USMLE World Notes-2

Celiac dis - 2
Pt present swith malabsorption, loss of muscle or subcutanous fat, pallor due to iron def anemia, bone pain due to osteomalasia, easy bruising due to vitK def and Hyperkeratosis due to VitA def. Hay fatigue and weight loss. Dx is with ELISA for IgA antibodies to gliadin and immunoflorescence for IgA antibodies to endosomysium. ALso antibodies against rtansglutaminase. But CONFIRMATION is small intestine biopsy. ****A 15mo old girl with dermatitis herpitiformis (erythematous vesicles symetrically distributed over the extensor surfaces of elbows and knees.) and chronic non-bloddy diarrhea with malabsorption (foul smelling stool) and distended stomach, is suggestive of CD.

Cellulitis - 2
Is an inflamation of skin that could extend into deeper tissues. In majority of pt is caused by Strep hemolytic or Staph aureus. Clinical symptoms can be Systemic as well as Local. Local findings are swelling, erythema, warm and tender and less well demarcated than Erysipela. The systemic signs are high grade fever chills and rigors, malise and confusion. When systemic signs are present IV Nafcilin or Cefazolin is preffered. **** The senario is usually a lady with painful leg DDX are:1-Cellulitis, high fever and chills. 2-DVT, cellulitis of calf is the one when there is high fever and no risk of DVT. 3-Necrotizing facitis is a deep seated cellulitis, suspect it in pt with bulla or crepitus. 4-Erysipelas, is a superficial cellulitis, it usually attacks cheeks, area is erythematous, painful and raised, with vesicles or bullae. No lymphangitis. 5-Erysipeloid is an edematous, purplish plaque with central clearing. Its caused by Erysipelothrix incidiosa. Usually at hands of fishermen and meat heandlers, its not as painful as cellulitis and there is no fever.

Central Cord Syndrome:
Characterized by burning pain and paralysis in the upper extremities with relative sparing of lower extremities. It is commonly seen in elderly 2ndary to forced hyperextension of the neck.

Central line complication:
Include pneumothorax, sesis and temponade occurs in 1-5% of pts. Cxy confirms that the tip is proximal to cardiac silhouette.

Central retinal Artery occulsion
Sudden painless loss of vision in one eye, however opthalmoscopy reveals pallor of the optic disk, cherry red fovea, cotton woolspots, retinal hemorrhages.

Central retinal Vein occulsion 2-
Sudden painless loss of vision in one eye, however opthalmoscopy reveals disk swelling venous dilation, tortuosity, retinal hemorrhage and cotton wool spots.

Cephalohematoma
Is a benign bleeding of newborn's scalp. It’s a sub-periosteal hemorrhage. It shows like a swelling. No tx is necessary. DDX:Caput succedaneum is a diffuse and ecchymotic swelling of the scalp. It may extend across the midline

Cerebral Hemorrhage
If its due to excess warfarin (PT is icreased) then FFP reverses the effect.Pt on anticoagulants should be on INR measure check. So if 1-INR <5, no significant bleeding DO omit next warfarin dose. 2-INR is 5-9 and no significant bleeding DO stop warfarin temporarily. 3-INR >9 DO stop warfarin and give oral VitK. Pts with serious intracranial bleeding cant wait for VitK, give them FFP right away to bring INR<1.5. Now to reverse Heparin give Protamine sulfate.

Cerebral infarction
Hypodense on CT ( white area over the cerebral surface).

Cervical cancer – 2.OBGYN 6.2
Risk factors: Young age at first coitus (<20). Young age at marriage and first pregnany. High parity, multiple sex partners, smoking, and low socioeconomic status. ****If pap is dysplasia, perform colposcopy. If it shows inflamatory Atypia then repeat after 4-6 weeks. ****If pt comes in with spotting, and you see the cervix having a gross lesion that bleeds by touching, dont even bother for PAP, go straight to Punch biopsy to rule out cancer. **** Once pt had the cancer check for cytology every year not every 2 year for normal people.

Cervical Spondylosis
It affects 10% of people >50. Hx of neck pain is typical. Osteophytes are the mc findings in cervical radiography in pt with CS. Bony spurs are the mc findings.

CGD
A defect of phagocytic cells Due to NADPH oxidase def. Leading to recurrent infection with catalase positive organism, Aureus, seratia, Klebsiela, Aspergillosis. Not suseptible to catalase neg (strep, influenza, Pyogenes). The MC clinical findings are lymphadenopathy, hypergamaglobolenemia, hepato and splenomegaly, anemia of chronic causse, short, gingavitis and dermatitis. NitroBlueTetrazolin is dx. Tx is prevention with trimeta-sulfa and Gamma interferone 3 times a week. BMT is curative. DDX1:Wiskot aldrich:Eczema,thrombocytopenia,recurent infection with encapsulted organism. Manifest at birth, petechia, bruises, circumcision bleeding, bloody stools. DDX2:Chediak Higashi, decreased granulation,chemotaxis and granulopoesis.Finding of neutropenia, ginat Lysosome in neutrophil will confirm Dx. Tx includes prevention with Trimeta-Slfa and daily ascorbic acid. DDX3:Jobs syn (Hyper IgE), chronic pruritic dermatitis, recurent staph infection, marked elevated IgE, eosinophilia and coarse facial features.

Chaga's dis
Caused by insect borne Trypanosoma Cruzi which is a common form of carditis in Centerl and South America. Pt presetns with Cardiomegally, conduction anomalies. Almost all pts have a hx of Megacolon or Megaesophagus.

Chalazion
a small swelling(NODULE) of the eyelid. It results from obstruction of the glands in the eyelid. First try to cure it by putting hot compress on it if it comes back again and again then do histopathology. It often requires surgery. Recurrent chalazion requires histopathologic exam because there is a risk of underlying Squamous cell carcinoma. DDX Hordeulom(Stye). Occurs at the edge of the eyelid(pretty red)

CHD risk factors:
Age (men>45, Women>55. Family Hx of premature CAD (<55 in first degree male parent, <65 in females relatives). Hypertension up to or equal to 140/90 even controlled w medication. Cigarret smoking. DM. HDL <35. HDL up to or equal to 60 negates one risk factor.

Risk factor LDL goal LSM Meds
CHD or Equiv <100 >=100 >=130
> or =2 <130 >=130 >=160
0 or 1 <160 >=160 >=190

Chediack Higashi:
Is a storage granulocyte abnormality resulting in hepatosplenomegaly, lymphadenopathy, anemia, thrombocytopenia, and susceptibility to infection in childood.

CHF - 6
CHF is a common cause of Pleural Effusion. Pleural analysis is consistant with transudate effusion. The effusion caused as a result of systemic factors (CHF) is Transudate. The effusions caused as a result of local factors is Exudate effusion. Existence of at least one of the following indicates exudate, if non exist its a transudate. 1-Pleural/Serum Protein is >0.5, 2-Pleural/Serum LDH is >0.6. The determination of pH is important in parapneumonic effusion in which a value of <7.2 requires a chest tube aspiration to prevent empyema. Pleural fluid pH<7.3 indicates pleural inflamation. **** If CHF is exacerbated due to develpement of Atrail fibrillation then tx of choice for that is Adding Digoxin. ******Measurement of serum B-type Natriuretic Peptide (BNP) can help ddx CHF from other causes of Dyspnea (COPD). A value of >100 is dx for CHF. BNP is like ANP but BNP is released from Ventricles vs ANP from Atria.Also remember in CHF pt sodium is reabsorped in kidneys in response to renin-angiotensinogen -Aldosterone system, therefre sodium in urine would be low .****ACE inhibitors increase survival rate in CHF pts, so cosider it in a pt with E<40%. Also out of all diuretics, Spironolactone is the only one that improves survival. *** Drugs that improve survival are B-blocers, Spironolactone, ACE inhibitors (Captopril and Losartan), and Aspirin. Digoxin helps the situation but NOT survival.

Child Abuse steps
A19-

Choanal Atresia
Suspect it in a infant who presnts with cyanosis that is aggrevated by feeding and releived by crying. Failure to pass a cathater through the nose is sugestive of dx. Dx is confirmed by CT with intranasal contrast. The first step in mgmnt consist of placing an oral airway and lavage feeding. Definite tx is repairing the obstruction with surgery.

Cholecystitis, Acute - 3
MM-402. Dx stages: 1-USG(initial workup), 2-HIDA (very specific, for confirmation. Its particulary useful in dx of Acalculus cholecystitis). ****Triad of acute RUQ pain, fever and leukocytosis. Pain radiates to scapula. Billirubin is normal and Murphy (pain on deep inspiration) exist. Its most commnly 2ary to gallstones. , in these pts it mc due to impaction of stones in a cystic duct. The inflamatory response results from any of the following, 1-Mechanical(increased intraluminal pressure), 2-Chemical(release of tissue factors) 3-Bacteria(2ary to stasis), this occurs in 50-70% of cases. REMEMBER although in 50-70 of cases there is infection due to bactreia, but the cause for AC is mc due to impaction of the stone in cystic duct.**** If pt still has pain after cholecystectomy, and ERCP shows sphincter of Oddi dysfucntion, then ERCP with sphincterectomy is the procedure of choice.**** After ERCP and shingterectomy, if pt has normal LFT and no dilation of biliary tree with US, then Oddi and CBD can be ruled out and pt is having FUNCTIONAL PAIN. Give analgesics and reassurance.**** Acalculus Cholecystitis occurs in CRITICALLY ill pts and imagin studies show thickening of gall blader wall and presence of pericholesistic fluid. Etiology might be stasis of bile ducts and ISCHEMIA of the gall bladder (after accident with loss of blood).

Cholecystectomy: Hepatology, 6/2
Post cholecystectomy pain most commonly is due to either Common bile duct stone, Sphincter of oddi or Functional pain. If LFT is normal and no dilatation of biliary tree then its functional pain, tx is symptomatically with analgesics and assurance. If pt has abnormal Alkaline phosphatase and dialation of billiary tree on US, then we do ERCP to confirm and treat, by stone removal or sphincterectomy.

Choledochal Cyst
congenital abnormalities of the billiary tree characterized by dialation of intra and extra hepatic billiary ducts. Presentation vary with age. An infant presents with jaundice and passage of acholic stools. In children it causes abdominla pain, jaundice and attakcs of recurrent pancreatitis, which maybe evident by increase inamylase and lipase. Adults present with vague epigastric or RUQ pain or Cholangitis. Choledochal cyst could degenerate into cholangiocarcinoma. Initial investigation of choice is US followed by CT or MRI. DDX1:Caroli's Synd, congenital disorder of intrahepatic dialation of bile ducts. DDX2:Biliary Atresia presents in infancy with marked obstructive jaundice and acholic stool.

Cholelithiasis - 3
Tx: 1-Asymptomatic pt, leave it alone. 2-Symptomatic pt, if ok with surgery choice is Laparoscopic Cholesystectomy, if surgery is CI or pt declines surgery then Ursodeoxycholic acid 10 mg/kg/day reduces biliary secretion of cholesterol and decreases the cholesterol saturation of bile, resulting in gradual dissolution of cholesterol-containing stones in 30 to 40% of patients.****There are 3 types: 1-Cholestrol, 2-Pigment stones(mostly calcium bilirubinate, 20%) and 3-Mixed stones. Water insoluble cholestrol is secreted in bile where its converted into soluble miscles by bile acids and phospholipids. If too much cholestrol and too little bile then cholestrol crystals precipitate. Predisposing factors are Fat,Femlae,Forty,Fertile(OCP), cloFibrate. Remember 80% of stones are radiolucent so xray cant see them.

Cholesteatoma, ENT 6/2
Causes acquired conducting hearing loss in CHILDREN .Its not a tumor. Its an Epithelial Cyst that contain desqumated Keratin. It could be acquired secondary to Otitis media or Eustachian tube dysfunction. Infection is usally due to Pseudomona. Pt presnts with recurrent infection. MC sign is drainage and granulation tissue and debris unresponsive to antibiotics & marginal tympanic perforation. They destroy bone. CT can detect defected bone. Tx is surgical removal. DDX Chronic Otitis media where there is no debris and granulation.

Cholesterol embolizarion
Or Atheroembolic disease, follows surgical or manipulation of arterial tree ( ie Angiography), due to showering of cholesterol from aorta or other major arteries. Its mc seen in elderly pt with evidence of diffused Atherosclerotic dis.. Renal failure, Livedo reticularis, sstemic eosinophilia, and low complement levels, should ake you think of this. Tx is conservative, antocoags should be stoppedsince it may prevent healing of the ruptures Plaque. Physical exam shows painless, redish blue mottling of the skin of the extremities.

Cholesterol lipid profile - 3
For CHILDREN the recommendation is: A child with a parental hx of elavated total cholesterol (>240mg/dl) or a chld with risk factors for CAD should be screened for total cholesterol level. If its >200mg/dl then we do a fasting lipid profile test. For screening we use HDL and Total Cholesterol. For Tx guidelines we use LDL levels.

Cholestyramine:
A bile acid sequesterant that lowers LDL and mostly increase HDL when combined with statin. In addition to binding bile acids in gut it also binds other drugs and reduces their bioavailibility so the pt needs higher doses ( ex hypothyrism )


Chorioamnionitis
Pts present with fever >38, uterine tenderness, irritability, elevated WBC and fetal tachycardia.Its asso with preterm or prolonged rupture of membrane. Fetal tachy could also be caused by Beta-2 agonist for tocolysis. Elevation of WBC could also be caused by steriods admin. Amniotic fluid cultures are gold for Dx (Nitrazine paper test). Once Dx is established samples are taken for culture and then Ampicciline and Gentamcin are given. Labor should be induced. If cervix is unfavorable C-section is done.

Choriocarcinoma
It’s a malignant tumor of the trophoblastic tissue. Clasically prestns w Hemoptosis, but it could also present with shortness of breath and chest pain. In any postpartum female you should suspect Choriocanrinoma. Quantitative Beta HCG is important in Dx. So once you have postpartum woman with hemoptosis chest pain and shortness of breath then we need to do Cxr, pelvic exam and BetaHCG.

Chronic Liver Disease
Do Merck. Asso with respiratory alkolosis.

Chronic Mesenteric Ischemia
suspect it in pt with chronic abdominal crampy pain, weight loss and people who don’t eat food because of pain and other malabsorptive symptoms. Evidence of Atherosclerotic dis is present. Abdominla exam might reveal bruit in 50% of pts. Dx needs angiography and Doppler US.

Chronic renal failure - 2
Secondary hyperparathyroidism with resultant renal osteodystrophy (loose calcium and retain phosphate) is almost universal in CRF.****Normochromic normocytic anemia due to eryhtropoetin def is a very common I pt with End Stage Renal Failure. Recombinant Eryhtropoetin is the tx of choice, however, Iron supplemnt should be given BEFORE erythropeitin. All Chronic Renal Failre pts hct<30, Hb<10 are canditetes for Erythropetin after Iron def has been ruled out. SE of Ertythropoetin therapy is 1-Worserning HT ( about 30% of pts. SC toute less common than IV route). Tx would be removing fluid with Dialysis and B-blockers. 2-HA, 3-Flulike symp, 4-Red cell aplasia.****Factors that improve prognosis in CRF are Protein restreiction and ACE inhibitors. ACE inhibitors are more likely to worsen RF when serum Creatinin are >3-3.5 mg/dl.

Churg Strauss
A20. MERCK:Its one of the group of diseases of known or unknown etiology characterized by eosinophilic pulmonary infiltrates and, commonly, peripheral blood eosinophilia.allergic granulomatosis (Churg-Strauss syndrome), a variant of polyarteritis nodosa with a predilection for the lungs.

Circumstantiality
is a thought disorder that answers in un-necassary details that deviate form the topic but eventually goes back to the topic. DDX is Tangentiality which is an abrupt permanent deviation from the topic. DDX2:Loose asso which there is no asso b/w sentences.

Cirrhosis - 3
Could happen 2ary to alcoholism. Pt has ascites, and esophageal varices 2ary to portal hypertension. Prophylactic tx of pt wth large varices who have never bled with propranolol significantly decrese the risk of futur bleeding. *In a pt with refractory ascites , refractory hydrothorax, and recurrent variceal bleeding, TIPS (Transjugular Intrahepatic Portosystemic Shunt). is used.****Alcoholism is the mcc of cirrhosis in US. 33% alcoholics, 10% HBV, 20-30% HCV(the mcc of liver transplant in US).****Pts with cirrhosismay have upper GI bleding due to : Erosve gastritis, PUD, Mallory-Weiss tear. Sclerotherapy isindicated for first varices, but not prophylactically. For PUD do consertavie mngmnt, if that didnt work then we do surgey, Excision of ulcer and vagotomy and pyloroplasty.

Clavicle Fracture
In bew borns it presents with irregularity,crepitus and fulness over the fracture site and decreased movemnt of the arm. Predisposing factors ar shoulder dystonia, traumatic delivery, large infant. No tx is needed.****For Adults do a figure of 8 bandage. *****Clavicle fractures that are displaced can damage subclavian artery, Artriogram is needed to rule out injury. Next step would be nerve donduction studies to rule out Brachial plxes injury. If fracture is in distal third then may require open reduction and internal fixation. Proximal and middle third are treated with closed reduction and figure of eight brace.

CLL (Chronic Lymphocytic Leukemia - 3
MC Leukemia in Western countries. In older pts. Mostly asymptomatic and discovered accidentaly. Smudge cells. In general don’t need to do lympb node biopsy to confirm dx, but if you want to a highly specific biospy is available to confirm dx. ****DDX:CML, presents with LEUKOcytosis with left shift Imyelocytes, neutrophils) not LYMPHOcytosis.****Smodge cells (leukocytes that break down because of theri greater fragility) are charcteristic. Staging is directly related to prognosis, stage 0= Lymphocytosis only, Good; StageI=Lymphocytosis+Adenopathy, Fair; StageII=Splenomegally present, Fair; StageIII=Anemia present, Intermediate; StageIV=Thrombocytopenia,Poor. Mean survival is 8-10 years.*****To CONFIRM dx do lymph node biopsy.

Clomiphene Citrate
Is an antiestrogen acts by competitive blocking of receptors of hypothalamous, inhibiting the negative feedback that estrogenhas on GnRH and consequently insreasing Lh & FSH and improving ovulation. Along with hMg and hCG itsindicated for chronic ovulation. SE are hot flashes, breast discomfort, spotting. DANAZOL is an androgen derivative that has gonadotropin inhibitory effect . Its indicated in Endometriosis, Fibroids and Fibrocystic breast disease.

Clonazepam toxicity
Clonazepam is used for insomnia. In elderly pt it could cause memory disruption. The next step in mngmt is to discountinue it.

Clozapine se
Agranulocytsis.

Club foot
Or Talipus Equinovarus. Calcaneum and talus are in equines and varus position. Initial mgmnt involves non-surgical methods (stretching and manipulation of the foot, followed by serial plaster casts, splint or taping). Surgical tx is indicated if that didn’t work , its performed b/w 3 and 6 month of age.

Cluster headache - 2
Tx for acute attack is 100% oxygen & subcutaneous Sumatriptan. *Presents with acute , sever retroorbital pain that wakes pt up at night. Maybe accompanied with redness of ipsilateral eye, tearing , runny nose, and Ispilateral HORNER synd (Ptosis, Myosis, Anhydrosis). Prophylaxis is key to mgmt, with verapamil, lithium and ergotamine.

CML
There is increased mature granulocytes like segmented neutrophils and band forms. BM shows hypercellularity with prominent granlocyte hyperplasia. When pt is in Crisis phase, IMATINIB is DOC. It’s a tyrosine kinase inhibitor that block signals w/I cancer cells. SE are mild naseau, diarrhea, leg cramps and swelling of the face and itchy rash. It has chenged the prognosis with CML.

CMV Pneumonitis
Is seen in 15-20% of Bone Marrow Transplants with case fertality of 84-88%. Pt presents with dypnea, cough and fever. Cxr shows multifocal diffused pathy infiltrates, and ground glass attenuation, parenchymal opacification or multiple small nodules on high res CT. BAL is dx in most cases. IT IS NOT SEEN IN IMMEDAITE post transplant period, wich is DDX with bacterial and fungus pneumonitis. PCP is also seen in immediate post transplant but its occurance has decreased dramatically due to routine prophylactic use of tri.sulfa in pre-transplant period.

Coarcation of Aorta
Present with rib notching (the 3 sign). HA is a presenting sign. Hay HT in upper extremity. Cxr shows dilatated ascending aorta and subvlavian artery. Indentation of aorta at site of coarcation and pre and post stenting dilation is called the '3' sign.

Cocaine Tox - 3
Pt presents with EKG abnormality of st depresion (ischemia and infarction), HT and excrutiating chest pain. Tx is Benzodiazepine, Nitrate and aspirine.If pt has MI then first line is Cathaterization. ****Fetuses exposed to cocain abuse exhibit intracranial hemorhage., nerotizing enterocolitis and cardaic defets and GU malformations. ****Could cause MI due to causing vasospasm, threre is blood in narises and dilated pupils . He has no risk for MI and is only 27.

Coccidiomycosis
Is endemic in California Arizona and new mexico and texas. Primary Pulmonary infection has non-specific features life fever, fatigue, dry cough weight loss. Cutaneous Erythem multiform and erythema nodosum anf arthralgias might be. Blastomycosis cutaneous dis is verrucous or ulcerative.

Colon Cancer
FOBT is the mc used screening test for colon cancer. Pts should be followed with colonoscopy.

Colorectal Cancer
MC presenting symptom is bleeding!

Communicable dis
If pt's dis could harm others he should be tx against his will. Senario is a man with Meningitidis and fever 104 for 2 days who wants to be tx at home. Answer is treat him in hospital agains his will since he will be harmful to others at home.

Compartment Synd
Dx is made clinically with pallor, pain, pulselesness, paralysis and paresthesia. PAIN on passive extension of fingers is the most sensitive marker of CS. Pain is persistant,progressive, unrelieved with imobilization and out of proportion to initial injury. CS is cused by increased pressure w/i an anatomical space.

Complex Patial Seizure
Breif episodes of impared consiousness, failure to respond to varius stimuli, staring spells, AUTOMATISM( Lip smacking, swollowing), and post-ictal confusion. EEG is usually normal. DDX1,Typical Absence seizure might have lip smalcking but they have n post-ictal confusion.

Conduct disorder
Charcterized by disruptive behavior that violate basic social norms for at least one year in pt <18 yo. Like stealing, setting fire, fighting, animla abuse. DDX is Antisocial disorder is when these boys become adults.
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Congenital Adrenal Hyperplasia- 2

Hyponatremia, HyperKalemia, Hypoglycemia, and metabolic acidosis. Its due to 21-Hydroxylase deficiency. Its auto recessive. Deficiency of both glucocorticoids and mineralocorticoids. Male infants will NOT have ambigous external genitalia unlike female infants, thats why male infants go on un-noticed until 2-4 weeks when they present with salt wasting. Treatment of 21-hydroxylase deficiency is with glucocorticoid replacement. *****Adolescent onset of hirsutism and virilism with normal mensturationand elevated 17-OH Progesterone.

Congenital Diaphragmetic Hernia:
In all emergency cases remember TX supercedes Diagnosis. The 1st step if oyu suspect CDH is to place orogastric tube and connecting it to a continues suction in order to prevent bowel distension and further lung compression. Bag-and-mask is to be avoided because this can cuase the stomach and intestine to become distended with air, further compromising lung funx.

Congenital heart defects
1-TOF: VSD. 2-Down: Endocardial cushing defect. Also ASD ( L to R shunt). 3-Turner synd:Coasrcation of aorta. 4-Congenital rubella: PDA.

Congenital Hypothyroidism:
The mcc is thyroid dysgenesis, 85% of cases. Infant has apathy, , weakness, hypotonia, constipated, sleeps a lot, large tongue, umbilical hernia. Screening is by T4 and TSH levels, Tx is Levothyroxine

Congenital Rubella;
Triad of sensorineural deafness + Cardiac malformation (PDA & ASD) + Cataracts. There could also be thrombocytopenia and purpule skin lesions ( Blueberry muffin spots). If transmission occurs in first 4 week of pregnancy the risk of developing CR is 50%, it drops to 1% in third trimester. The child might show symptoms when he is 2 years old.

Congenital Toxoplasmosis:
Triad of Chrioretintis + Hydrocephalus + Intracranial calcification. Look for pet in the picture somewhere.

Conjunctivitis, Neonatal - 2
Hay 3 causes for NC in US. 1-Chemical is the mc of the red eye presents at 1st 24hr of life. About 80% who receive prophylaxis w silver nitrate (to prevent gonococcal) experience mild conjuncitivis and tearing that resolves w/I 24 hrs. 2-Gonococcal: is acquired through contact with infected vaginal secretions, it occurs 2-5 days after birth, it presents as Copious purulent eye discharge with swellen eyelids & Chemosis(conjunctival edema), dx is by obtaining a smear and culture of the discharge, tx is a single intramuscular dose of ceftriaxone. 3-Chlamydia:Trachoma,presents with mild hyperemia and scant mucoid eye discharge and pannus (neovascularization) formation, it occurs b/w 5-14 after birth. TX is Systemic Erythromycin to decrease risk for Chlamydial pneumonia.

Constrictive Pericarditis. - 2
Asso with TB in immigrants.****Etiology could be early TB in life. The early third hear sound, called Pericardial knock and the respiratory increase in JVD (Kussmal sign) are important findings. Kusmaul is also present in right side hear failure, sever tricuspic regurgitation ,RV infarction and cardiac temponade. ******CP will lead to inability of ventricles to fill during diastole and would furthur cause the signs of decreased cardiac output (fatigue) and signs of venous overload like JVD, dyspnea, ascites, Kussmaul, pedal edema tender hepatomegaly. Sharp ‘x’ and ‘y’ descent on central venous tracing is the sign of CP as is Pericardial Knock (early sound after S2).

Contraception
Lactation is a contraceptive methid in itself because prolactin inhibits GnRH thus preventing ovulation. However, it is not a reliable methis. If a woman wants contraception right after giving birth, give her Minipill (Progestin only pills), Don’t give her Combined OCP because Estrogen may cause decrease in milk production.

Conversion disorder - 2
Tx is psychotherapy. Pt looses eye site in stressful situation. *** If pt comes with bilateral leg paresis, give him Sodium Amytal and he will dramatically improves.

COPD - 8
If pt is not crashing, the first line of tx is non-invasive positive pressure ventilation before intubation. All pt with PaO2<55 and SaO2<88 are candidates for long term home oxygen therapy. Pt with pulmonary hypertension and hemoatocrit >55 should be started with home therapy if PaO2 falls <60mmhg. Smoking cessation and home oxygen therapy are two modalities that can reduce mortality in pt.****Acute exacerbation of COPD is tx with combination of inhaled /nebulized bronchodialators and systemic steriod (Methyprednisone).*****In a pt with multifocal atrail tachycardia due to exacerbated CODP Theophyline and Beta Agonist (Albuterol)(remember beta agonists decrease potasium and worsen arrythmia) will WORSEN tachycardia. Give Oxygen to stop the arrythmia.****COPD comprises lung OBSTRUCTIVE diseses, which includes Chronic Bronchitis and Emphysema. The airflow obstruction is irreversible. A chronic smoker with a productive cough and dyspnea on excertion, with decreased FEV1/FVC is suggestive of COPD. Chronic Bronchitis is characterized by chronic cough for at least 3 months for two consequetive years.The presence of chronic productive cough, prominant bronchovascular marking, mild flatening of diaphragm, and normal DLCO is suggestive of CB rather than Emphysema. These are called Blue Bloaters (for Bronchitis) they have heart failure sings and profound oxygen desaturation. Emphysema is destruction of alveolar wall, Pink Puffer (emPhysema) , hyperinflation of the chest, Decreased vascular marings, Decreased DLCO(due to destruction of alveoli) and moderate oxygen saturation. Now remember Sarcoidosis, Silicosis, Asbestosis, Scleroderma and rheumatoid lung are all RESTRICTIVE lung dis characterized by NORMAL Fev1/FVC. ****The most impact on COPD pt is by Oxygen home tx. The guidline is PaO2<55 and O2 saturation <90%.*** chronic pt comes in with severe sypnea and confusion and profuse sweating. Cxr shows complete collpase of L lung, possibly by a mucus plug (atelectasis is the same after surgery). Tx is emergency Bronchopscopt to remove the plug. And that will improve PaO2.*****Non Invasive Positive Pressure Ventillation is the best option for pts with COPD exacerbation. It should be tried before intubation and mechanical ventilation in COPD pts with CO2 retention.

Core Pulmonale
Combination of Elevated JVP, Hepatomegaly,ascites, and lower extremity edema w/o evidence of pulmonary congestion is suggestive of isolated right heart failure. If there are no RALES it means there is no pulmonary congestion. The mcc of Right side heart failure is Pulmonary disease, and its known as Core Pulmonale. CP is most likely caused by COPD(Smoker) , lees common causes are pneumoconiosis, pulmonary fibrosis.

Court order
T9Q38

Craniopharyngioma - 2
Althought mc in children, they are bimodal and could happen in adults too. In children retarded growth is the mc presentation. In adults hyposexuality. Bitemporal blindness is a classic sign. Dx is MRI or CT. Tx is surgery or radiothreapy.****A young boy with symptoms of increased ICP (HA,Vomit) , Bitemporal anopsia and a calcified lesion above sella has Craniopharygioma until proven otherwise. Presense of a Cystic Calcified parasellar lesion on MRI is almost Dx. DDX is Pituitary Adenoma, where its more frequent in women and Prolactinoma is an important part of it, and there is no CALCIFICATION of the gland.

CREST Synd - 2
Anticentromere antibody is Dx.*****Calcinosis, Reynauds, Esophageal dysfunction, Sclerodactyly and Telangiectasia. It has a better prognosis than diffused Scleroderma.

Creutzfeldt-Jacob - 2
Pt is b/w 50-70, with rapidly progresive dementia, myoclonic and periodic synchronous bi or triphasic sharp wave complex on EEG.Brain biopsy shows cortical spongiform changes. CSF is normal, Death w/I 12 months, NO TX. Spongiform encephalopathy is caused by prion.

Crohn's disease - 2
DDX with UC is non-caseating granulomas.

Croup
Also known as Laryngotrachiatis or LaryngoTrachioBronchitis, is characterized by laryngeal inflammation that results in hoarseness, a barking cough and respiratory distress. Typical pt is <3 and the mcc is Parainfluenza virus. Dx is clinical and lateral xray shows subglotial narrowing. Always give Epinephrine before any invasive tx like intubation. This is ONLY for croup not Epigolitis. Tx is 1st O2, 2nd Epi, 3rd intubate in ER.

Cushing's Syndrme - 3
Due to ectopic ACTH.***Pt with lung cancer and ectopic ACTH production can have Cushing's. ****Dx procedure.

Cutaneous Larava Migrans
Is a cc of dermatological disease in tropical travelers. Its caused while "Sand box handling" and its characterized by serpiginous lesion in the skin. Tx is Applying thiabendazole or mebendazole

CVA
Occurs in middle and late years of life. Could be either Ishcemic (85%) or Hemorrhagic (15%). Ischemic CVA orignates from aortic arch, carotid bifurcation, and obstruct arteries. Clinically atherothrombotic stroke occurs at rest and have a gradual onset. Pt experiecne successive strokes. Babinsky indicates UMN due to major cerebral artery obstruction. Ischemic CVA could also be caused by thrombi from left heartIts asso with sudden onset and preexisting cardiac disease. EKG is characteristic. The mc site islaterl astriae arteries (arteries of stroke) which are branches of MCA, they supplt internal capsule,putamen. So if a pt has normal EKG and cardiac enzyme, this kind of stroke is unlikely.

Cyclical vomitting
recurrent self-limiting episodes of vomitting and nausea in children. Tx is antiemetis and reassurance.

Cyclosporine side effects
1-Nephrotoxicity:the mc and serious side effect. It manifest as acute azothemia or irreversible progressive renal disease. 2-Hypertension:due to vasoconstriction and sodium retension. Ca chanel blokers are doc. 3-Neurotoxicity:Often reversible. Tremor, headache, nasea, seizure, visual problems. 4-Glucose intolerance. 5-Infection: 40% of pt get infection chronically. 6-Malignany: Risk of squamous cell carcinoma. 7- Gingival hypertrophy and hirsutism. 8-GI, mild. Tacrolimus has the same se except hirsutism and gum hypertrophy. Azothioprine se is dose related diarrhea, leukopenia,hepatotoxicity. Mycophenolate se is Marrow suppression.

Cyclphosphamide SE
Bladder carcinoma is a SE. Also alopecia, sterlity, amenorrhea, acute hemorrhagic cystitis.

Cystic Fibrosis - 8
Bronchiectasis due to pseudomona and infertility and recurrent respiratory infections. Cxr showing "Tram Track pattern" and opacities is dx for Bronchiectasis. CF is due to abnormal chloride transportation in all exocrine glands. Sweat chloride concentration >60 is DX. Since there is fat malabsorption, fat soluble vitamins are deficient. So vit K is deficient and since vit K is a cofactor for the enzyme gama-glutamil carboxylase which adds carboxyl group to glutamate residue of factor II,VII,IX & X, and protein C & S, those coagulation factors will be also deficient.*****A routine influenza vaccine is indicated in all CF pts, but not Pneumococcus vaccine. There is asso b/w Pseudomona pneumonia and CF, use Gentamycin+Pipercilline. *****Tx of an acute severe exacerbation of lung dis in CF is IV Pen/Cephalo+Gentamycin. *****Aut rececive, we need to know both parents DNA status to determine child's possibility of having CF. *****The mc mutation is a DELETION of a three base pair coding for Phenylalanine (DjO8) in the CFTR gene in CH7.****Pts with CF present with Meconium Ileus characterized by bilious vomiting, failure to pass meconium at birth, and ground glass apperance on abdominla xray.*****Suspect it in a pt with Bronchiectasis(cough productive of sputum for 3 months) and Malabsorption (foulsmelling stool) due to pancreatic insufficeny. One clue if the pt starts to show in his 20s is a hx of Meconium Ilueus (intestinal obstruction) as a neonate. Whenever hay acute exacerbation of pulmonary infection in a pt with CF, think Pseudomona and treat it with Pipercillin + Gentamycin.

Cystinuria:
An inherited disease causing recurrent renal stone formation. Look for positive family history and stones since childhood. Stones are radiopaque and Hexagonal. The urinary cyanide nitropruside test is a screening procedure.

Cystitis - 2
Most commonly caused by Ascending infection. Pt presents with UTI symptoms and suprapubic tenderness.**** In an Uncomplicated Cystitis, where pt presents with suprapubic discomfort and signs of UTI, then there is NO need to do culture. Just give Oral Trimeta-Sulfa. If there is resistance to it then give Cipro or Nitrofurantoin.

Dacryocyctitis
Inflamatory changes in medial canthal region. Staph aureus and Strep are common causes. Acute dacryocystitis is treated by frequent application of hot compresses; cephalexin or cefazolin; and incision and drainage if an abscess has formed. Chronic dacryocystitis may be treated by dilating the nasolacrimal duct

De Quervains Tendonitis
(abductor or extensor tendons of the thumb) is usually diagnosed by localized tenderness, if not mild swelling, along the course of the tendon .Sharp pain is elicited or accentuated when the ipsilateral thumb is flexed across the palm, enclosed by the fingers, and the wrist is deviated ulnarly to stretch the tendons and surrounding sheath (Finkelstein's sign in stenosing tenosynovitis). Symptomatic relief is provided by rest or immobilization (splint or cast) of the tendon, application of heat for chronic inflammation or cold for acute inflammation (whichever benefits the patient should be used),and NSAIDs.Surgery for release of fibro-osseous tunnels.

Dehydration - 2
Mainstay of tx is IV sodium containing crystaloids (0.9% NaCl=Normal Saline)***Elderly pts are sensitive to dehydraion and even mild Hypovolemia can lead to orthostatic syncope, especially upon getting up in the morning. INCREASED BUN/Creatinin is a good indicator of dehydration.

Delirium Tremors
Tx is Chlordiazepoxide.

Delirium vs Dementia
Delirium has:Acutenes, impaired conciousness, fluctuating course, reversible symptoms and global memory impairment. In the absence of any focal neurological signs, even if there is evidence of carotic bruit (Vascular Dementia) Delirium is the most like Dx.

Delusional Grandiosity
Pt thinks she has special powers, extraordinary accomplishments, or specila relationship with God. There are three types of Delusion: 1-Grandiose (religious in nature) 2-Paranoid 3-Somatic.

Dependant personality
When ot is so agreeing and depends on whatever the doctor suggests.

Dermatitis Herpetiformis-3. Dermo. 6/3
Pruritic papules, vesicles over the knee, elbow, buttocks. Immunofloresence shows granular IgA desposits along dermal papillae. Asso w Celiac sprue. Tx is Dapsone. Suspect DH in a pt with Malabeosrtion and pruritic papules and vesicels over the extensor surfaces. Anti-Endomysial anribodies are charcteristic. Pt also suffers from Gluten sensitive enteropathy or Celiac Sprue. Tx:Strict adherence to a gluten-free diet for prolonged periods (eg, 6 to 12 mo) may control the disease in some patients, or Dapsone.

Dermatomyocytis:
Is an autoimmune disorder involving muscles and the skin. Skin eruption is dusty red in color. Edema around the eye and the helitrope rash of the eyelid are more specific. Gottron’s sign is highly suggestive of this disorder in which skin over the back of knuckles show non-scaly violacious erythomatous eruption.

DES toxicity
If given to pregnant women causesClear cell ADENOCARCINOMA of vagina in their duaghters. In the old days it was the best tx for threatened abortion. With erly dx and tx survival is 80%.

Development Dysplasia of Hip
DDH is characterized by subluxatable and dislocatable proximal femur and acetabulum. Early dx and tx is important because failure will result in sigificant morbidity. On inspection uneven gloteal fold are seen. Its mc in femlae cockasian females. Dx is confirmed by USG in infants <6mo. Positive Barlow and ortolani are highly suggestive. Tx is surgical reduction.

Developmental Milstones
1-LANGUAGE:Social smile=2mo, Bables=6mo, 2words and obey one step command=12mo, 2-3Phrase& 2 step command=2yr. 2-GROSS MOTOR: Hold head=3mo, Rolls back to front=4mo, sits unsuported=6mo, walks alone=12mo, walks staris=2y. 3-FINE MOTOR: Raking Grasp=6mo, Throw objest=12mo, Build tower of 2 block=15mo, build 6 blocks=2yr. 4-SOCIAL: Recognize parents=2mo. Recognize strangers=6mo, Imitates/comes when called=12mo, play with other kids=18mo, Pararel play=2yr.

Dextrometorphan- Poisenining 6/3
A cough medicine. has drung toxicity with MAO inhibiors, causes hyperthermia

Diagnostic Peritoneal Lavage
Is the best dx procedure for intraperitoneal organ laceration. Like a guy being hit in the stomach. Angiography is never done.

Diabetes Incipidus - 3
Presents with polyuria and polydypsia, due to ADH def or resistance. Pt prefer cold beverages and their urine osmolarity is < serum osmolarity. Pts pass excessive amounts of diluted urine. Normal saline is the initial fluid of choice in hypotensive pt and later on Hypotonic fluids. DDX1:Primary hyperaldosteronism (aldosterone=saves sodium and loses K), Hypernatremia is rarely symptomatic, other features are hypertension & hypoKalemia. DDX2:Osmotic Diuresis(increase renal excretion of water relative to sodium), occurs in cases of hyperglycemia and manitol intake. Urine osmolarity is > serum osm. DDX3:SIADH, results in hyponatremia, low serum osmolarity and inapropriately high urine osmolarity. sually seen in pt with lung cancer and abnormal brain pathology like trauma or stroke. DDX4:Primary polydypsia, is a disorder where pt drinks fluid in excess of 5L/day and both plasma and urine osmolarity are low (diluted).****Administration of DDAVP (desmopressin) ddx b/w CDI and NDI. Pt with CDI will have increase of urine osmolarity following admin of AVP (arginin Vaso Pressin, or DDAVP), but NDI pt wont have that increase. Tx for CDI is intranasal Desmopresin.

Diabetis Melitus - 34
1-Normal anion gap metabolic acidosis in a diabetic pt with Gastroenteritis could be either due to loss of bicarbonate due to diarrhea, or defective NH4 sunthesis due to nephropathy. So next we need to calculate urine anion gap. [Urinary (Na+K) - Urinary Cl]. If its positive value problem is Nephropahy, if its a negative value its due to Gastroenteritis. 2-Diabetic Osteomyelitis (due to arterial insufficiency) that involves bone adjasent to the foot ulcers is explained by contigous spread of infection. 3-Acanthosis nigrans is a complication of DM. Although its associated with both DM and Addison's disease insulin resistance is the mcc in young population, and its asso with malignany in older individuals. 4-Somogi effect. 5-Diabetic neuropathy tx is Gabapentin and TCA (imipramine). 6-Diabetic Cystpathy tx is Bethanechol. 7-Diabetic retinopathy. 8-Infection in diabetes. 9- Diabetic Nephropathy, detection of microalbunemia is the best detection. Fasting blodd glucose is now test of choice for screening high risk individual for DM. When fasting G is 126 or greater, repeat it, and if its still elevated the Dx is made. Dx could also be made if pt is SYMPTOMATIC and G after 75gr tolerance test its 200 or greater. Ketones responsible for DKA are Acetone, acetoacetate and beta hydroxy butyrate. Diabetic Neuropathy leads to denervation of bladder resulting in urinary retention, Overflow incontinence day and night, aside from strict glucose control tx includes intermittent cathaterizarion and Bethanechol, avoiding alcohol maybe helpful. **** Antibiotics dont cure ulcers, do a debriment of the wound. ****Glomerular Hyperfiltration is the earliest renal abnormality seen, as early as several days w/i dx of DM. Its the major pathophysiologic mechanism of glomerular injury in these pts. Thickening of the glomerular basement membrane is the first change that can be quantified. Effectiveness of ACE inhibitors is related to their ability to reduce intraglomerular hypertension and decrease glomerular damage. **** In pt with Diabetic Nephropathy add ACE inhiitor even if BP is under control, it slows progression of nephropathy and keeps glomerualar bp reduced. ****Glycosylated Hemoglobin (HbA 1-c) is the best way to monitor DM control. HbA1c is fomred by non-enzymatic glycation of Hb. Its reflective of the average glucose blood levels w/i the precedding 2-3 months, which corresponds tothe life of RBC. Every 1% increase in HbA1c correspodes to 35mg increase in glucose. Remember measurement of C-peptide is done to determine if the insulin use is internal or external. DIABETIC KETOACIDOSIS:Anion Gap Metabolic Acidosis observed during DK is accompanied by HyperKalemia, its called paradoxial because body K reserves are actually depleted. Hay hyperKalemia for 2 reasons: 1-extracellular shift of K in exchange for H with resultant intracellular K depletion. 2-Impaired insulin-dependant K entry. So in Tx for DKA, after insulin and diuresis administer K. ****Suspect it if pt presents with rapid breathing, hx of weight loss, polydipsia nd polyuria.END OF KA. ****Fasting bloog glucose measurement is now the screening of choice. A FBG of 126 or more on two occasiona is Dx. FBG b/w 100-125 is categorized as impaired FBG or pre-DM. If pt has symptoms, poluuria, polydyspsia, and obesity FBG of >200 may confirm the dx but its not appropriate for screening. The 50gr glocose tolerance test is used for screening gestational DM, while 100gr is used to confirm it.***DM Neuropathy seen in 50% of pts. Pt manifest with poplyneuopathy,mononeuropathy or Autonomic Neuropathy. AN is related to the duration of disease and glycemic control. Any part of GIT can be affected. Involvement of small intestine causes diarrhea, and Colon causes constipation, and stomach causes gastroparesis which presents as nausea, vomit, bloating, anorexia, and early satiety. Due to delayes gastric emptying, glucose control is difficult to achieve. Pt have post meal hypoglycemia after insulin injection. Nuclear Medicine Scintigraphy after ingestion of radio-labeled food is the best method to document Delayed gastric Emptying. Management includes:1-improved glycemic control, 2-small,frequent meals, 3-Dopamine agonist(Metachlopromide,domperidone) before meals, 4-Bthanechol, 5-Erythromycin (reaction with Motilin promotes emptying), 6-Cisapride. *****The most beneficial therapy to reduce progrssion of DN in presence of renal insufficiency is to control HT. *****Nonketotic Hyperosmolar synd occurs in DM2 pt because level of insulin in these pt is enough to prevent ketoacidosis but not hyperglycemia. Hyperglycemia occurs, with hyperglycosurea and dehydration. They will present with semicomatose state. So first thing you do is to check blood glucose.*****Diabetes screening in pregnant women is performed b/2 24-28 weeks of gestation. If urine dipstick reveals glycosuria then the next step is Fasting Urine samples if its positive then do a 1hr-50g oral glucose tolerant test. If its <140, DM is rules out. If its >140, 3hr-100gr OGTT is used for confimation.****Diabetic Neuropathy can present with ulcer in the foot. Risk factors for development of diabetic foot ulcer are: Diabetic Neuropathy, peripheral vascular dis, poor glycemic control, bony abnormalities of the foot, male sex, smoking, chronic DM (>10ys), and a hx of previous ulcer or amputation. Neuropathy is found in 80% of diabetics with foot ulcer.****Symetrical distal sensorimotor polyneuropathy is the mc type of diabetic neuropathy. Characterized by "stocking glove" pattern or sensory loss. ****DM is a risk factor for Non alcoholic fatty stetosis.*****Hyperglycemic, hyperosmolar, non-ketioc coma is characterized by very high blood glucose, plasma hyperosmolarity, normal aion gap and negative serum ketones. DDXKA is sugested by 1-blood glucose >250, 2-pH<7.3, 3-Bicarbonate<15-20,4-Plasma ketones.DDX2:Alcoholic Ketoacidosis is ketoacidosis with increased anion gap BUT near normal glucose levels. ****Always consider candida albicans as a casue of infection in a pt with uncontrolled DM.****Diabetic mothers babies are often born with clavicle fracture that heals spontaneouly w/o any tx.***The Dx procedure of choice for Diabetic Polyneuropathy is Electromyography and conduction studies. ****Poorly controled pt with low grade fever,bloody nasal discharge,nasal congestion,involvement of the eye and chemosis ,proptosis and diplopia is more likely suffering from Mucor Mycosis and maxillary sinus due to Rhizopus. Involved turbinates usually become necrotic. DDX is Pseudomona which causes Malignant Otitis Externa, it my also cause black necrotic lesions. DDX also H.inf and Moraxella are the mcc of bacteria sinusitis, they dont cause NECROTIC infections*****Non-ketoic Hyperosmolar coma presents with gllucose 1000, and normal pH. Tx is normal saline initially and then replaces with 0.45% saline. Once glucose is down to 250, then we give 5% dextrose that prevents cerebral edema. **** Diabetic Cystopathy usually secondary to diabetic autonomic neuropathy. It begins with inability to sense s full bladder & failure to void completely. With time bladder size increase leading to signs of BPH & recurrent UTI. Dx is made with Cystometry and Urodynamic studies. Initial mgmnt is strict voluntary urinary scheduling couplded with Bethanechol. If there is no response intermittent catheterization is recommended. ****Emphysematous Pyelonephritis: is a life threatening condition caused by E. Coli. Dx is confirmed by CT. TX is IV antibiotics and possible Emergency Nephrectomy.

Diamond Blackfan Anemia:
Also called “congenital hypoplastic anemia”. Suspect it in a child with macrocytic anemia, low reticulocyte count and congenital anomalies. Primary path is an intrinsic defect of erythroid progenitor cells which results in increased apaptosis. Over 90% are dx w/I the first year of life. Macrocytic anemia is distinct from megaloblastic anemia because hay no hypersegmentation of the nucleus in neutrophils. Pt presents with anemia, short stature, webbed neck, shielded chest, triphalangial thumbs. Tx is mainly corticosteriods, if unresponsive then transfusion therapy.

Diaphragmatic Herniation
Occurs in accidents and Cxr sign of elevated left diaphragm could be the only sign.*****One dx often missed in er is traumatic rupture of the diaphragm. Usually on the left side. Pt comes back months later with breathing difficulty. Cxr shows deviated mediastinum with a mass in the left lower chest. Barium Swallow is dx. In acute cases surgery is done via abdomen and in chronic cases via chest.

Diarhhea - 6
Campylobacer Jejuni is the mcc of bloody diarrhea in US. Its from undercoocked pultery****Vibria Parahemolyticus:by ingestion of sea food. Bloody diarrhea,abdomnal cramps,nasea and feve. Incubation 12-24hrs. Shigela diarrhea occurs in day care and institutional settings. Yersinia diarrhea is by eating undercooked pork. Campylobacter is the mcc of diarrhea in US due to uncooked infected poultry. could be watery or hemorrhagic. ***Staph causes toxin induced gastroenteritis mostly emetic type that starts w/i 6 hours.Salad,meat and egg.***Travelers diarrhea, due to E Coli, is the cause of diarrhea w/i blood,mucus,explosive,rice watery diarrhea even in Mexico travelers. DDX Giardia is endemic in Nepal. ***MCC of diarrhea in children is Roto virus that causes acute gastroenteritis.Most causes are self limiting but maintain hydration Ther is now a vacine for it but it was withdrawn due to risk of Intussusseption*****Types of diarrhea are: 1-Inflamatory, where ESR is elevated and there is anemia and blood positive stool. 2-Osmotic, caused by meds or hormonal disturbance. 3-Motor, exemplified by Hyperthyroidism. 4-Factitial, is psychologic.

DIC:
Tx is FFP if pt is bleeding only. If pt is not bleeding and has sepsis (high T and low BP) first step is IV antibiotics plus Activated Protein C.

Diffuse Esophageal Spasm - 2
Manifest with chest pain and dysphagia. Etiology in unknown but its related to emotional stress. Unlike Achalasia LES has a normal relaxation response. Esophagogram might show Corkscrew. Tx is with antispasmic drugs, dietry modulation and psychiatric counselling. for USMLE know 1-pathophys, 2-present or absence of perstalsis, 3-LES tone. MERCK:A generalized neurogenic disorder of esophageal motility in which phasic nonpropulsive contractions replace normal peristalsis and, in some cases, lower esophageal sphincter malfunctions occur. Esophageal manometry shows: contractions are usually simultaneous, prolonged or multiphasic, and possibly of very high amplitude.*****Esophagography may not show the corkscrew, so do Manumetry, if revealed "repetitive,nonpeistoltis,high amplitude contraction either spontaneoud or after Ergonovin stimulation then its Dx.

Di-George synd:
Infants have cyanotic heart dis, cranofacial anomalies, thymic dysplasia, cognitive impairment and hypoparathyroidism. Asso with Ch 22/11 deletion. In Surgery keep an eye on Ca levels.

Digitalis Toxicity - 2
Some of the toxicities occur in therapeutic range (AV block, ST depression, T inversion) and there is no need to discountinue the drug. Some occur in Toxic serum levels (Atrial Tachycardia and AV heart block) and we need to discountinue the drug. Digoxin also causes Nasea and Anorexia.

Diphenhydramine Toxicity
Prduces seizure as well as anti-cholinergic effects.

Dipyridamole
used during myocardial perfusion scaning to reveal areas of restricted myocardial perfussion. It shows "Coronary steal phenom"

Disk Herniation
Once you know its DH and straight leg is positive, then NSAID and early mobilization s the tx of choice.

Displacement - 2
An immature defense mechanism, in which individual displaces negative feelings asso with unacceptable situation onto a safer one.

Disseminated GonoCoc infx
Persents in menturating women with tampon, many partners, occasional condom, presents with high fever, rash, tenosynovitis and migratory arthralgia. DDX with TSS which presents with Fever, macular erythema of palms and soles,, vomit and diarrhea nad hypotension.

Dissociative Fugue
Pt get lost in another city.

Diverticulitis - 2
the dx test to evaluate the abdomen during an acute episode of diverticulitis is a CT scan. Colonoscopy and Sigmoidoscopy can cause perforation.*****Acute diverticulitis complication may be bowel perforation where xray shows air under diaphragm and rigidity and guarding. Next step is Laparotomy with surgical resection of perforated bowel and proximal colostomy.

Diverticulosis
Pseudodiverticulum can erod a penetratinf atrery. This leads to perfuse arterial bleeding of bright red blood. Diverticulosis is the mcc of bleeding in elderly pt. Chronic constipation is the single most predisposing factor to develop Diverticulosis. Normal xray does not rule out diverticulosis if its negative. You need xray with contrast ( Barium ) to be able ro see it. DDX1: Colon Cancer, presetns with chronic,occult bleeding NOT BRIGHT RED. DDX2:Ischemic Colitis, Asso with Abdominla pain, feverand vomit and atherosclerosis, xray shows thickening of colon wall. DDX3:Mesenteric Thrombosis, Pain out of proportion is a classical symptom, Bloddy diarrhea rather than bright red blood is charcteristic, Bowel sounds are diminished.

Down Synd in Pregnancy
T14Q12 explains how to test for DS in older women. Decreased MSAFP and Estriol and Increased B-HCG is the best test. SEE FIRASR AID.. Know heart defect, and also that they have Duedenal atresia. Learn this.***** Hay ASD and endocardial cushin defects. *****Duodenal Atresia is the mc anomaly asso with Down, in xray you see a double bubble sign. Other anomalies are Hirshsprung, Esophageal atresia, Pyloric stenosis, malrotation. Congenital heart disease is the mcc of death in childhood, like endocardial cushin defect, VSD, PDA.

Dressler Syndrome:
It’s a post MI Pericarditis. Non specific ST elevation. NSAID is tx of choice.

Drug induced Pancreatitis
1-Diuretics, furesamide and thiazide. 2-IBD, Sulphasalazine and 5-ASA. 3-Immunosupresants, azathioprine. 4-Seizures, Valprioc acid. 5-AIDS, Didanosine, Pentamidine. 6-Antibiotics, Metronidaole, tetracycline. CT is dx with inflamed pancrease. Tx supportive.

Drug induces Interest Nephritis - 2
Caused by Cephalosporins, Penicillins, Sulfa drugs, NSAID, Rifampin, Phenytoin and Allopurinole. Pt presents with Acute renal failure+Arthralgia+rash.*** 70% of cases are induced by drugs, discountinue the drug and it will be OK. Pt present with fever, and urine analysis shows RBC, WBC and white cell casts, eosinophelia and proteinuria.

Drugs CI
1-Beta blockers: peripheral vascular dis (pt presents with worsening intermittant claudication), asthma, copd, Raynaus. 2-ACE inhibitors: Hyperkalemia, pregnancy. 3-Calcium channel blockers:Second&thrid degree heart block and CHF.

Dubin-Johnson
A familial disorder of hepatic bile secretion. Leads to conjugated Hyperbilirubinemia. May be aggrevated by women taking OCP. Liver biopsy reveals cells with DARK granular pigments. DDX1:Rotor, like DJ but no DARK granule pigments.

Duchenes MD
Muscle biopsy will reveal dx.

Dumping Synd
Is a common post-gasterectomy complication. Pt with recent Gasterectomy presents with postprandial abdominal cramps, lightheadedness, diaphoresis. First thing to do is to Modify diet, small frequent meals and avoid simple CHO. Dx is made clinically but occasionaly Contrast xray (barium swallow) is used.

Duedenal Atresia:
Bilous vomiyying few hous after the FIRST eating, usually asso with congenital anomalites and Down’s Synd.

Duodenal Hematoma, isolated
If pt is hemodynamically stable, she needs nasogastric succion and parenteral nutrition (food ) not IV fluid.

Duedenal Injury:
Isolated duodenal injury is easily missed. They occurin accidents due to the belt or steering wheel. Present with epigastric or RUQ pain. Retroperitoneal air or obliteration of right psoas margin on xray is very suggestive. Best dx with CT scan of the abdomen with oral contrast or an upper GI study with gastrograffin, followed by barium if necessary.

DVT - 3
OCP is a well known risk factor for DVT. TX steps:Anticoag therapy has serious Ses so accurate dx must be made before anticoag is started. Test of choice for DVT is Compression US. Impedence Plethysmography is for recurrent DVT. Venography is the Gold standard for dx of DVT, but it causes discomfort so its not the initial test for suspected DVT. Its only done when other tests are impossible or inclusive.***Surgical pts can be categorized according to their risk of DVT. 1-Low risk, Minor surgery in a pt <40 with no additional risk factors. w/o prophylaxis risk for DVT is <2%. 2-Moderate risk, Pt>40, one or more addiiotnal risk, minor/non-minor surgery, risk is 2-10%. 3-Hihg risk, pt is >40, additional risk factors, major operation, risk of DVT is 10-20%. In Low risk pt, prophylaxis other than early mobilization is not recommended. In Moderate risk pt, LMWHeparin or Unfractionted Heparin is recommended. Pts in whom bleeding risk are unacceptable (intracranial.spinal cord injury) should receive intermittant pneumatic compression. In High risk pt, undergoing general surgery can be given LMWH, those pts going under Orthopedic surgery of lower extremity (knee replacemnt) LMWH or Oral Warfarin.***INR (International Normalized ratio) is used to monitor tx response to Warfarin. Therapeutic Range of INR for most pts is 2-3, which is for venous thromboembolism, valvular heart dis. 3-4.5 is for Proshtetic valves.*****The besr DVT prophylaxis for high risk surgery ptgoing under orthopedic surgery includes either warfarin or LMWH.

Dysfuncx Uterine Bleeding- 2
Heavy unremiting endometrial hemorhage throught menarche and perimenopause requires Estrogen (conjugated) to supress the bleeding to ensure CV stability. Once that is achieved D&C should be performed. The MCC of DUB in adulescent is anovulation. Therefore endometrial biopsy is not required in these pts. Once bleeding is stopped , advise pt to take the following: conjugated estrogen for 25 days , then add methoxyprogestrone for the last 10-15 days and then allow 5-7 days for withdrawl bleeding to mimic menstural cycle.****In which pts with CUB do you perform endometrail biopsy to rule out endometrial carcinoma? When a pt is >35, obese, DM or has chronic HT.

Dysthymia
Depressed mode for more than twoyears.

Dystonia
from antipsychotics, tx is Benztopine or Diphenhydramine.

Eaten Lambert
Is asso with small cell carcinoma. And antibodies against the voltage gated calcium channels in presynaptic motor nerve terminal. It is presynaptic, resulting from impaired release of acetylcholine from nerve terminals.The diagnosis is confirmed by finding an incremental response to repetitive nerve stimulation: Amplitude of the compound muscle action potential increases > 200% at rates > 10 Hz. Treatment is first directed at the underlying malignancy and sometimes induces remission. Guanidine facilitates acetylcholine release.

Eating disorder not otherwise sp
If the senario shares features of both bulemia and anorexia, its this disorder.

Echinococcus
Due to close cntct with SHEEP. Pt presents with hepatomegally, forms hydatid cyst in liver after US. Hydatid cyst has an inner germinal layer and an outer acellular laminated membrane. DDX is Neurocysticercosis, due to PIG farming. With cysts in Brain, kills fast.

Eczema Herpeticum
T9Q23. A form of Herpes simplex that is asso with atopic dermatitis. Numeric umbilicated vesicles around The healing area is typical. In infants tis could be life threating, start acyclovir asap.

Edward synd - 2
Microcephaly, prominent occiput, micrognathia, closed fists, index finger overlaping 3-4-5 bilaterllay, rocker bottom feet. 95% die by first year.*** Pts have hear mumur due to VSD. This is trisomy-18 (E-lection age)

EKG abnormalities
1-T wave inversion, in ischemia of myocardium. 2-ST depression, subendocardial infarcts and unstable angina. 3-Ptoonged PR, first degree heart block. 4-Delta waves, WPW. 5-New RBBB, seen in PE. 6-Electrical Alterns, seen in pericardial Temponade.

Embolus, limb
If pt presents with cold hand due to embolus, immediate antocoag with heparin and surgcal intervention is indicated.

Emphysema
In a non smoker should raise the suspicion to Alpha-1 anti trypsin def. Its also asso with Neonatal Jaundice in the hx of the pt. Dx is made by estimating alpha-1 trypsin levels.

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. Dx is confirmed with abdominal xray showing air-fluid level in the gall bladder or US showing gas line. Lab shows moderate unconjugated hyperbillirubinemia or small elevation of aminotransferases. Tx includes early fluid resuscitation, early cholecystectomy, and parenteral antibiotic therapy effective aginast gram positive Anaerobic Clostridium sp. (Ampicillin- Sulbactam, or combination of aminoglycoside or quinolone with clindamycin or metronidazole.

Empyema
Can occur from parapneumonic effusions(In parapneumonic effusions, the visceral pleura overlying a pneumonia becomes inflamed; often, an outpouring of serous exudative fluid accompanies acute pleurisy. The fluid contains many neutrophils and may contain bacteria. Parapneumonic effusions are usually caused by bacteria. If the body's defenses do not control infection in a patient with pneumonia and parapneumonic effusion, the number of neutrophils and bacteria increases, and the fluid takes on the gross appearance of pus. The result is empyema of the thorax (purulent exudate in the pleural space). Fluids with > 100,000 neutrophils/µL, bacteria seen on Gram stain, and pH < 7.2 may be presumed to be empyema). Pt presents with low gade fever, dyspnea and chest pain. Dx with CT. When its localized, complex and has a thick rim best tx is surgery to remove the clotted blood.

Endometria hyperplasia
A28. Printed out

Endometriosis - 4
Pt presnts with painful periods. Bimanual exam shown a few firm nodularities in pouch of douglas.The first line of tx is OCP. They cause a state of pseudopregnancy and causing an "exhaustion atrohpy" of the endometriomas. If OCP fails or not tolerated then we give Danazole, its an androgen deivative that causes Pseudomenopause state. SE are acne,hirsutism deep voice.GnRh agonists have an inhibitory action of LH & FSHwhen given continuslywhich produces temporary castration. Its also a 2nd line of choice. ****Typically pt prestns with Dysmenorrhea, Dysparunea(when endometriomas is in cule-de-sac), Dyschezia(Pain on defecation), hematochezia, hematuira, and pre post menstrual spotting. Laparoscopy is GOLD standard which shows powder burns. The hemorrhage of endometriomas into the ovaries results in formation of cystic cavity filled with blood with dark color, hence the name 'Chocolate cyst'. ****The '3Ds' are Dyspareunia, Dysmenorrhea and Dyschezia (defecation pain). Tx is OCP. DDX1:Vaginismus, use Vaginal dialators. DDX2:Pain disorder, pain in one or more anatomical sitetxis pain managment training. DDX3:Somatization disorder, tx is follow up visitsregularly scheduled. *****Endometriosis is the location of tissue outside uterine cavity so hysterosalpingogram cant see it.

Endometritis:
It usually occurs on 2nd-3rd day postpartum. Predisposing risk factors are prolonged labor, prolonged and premature rupture of the membrane, manual removal of placenta, and repeated pelvic exam. Clinically it presents with fever, uterine tenderness and foul smelling luchia. Antibiotic start asap to conver both aerobic and anaerobic. Clindamycin with aminoglycoside or ampicillin. MC pathogen is anaerobics.

End stage lung dis:
PFT is the best test to to determine if the pt can benefit from lung resection surgery. Predicted postoperative FEV1 is very useful for this. Blood tests don’t reveal any good info in this regard, they’re more useful in determining the level of respiratory compromise and appropriate ventilator settings for pts undergoing lung resection surgery. Results of split function quantitative lung scans and exercise testing are useful in pts in whom the potential benefit is doubtful even after determining the results of the predicted postoperative FEV1.

Enterobius Vermicularis
Or Pin worm is the MC helminthic infection in US. Most commonly seeb in school children 5-10. Larva goes to perineal area to lay eggs, which gives characteristic Nocturnal perianal pruritis. Dx is made by "Scotch tape test". Albendazole or Mebendazol is the first line of tx. Pyrantel Palmate is an alternative.

Enuresis - 2
Tx is low doses of Imipraimne or desmopressin.***It should go away begore school age. The first step is reassurance. Then wet alarms and walking the child to bath room is tried. If persiss, then Desmopressin (ADH) is first line, Imipramine is the 2ns line tx. ****Its important to rule out treatable causes like UTI. The initial evaluation is urine analysis.

Epididymitis, Acute

Epidemiology:
Mean is average, Mode is the number repeated mostly, Median is the number in the middle given by vigniette, don’t put them in order treat it as is. Reliable test is one that gives similar results repeatedly. Accurate is when the results are on the target.**** Sensitivity curve movements and its effect on PPV.

Epiglotitis - 3
MC by H. inf and 2nd mc by Strep. Tx is antibiotics, antipyretic, racemic epinephrine, steriods and immediate intubation. Dx is by Fiberoptic Laryngoscopy in the operating room, once its made then nasotracheal intubation secures the airway. If intubation is CI then Emergency Tracheostomy is performd.. *****you dont need epinephine before intubation, intubation is the first thing to do here.

Erectile Dysfunction
Types are 1-Neurogenic:A pelvic fracture with an urethral injury is usually accompanied with ED. The cause is nerve injury and altered blood supply. 2-Venogenic:After penile fracture and disruption of tunica albuginea. 3-Endocrinologic:Prolactinoma. 4-SystemicM can cause Ed through many systems (neuro, vascular). 5-Situational:Psychogenic, where night and morning eection is preserved.****If pt is taking Nitrate drugs, Sildenafil is CI so the next step is Penile prosthesis devices or Vaccum devices.

Erysipelas
Is a specific type of cellulitis in which there is superficial inflamation of epidermis producing prominent swelling. The characteristic finding is a sharply demarcaded , erythomatous, edematous tender skin lesion with raised borders. Onset is abrupt with systemic signs. Group A strep is the mcc. Penicillin V or erythromycin 500 mg po qid should be given for >= 2 wk. See pic on desktop.

Erythema Multiform. Dermo. 6/3
Onset is usually sudden, with erythematous macules, papules, wheals, vesicles, and sometimes bullae appearing mainly on the distal portion of the extremities (palms, soles) and on the face. The skin lesions (target or iris lesions) are symmetric in distribution and often annular. Stevens-Johnson syndrome is a severe form. EM Usually folows infection with Herpes Simplex. Erythema multiforme associated with mycoplasmal pneumonia should be treated with tetracycline. If frequent or severe erythema multiforme is preceded by herpes simplex, acyclovir

Erythema Nodosum
Pink to redish painful subcuataneous nodules that usually develop in pretibial region. Most often in woman 15-40. Lesion resolve w/o scaring w/I 2-6 weeks. Histologically there is paniculitis involving inflamation of septa in the subcutaneous fat tissue. There are other conditions that could cause EN, like TB and Sarcoidosis. So the initial work up is include Antistreptolysin O (ASO) titer, a TB test and chest CXr. Its also asso with IBD. Sarcoidosis pt often presents with EN as an initial symptom, cxr will show bilateral hilar adenopathy. An inflammatory disease of the deep dermis and subcutaneous fat (panniculitis) characterized by tender red nodules, predominantly in the pretibial region but occasionally involving the arms or other areas. Bed rest helps to relieve painful nodules. If an underlying streptococcal infection is suspected, antibiotic therapy is beneficial (eg, penicillin for >= 1 yr).

Erythema Toxicum
Is a benign self imited condition in newbors characterized by rash with red haloes, and eosinophils in sin lesions. Neonate presents with No fever, no infectious risk factoe, looks healthy, with erythematous papules and vesicles surrounded by pathes of erythema.

Esophageal Atresia:
It’s the mc esophageal anomaly w esophagotracheal fistula. It leads to gastric distention. It results in drooling and regurgitation due to incomplete esophagus. In addition food gets into trachea and lungs and cuses aspiration pneumonia. Inability to pass tube is suggestive.

Esophageal cancer - 2
It mimics Achalasia. Short hx , rapid weight loss, and inability to pass esophaguscope isindicative of cancer. The next step is biopsy. Ofcourse BS followed by endoscopy should be done first.

Esophageal Varices, Acute - 2
Variceal bleeding is a life threatning emergency. FIRST step is fluid replacement with two large bore IV needles followed by fluid resucitation. SECOND step is control of bleeding medically with vasoconstrictors (Octreotide, somatostatin) THIRd step is Endoscopic Sclerotherapy or Band Ligation (which is better due to less SE). If endoscopic therapy is not available then Baloon temponade with S-B tube is done. If all this fails then surgery is indicated (TIPS). ****In case of EV, need for 5 or more units os blood transfusion in a period of 24 hours is considered an indication for surgery and Transjugular Intrahepatic Portosystemic Shunt. Remember both ligation andmeso-caval shunt have high mortality rate in ER setting, TIPS has less mortality rate.*****Varices are submucosal veins dilated due to portal HT.

Estrogen Replacement Therapy:
Affects metabolism of thyroid hormones. The requirement for L-Thyroxine increases, although the exact mechanism not known it could be due to induction of liver enzymes, increased level of TBG. In pregnancy also thyroid hormon requirement will be increased and the pt should be monitored for dose adjustment.


Essential Tremors - 3
DOC is Beta blockers.***Another drug is Primidone, Its SE is Acute Intermittent Porphyria (Abdominal pain, neurologic and psychologic abnormalities, it can be dx by urine prophobillinogen. ****Propranalol is the DOC for pts with benign essential tremors + HT.****Its famililal, its worse with action and resolved at rest. Rule out Thyroid problem before starting therapy.

Ethyline alcohol poisening
Presents with anion gap metabolic acidosis with Rectangular envlope shaped crystals (calcium oxalat).

Eustachian tube dysfunction
Is a common cause of conducting hearing loss in children. Aurul fulness, pop when swallow, hearing loss, intermittant ear pain. Usually following URT infection or allergic rhinitis. Retraction and decreased mobility of tympanic membrane. Hallmark is a middle ear effusion. "Acute Otitis media": Otalgia, hearing loss, fever and dysequilibrium, bulging membrane. "Serous otitis media": Due to prolonged blockage of auditory tube, common in children, membrane is hypomobile and dull, air bubbles in the middle ear. "Otitis externa": Purulent dischatge, common in swimmers, pain with tenderness is the hallmark. "Foreign body in children": Foul-smelling discharge and signs of infection.

Ewing sarcoma
Highly malignant tumor of lower exremities in children. With early metastasis. Presentation is pain and swelling for weeks. Oftern confused with Osteomyelitis due to intermittent fever, leukocytosis, anemia, elevated ESR. CXr shows "ONION SKINING" peroosteal retraction. Lesion is Lytic and central. Onion skin is followedby 'moth eaten' appearance. Tx includes surgery , radiation, and multiple drug chemo. DDX is Osteomyelitis:Pt presnts with feve, malaise, local pain in joints and swelling. Xray in chronic osteomyelitis shows Lytic bone defect with surounding sclerosis termed as "Brodie's Abscess".

ExtraPyramidal Synd (EPS)
Is seen as SE of antipsychotics (Risperidone). 1-Tardive dyskinesia, lip smacking, tongue protrusions, chewing,biting. It occurs b/w 4mo-4ys. Tx is discontinue Risperidone and give Clozapine. 2-Akathesia is the feeling of restlessness, beta blocker gives some releif. 3-Dystonia, occurs b/w 4h-4d, there is muscle spasm, stiffness, twisting, opisthotonus. Antihistamine (diphenhydramine) or Anticholinergic (Benztropine) releif.

Factitious diarrhea
Laxative abuse, profuse diarrhea. 10-20 times a day. DDX with IBS diarrhea is that IBS does not happen nocturnaly but factitious does. FD is usually done by women of high socioeconomic status and Nurses. There is also characteristic dark brown discoloration of the colon with lymph folicles shining through as pale patches that confirms the dx.

False Labor
Characterized by painless and irregular contractions for 5hrs or more. In the last month these contractino may become rhythmic occuring every 10-20 minutes mimicking contraction of real labor. The main characteristic is however they are not accompanied with progressive cervical changes, so cervix is closed shut. All the pt needs is reassurance.

Familial Colonic Polyposis
Pt hace 100% risk of colon caner, so when they are dx (colonoscopy reveals 100s polyps), then then next step is elective proctocolectomy.

Fanconi’s Anemia:
An auto recessive dis, progressive pancytopenia and macrocytosis. Deformities include, café au lait spots, microcephaly, micropthalmia, short staure, horseshoe kidneys and ABSENT thumb. Dx agerage age is 8 YO

Fantacy Defense Mechanism
An immature defense mechanism, that does not exist in the real world, like an angel telling you things are gonna be OK.

Fat embolism
Dyspnea, confusion and petechia in the upper part of the body, After multiple fractures of long bones. Tx should include prompt respiratory support. Use of heparin, steriods is controversial.

Fat Necrosis
Biopsy shows foamy macrophages and fat globules. Coarse calcification is indicative of benign, and microcalcification indication of malignant tumors. FN is asso with hx of surgery or trauma and it mimics breast cancer.Exisional biopsy is dx and no tx is needed and standard follow up and mamogram is sufficient.

Febrile Neuropenia - 2
A neutropenic pt with sustained fever of >100.4 for one hour. Its an emergency, admit to hospital and obtain blood cultures and IV Cefepime, or Ceftazidime, or Imipenem. Vancomycin is added IF pt is hypotensive, evidence of skin or line infection, Hx of resistant to S. Aureus or pneumococcus, or recent prophylaxis with flouroquinolones.

Femor Shaft fractures
Most can be managed with closed intra medulary fixation of the shaft. This allows for early mobilization improved hip and knee function and less hospital cost. I this technique, closed reduction of fracture segment is followed by inrta medullary nail insertion through small skin insertion over the greater trochaner.Closed nailing is preferedover OPEN nailing due to reduce risk of infection. Internal fixation with plates and screws are used in NECK fractures of femur.*****Interochanteric fracture of the femur is mostly an extracapsular fracture in elderly. Occurs along the line b/w greater and lesser trochanter, Extremity is shortended and internally or externally rotated. Dx is xray. Operative tx is indicared asa pt is stabilized. Do internal fixation with sliding screw with plate and early mobilization.

Femoral Neck Fractures
They are seen in Elderly. The limb is shortended and rotated and painful with limited motion. Unstable fractures (complete neck fractures), need Open reductionb and internal fxation or Primary Athroplasty(surgical reconstruction of the joint) as soon as pt is stabalized. If surgery is CI the pt should be mobilized asap and eventual malunion can be dealt with later.

Fetal Alcohol Synd - 2
Irritability, mild to moderate mental retardation, hpoplastic maxilla, lng philtrum, thin upper lip border and microcephaly, and epicanthal folds.

Fetal Demise – 6/24/06
if pt comes to you due to not feeling any mvemnt and you cant hear any beats with Doppler, then the first thing to do is to do a Real Time Sonogram.. It’s the most appropriate test to confirm fetal demise. BhCG might be lower but it doesn’t make it a dx tool.

Fetal Distress (Repetative Late Decelerations
Is an indication for C-section. Remember Tocolysis means not delivering.

Fetal Hydantoin Synd. - 2
Caused by using Phenytoin in pregnancy due to seizure. Infants presents with small size, microcephaly, hypoplasia of distal phalanx of fingers and toes, nail hypoplasia, low nasal bridge, cleft rib and rib abnormality and cardiac mmurmur. Its also asso with Neuroblastoma. Karytype and TORCH should be measured.***Diphenylhydantoin (phenytoin) is metabolized to Epoxide Metabolite, which is eliminated inturn by enzyme Epoxide Hydroxylase. The genetic expression of EH is different from one subject to other and its substrate EMis the agent incriminated in the syndrome.

Fever, Post operative:
Fever after the first day is due to Atelectasis. Pt might have pain at the incision and not take deep breaths causing atelectasis. Fever 3-5 days post surgery is due to UTI. Fever 3-7 days post surgery may be due to Pulmonary Embolism. Pt is Tachypnea,tachycardia and Hypoxia. Dx requires Duplex US to look for clots in extremities. Eventhough pt are given anticoags, 200,000/y die of PE. Fever one to two months post durgery is due to post spleenectomy sepsis. All pt are given Pneumococcal vaccine after surgery to prevent this. Fever due to Pneumonia can occur 3-6 days post surgery. Pts are most likely, smokers,obese, elderly and fail to ambulate. Pt will have sputum and leukocytosis. Fever due to wound infection is 4-7 days post surgery. Redness, pain and induration.

Fibroadenoma:
1x1 cm firm rubbery freely mobile round mass in a 35 yo women w/o axillary nodes palpable. Best initial step is Mamogram.

Fibrocystic Dis of Breast
A 4x5x6 cm moveable rubbery mass that will go away after poking the needle and secretion of clear discharges. The best approach after aspiration of fuid is to wait 4-6 weks . In FCD the mass goes away and doesn’t come back. It it recure or doesn’t go away, then a biopsy is indicated. If the fluid (initially) was bloody or foul smelling, cytology is needed at that stage.

Fibroid uterus
Presents with Dysmenorrhea, heavy menses, and enlarge uterus is almost dx of either Adenomyosis or FU. Submucosal fibroids often imterefre with rmbryonal implantation and infertility. Fibroids are the mc benign uterin tmors in women and the mc indication for hysterectmy. Tey are estrogen-dependent tumors, therefore they increase in csize with OCP and pregnancy. and often regress after menopause. DDX is Endometriosis which presents with Amenorrhea. Make sure you can DDx the above conditions with Adenomyosis.

Fibromuscular Dysplasia - 2
Is the mcc of 2ary HT in childern. It responsible for 20% of the cases of renal HT. Its also seen in premenopausal women. PE shows a hum or bruit (soft to-and-fro bruit) in the right costovertebral angle due to well developed collaterals. The right renal artery is more affected than the left. Angiography shows 'string of beads ' pattern in the renal artery****Pt presents with Occipital HA, HT and renal bruit, suggestive of renovasculat HT due to Renal Artery Stenosis. The usual cause in youner pt (30) is FMD. In older pt its atheroslcerotic plaques. Goal of tx is decrease BP and restore perfusion to kidneys. Interventanl therapy is better than medical mgmnt alone, so Angioplasty with stent replacemnt is best tx. If it fails then Surgery is indicated. Ace inhibitors are reserved for Elderly pts who are not good candidate for surgery. Remmber Ace inbitors are CI in bilateral renal stenosis.

Fibromyalgia- 4. Rheumo 6/3
Occurs mainly in females and may be induced or intensified by physical or mental stress, poor sleep, trauma, or exposure to dampness or cold .Pt presents with diffuse musculoskeletal pain, multiple tender points, with no joint swelling/pain. Initial work up is 1-CBC, 2-ESR, 3-TFT, and 4-CK enzyme. Normal spine movement makes "Ankylosing Spodylitis" unlikely. Normal ESR with pain rather than stiffness makes "Polymyalgia Rheumatica" unlikely. "Polymyocytis", usually presents with weakness rather than diffuse pain and increased CK. *Characterized by muskuloskeletal PAIN and presents of 11-18 tender points. Pt prsents with recurrent HA, IBS, Reynauds, The most importnat ddx of this diseases is masked depression and somatoform disorder. Tx is excercise & Antidepresssants.****DDX1:Chronic Fatigue Synd: pt prestns with extremem fatigue and not body aches. It must be there for 6mo. DDX2:Polymyalgia Rehumatica:Pain and stiffness of shoulder and pelvic. Very unlikely in pt <50yo. ESR is elevated. Complain of stiffness rather than weakness or pain. Asso with fever,weight loss and HA. DD3:Polymyositis:Proximal weakness of muscle in upper and lower extremity. Pt complains of difficulty raising from chair position or climbing stairs. No pain just weakness***** Fibromyalgia is not an inflmatory disease so NSAISs like Naproxen & steroids are not helpful. Tricyclic antidepressant like Amitriptine are tx at bedtime. For daytime pain use acetaminophen. You can also use Cyclobenzaprine. So the initial tx is either Amitriptalin or cyclobenzaprine. If refractory to the above medicine then SSRI are added. When pt feels better then exercise is initialed. Other refractory tx is trigger point injections

First degree heart block


Fluphenazine SE:
Hypothermia by causing vasodialation and inhibition of shivering.

Focal segmental GN
Asso with HIV.

Fragil X syndrome - 2
Pt can be tought to take care of himself with and perfor simple task with close observation, like down's. *** Low to normal IQ, with learning disability. , general language disability, short attention span, autism, Mutation of FMR-1 gene caused by increased number of CGG trinucleotide repearts. Large head, prominent jaw and large low set ears.

Friedrisk Ataxia
Auto rec. excessive number of trinucleotide repeats resulting in abnormalilty of topopheral transfer protein. Poor ptognosis. Tell the parent to seek genetic counseling for future pergnancy. MRI of the brain and spinal cord shows marked atrophy of cervical spinal cord and minimal cereberal atrophy. *****Auto rec dis. Begins before 22 years of age. Neurological manifesration gait ataxia, falling, dysarthria) result from degeneration of spinal tracts (spinocerebellar, posterior tract, pyramidal tracts). Non neuro symptoms include concentric HCM, DM and skeletal abnormality (scoliosis annd Hammer toes). Median survivial is 20 years. Mcc of death is CV, 90%.

Frost bite injury
Warm up the body with warm water is the tx