease
Myocarditis
Doxorubicin An antineoplastic antibiotic isolated from Streptomyces peucetius; also
used in cytogenetics to produce Q-type chromosome bands. Syn: adriamycin.
272. A Fib Tx:
Synchronized cardioversion (not unsynchronized one, this is reserved for V tach)
Amiodarone for chemical cardioversion
Quinidine for chemical cardioversion
Procainamide for chemical cardioversion
Ibutilide for chemical cardioversion
-blockers to slow the ventricular rate.
Digoxin to slow the ventricular rate.
Centrally acting calcium channel blockers (verapamil or diltiazem), to slow the

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ventricular rate.
Anticoagulation with heparin
273. Best way to increase power is to increase the sample size.
274. MC primary tumor of the liverhemangioma.
275. MC primary malignant tumor of the liver in adultshepatocellular carcinoma.
276. MC primary malignant tumor in the pediatric age grouphepatoblastoma.
277. Relative risk cant be calculated from a retrospective study. The odds ratio, an
approximation of the RR, can be calculated from retrospective data.
278. Schistosoma mansoni: causes Katayama fever (schistosomiasis). Tx of choice:
Praziquantel.
279. Eyesights:
Myopia
Hyperopia
Presbyopia
Amblyopia
280. List of disease we should think when we see oral pigmentations:
Peutz Jeghers syndrome
ACTH and MSH like effect) Addisons (because of
Pb poisoning.
281. Tx. for uterine atony: diluted oxytocin infusion, bimanual compression with
massage of the uterus. If fails, second-line drugs, such as ergonovine, may be tried, but a
hysterectomy may be required if medical management fails.
282. Risk of uterine atony:
Multiple gestation
Polyhydramnios
Macrosomia
Prolonged labor
Oxytocin usage
Grandmultiparity
Precipitous labor
283. Omphaocele: is in the midline, the sac generally contains multiple abdominal
organs, the umbilical ring is absent, and other physical anomalies are common.
284. Gastroschisis: is to the right of the midline, only small bowel is exposed (there is no
true hernia sac), the umbilical ring is present, and other anomalies are rare.

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285. Congenital diaphragmatic hernia: more common on the left side, with bowel that has
herniated into the left thorax. Main complication: pulmonary hypoplasia that develop on
the side of the lesion and sometimes both sides becasues of bowel compressing the
developing lungs. Tx: surgical correction.
286. Most likely cause of an isolated oculomotor palsy with a normal and reactive pupil
on the affected side in a 57 yo man with HTN and DM: microvascular complications of
DM, HTN, or both.
287. -thalathemia:
Mediterranean descent
A microcytic, hypochromic anemia
Reticulocytosis
Elevated Hb A2 level.
288. Lower the cut-off value for Dx: increase sensitivity, decrease specificity, decrease
PPV, increase NPV.
289. Acne Tx: (blockage of pilosebaceous gland and the bacteria Propionibacterium acne
are thought to be responsible for it)
First topical benzoyl peroxide
Then topical or oral antibiotics
Topical vitamin A derivatives
A last resort is oral isotretinoin
290. Folate: is the only B-complex vitamin deficiency that has not been associated with
peripheral neuropathy.
291. Left sided heart failure: orthopnea, paroxysmal nocturnal dyspnea, pulmonary rales,
and toher respiratory symptoms, as fluid backs up into the lungs.
292. Right sided heart failure: fluids back up into the peripheral systemic circulation,
causing JVD, peripheral edema, hepatomegaly, and abdominal fullness or ascites.
293. Phenylephrine and handgrip: increase afterload, so will intense murmur in VSD,
mitral regurgitation, will decrease the murmur in Aortic stenosis, HOCM
294. Bartters syndrome: a disorder due to a defect in active chloride reabsorption in the
loop of Henle; characterized by primary juxtaglomerular cell hyperplasia with secondary
hyperaldosteronism, renin or angiotensin levels, hypokalemic alkalosis, hypercalciuria,
normal or low blood pressure, and growth retardation; edema is absent. Autosomal
recessive inheritance, caused by mutation in either the Na-K-2Cl cotransporter gene
(SLC12A1) on chromosome 15q or the K(+) channel gene (KCNJ1) on 11q.
295. Henoch-Shoonlein purpura (HSP): abdominal pain with guaiac-positive stools,
prominent rash (mostly on lower extremities), hematuria and joint pains (ankles, knees,

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wrists and elbows). Rash starts out as an urticarial rash and progresses to become
petechial and purpuric.
296. Normal ejection fractions value: 60%5%
297. Reference values:
CO (cardiac output): normal 3.5-5.5
CVP: normal 0-8
, Left ventricular dysfunction) PCWP: normal 4-12 (if
SVR: normal 800-1200
298. Kussmauls sign (+), pulsus paradoxus (-): constrictive pericarditis
299. Kussmauls sign (-), pulsus paradoxus (+): cardiac temponade
300. Kussmauls sign: may be present in restrictive cardiomyopathy, Apical impulse is
palpable in restrictive cardio as opposed to constrictive pericarditis
301. Hypercortisolism: new onset HTN, dermal striae, easy bruisability, glycosurianext
step is to do dexomethasone suppression testif cortisol level is high, then determine if
this is due to ACTH (do a measurement of baseline ACTH)
302. Tx.to slow the progression of osteoporosis: aldendronate
303. In rate control of A.Fib,: Digoxin alone works better than -blocker alone.
304. Exercise-induced asthma is best prevented by inhalation of a 2 agonist immediately
before exercise.
305. "growing" pains. Although such pains are most likely unrelated to growth, they do
affect children between 3 and 10 years. Growing pains are most commonly bilateral,
involve the lower leg and knees, manifest with pain during rest (usually at bedtime), and
are relieved by massaging or rubbing. Children awaken the next morning feeling fine.
Physical activity is not impaired. Limb pains produced by organic disease will usually be
unilateral (except for rheumatoid arthritis) or associated with physical signs (swelling,
warmth, etc.). The child with physical injuries or disease cannot bear to have the affected
area touched. Growing pains often have a familial predisposition.
306. DDAVP: 1-Desamino-8-D-arginine-vasopressin.
307. Testicular ferminzation syndrome: androgen insensitivity syndrome, 46 XY, has
very shallow, blind ending vagina, palpable mass in the labia (testicles). During early
fetal life, MIF was presented.
308. DOC for HTN Tx:
HTN with stable angina: a -blocker

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HTN with a benign essential tremor: -blocker

HTN with BPH and an unfavorable metabolic profile (dyslipidemia, glucose
intolerance): -blockers are preferred.
HTN with significant peripheral vascular disease: calcium channel blockers
(almodipine, nimodipine etc.)
Isolated systolic HTN: hydrochlorothiazide
Isolated diastolic dysfunction HTN: -blockers.
HTN in a post-MI patient: -blockers and ACEIs are preferred over diuretics and
calcium channel blockers. (ACEIs are indicated when EF is decreased, EF normally is
2/3)
HTN with chronic asthma: Hydrochlorothiazide
HTN due to renal vascular disease: should not use ACEIs, will precipitate acute renal
failure.
HTN with A.fib: verapamil.

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