USMLE World Notes-4

Juvenile RA or Still’s Dis.
Child presents with systemic features, high fever, fleeting maculopapular rash (central clearing), hepatospleenomegaly, lymphadenopahty, pleuropericarditis, and myocarditis. Rheumatic factor is rarely positive. Tx is NSAID and monitoring of liver enzymes. Cortcosteriods are used if pt does not responde to NSAID or if hayt myocarditis.

Kallman Synd
Consists of congenital absence of GnRH secretion asso with Anosmia (cant smell) and a normal 46XX. Also amenorrhea and absent 2ndary sexual characteristics.

Kartagener
Baby with recurrent sinusitis, bronchiectasis, destrocardia due to sydmotile cillia (dynine aberannt).

Kawazaki Disease - 2
Fever >5 days. Mucous membrane changes (fissured lips) extremity changes (edema, erythema) , at least one cervical node >1.5cm and polymorphus rash. Coronary artery aneurysm or ectasia(widened) develps in 15-25% of children. MERCK:A syndrome occurring usually in infants and children < 5 yr, characterized by prolonged fever, exanthem, conjunctivitis, mucous membrane inflammation, cervical lymphadenopathy, and polyarteritis of variable severity. Therapy is started ASAP, optimally within the first 10 days of illness, with a combination of high-dose IGIV and oral high-dose aspirin. MERCK END.***Criteria are: 1-Fever>5 days. 2-4 of the following, Bulbar conjunctival injection, Desquamation of finger ans toe tips, Erythema fissuring and crusting of the lips and strawbery tongue, Morbiliform truncal exanthem, Cervical lymphadenopathy. Kawasaki or Mucocutanous Lymph node Syns is one of the mcc of generalized vasculitis in children. Its self limited It can be fatal due to thrombos leading to MI. A 2D Echo is done to asses cardiac function. A baseline Echo is done w/i 7 days then repeared 6-8 weeks later. Fever does not respond to Acetaminophen. All pts with Kawasaki should be hospitalized and treated with IV IG and High dose Aspirin. If untreated 25% will develop coronary artery aneurysm. DDX1:Scarlet fever, which have poitive strep test and no LIP fissures. Latex Agglutination test id a rapid Dx test. Tx is 10 day Penicline course, or Erythromycin for Pen allergy.

Klumpke Paralysis
Is a brachial palsy that occurs in newborns following excessive traction of arms. It consist of hand paralysis, and ipsilateral Horner syndrome (ptosis & myosis) and its secondary to injury to seventh and eight cranial nerves and first thoracic nerve.

Knee Injury:
MCL injury is Dx with MRI. As MCL resists valgus angulations at the knee, injury to this ligament leads to increased angulation of the affected knee in vlgus maneuver. If MRI in inconclusive then we do Arthroscopy. Surgery is rarely necessary for MCL tear. *****ACL prevents leg from gliding anteriorly, it is damaged when knee is hyperextended. Its asoo with MCL and medial meniscus. Lachman is the most sensitive test for Dx. Anterior drawer sign is also used for testing but its not as sensitive. Mc Murray is for meniscus testing. Valgus is used for MCL (Medial Colateral Ligamnet) testing. ****Meniscal injury result from twisting injury with the foot fixed. Bucket handle tear is mc. Tenderness along medial side. It results in LOCKING of the knee joint during the terminal extension. Initial tx is conservative with immobilization and bracing.

Krabb’s Dis:
Sphingolipidoses due to def in galactocerebrosidase. Characterized by hyperacusis, seizure and irritability.

Labor - 2
Labor is defined as progressive cervical effacement, dilatation, or both resulting from uterine contractions, which occur at least every five minutes and last 30 to 60 seconds,
Labor progress through four stages:
The first stage from the onsert of labor until full dilation of the cervix, and includes two phases: a latent phase, during which dilation progresses in a slow rate until reachins 2-3 cm, followed by an active phase, during which the dialation is more rapid. The length of the latent phase is highly variable but its considered prolonged when it exeecds 20 hours in the primiparous and 14 hours in multiparous. The progression of active phase is measured by the rate cervical dilation. At this phase, the cervix is dilated with a ate of at least 1cm/ hr. in the primiparous and 1.2cm/hr in a multiparouse.
The second stage of labor extends from complete dialation of the cervix to delivery of the baby. It usually last 30 min to 3 hours in primiparous and 5 to 30 minutes in multi.
The third stage starts with delivery of the baby, and ends with the delivery of placenta.
The forth stage starts with delivery of placenta to 6 hours postpartum.The mother should be closely observed because of high risk of postpartum hemorrhage.
Prolonged latent phase can be caused by hypertrophic uterine contractions, hypotonic contractions, or premature or excessive use of anesthesia or seduction, Hypertonic contractions, although intense are ineffective. They are more painful and asso with increased uterine tone. Hypertonic activity of the uterus usually responds to therapeutic rest with Morphine Sulphate. Hypotonic contractions are less painful and are characterized by easily indentable uterus during the contraction. Sometimes pts diagnosed with prolonged latent phase may actually still be in false labor. Contractions of false labor are painless and sporadic, but can be rhythmic, occurring every 10-20 minutes. Their main characteristic however is that they are not accompanied by cervical changes. Pts with hypocontractile dysfunction are best treated with a diluted infusion of oxytocin. *****Fetal head compression is asso with early deceleration, Uteroplacental insuff presens with late deceleration and Fetal cord comprerssion is asso with late deceleration (decrease in fetal HR of 20 for a duration of 35 sec with absence of contraction). 1st step in Tx for FCC is O2 admin and change in maternal position and elevating the presenting part .

Lactation suppression:
Tight fitting bra and ice packs. Bromocriptine is no longer used.

Lactic Acidosis, posticteric
T9Q45. Its transient and it resolves in 60-90 inutes.

Lactose Intolerance
Chatacteized by a positive hydrogen breath test, positive Clinitest of stool for REDUCING substances and increased osmotic gap.

Lacunar Infarction
The principal cause is HYPERTENTION. There are 4 types, MEMORIZE THEM: 1-Pure motor Hemiparesis:Lacunar infarction in post Genu of Internal Capsule, presents with unilateral motor deficit (face, arm and some leg);mild dysarthria(poorly articulated speech);NO sensory or visual dysfunction. 2-Pure Sensory stroke:in VPL nucleous of thalamus, presents with Unilateral numbness, paresthesias, hemisensory deficit involving face,arm and leg and trunk. 3-Ataxic Hemiparesis:Lacunar infarction in post limb of IC, presents with weakness more prominent in lower extremity, and ispilateral arm and leg incoordination. 4-Dysarthria-Clumsy hand synd: Lacunar stroke of basis of pontic, presents with Hand weakness, mild motor aphasia, NO sensory abnormality.

Laryngomalacia:
Is the mcc of chronic inspiratory noise in infants. Laryngoscopy shows flaccidity of the larynx, and collapses during inspiration. It’s a self limiting condition mostly. Mother needs to hold the baby in upright position for half an hour after feeding and never to feed the child while lying down.

Latex Allergy
can manifest as an anaphylactic reaction during exposure to gloves or condoms. Pt is anaphylactic during surgery and sex.

Lead Poisening
Microcytic Hypochromic anemia and basohilic stippling, not normocytic normochromic.

Leg nerves
1-Femoral: thigh ext, hip flex. Sensory ant thigh and medial leg through saphanus. 2-Tibial: Flextion of knee and sigits. Plantar flexion of foot . Sensation ro leg (except medial) and plantar foot. 3-Obturator: adduction of thigh. Sensation of medial thigh. 4-Common Peroneal: muscles of ant and laterla leg. sensation of anterolateral leg and dorsum of the foot.

Legg-Calve-Perthes - 3
B/t 2-12 yo. Pain is absent or mild. Gait is antalgic and range of motion is lilmited to internal rotation,flextion and abduction. AP and lateral view show widening of the joint spaceand collapse of the femoral head. DDX:Osgood-Shlatter involves tibial tuberosity resulting in tendernes over it. Ages 10-16. Xray shows irregularity of tubercle contour. DDX SCFE occurs in obese kids, with painful limb, xray shows displacement of femoral epiphysis.****A serious but self limiting dis of children 4-10yo, characterized by avasculat necrosis of th ehead of feur. MC in boys and usually unilateral.Pt prestns with painless limp or mild pain. There is sever limitation of internal rotation and abduction at the hip joint.MRI and bone scan show findings of necrosis of the headof femur. Children <5 no tx. Children >5 need abduction bracing or surgicacl corrrection. DDX1:Slipped Capitis Femoral Epiphysis, seen in adulescent obese boyswith a gait. DDx2:Septic Arthritis presents with systemic signs and leukocytosis. DDX3:Osteomyelitis, of the hip also systemic signs nad leukocytosis. DDX4evelopmetnal Dysplasia of the Hip, a congenital disorder. DDX5:Osgood-Schaltter( 2 Qs) or Osteochondrosisof tibial tubercle, its an apophysitis of tibial tubercle, caused by overuse commonly seen in teenagers. Chief complain is pain and swelling around tibial tubercle. Pain increases on contraction of quadricept muscles. Xray shows characteristc fragmentationon laterla view. Tx is symptomatic with rest, NSAIDs and breif casting.

Legionella
T9Q39. Remember PhD (Pneumonia, Hyponatremia and Diarrhea) is almost always indicative of Legionella. Tx is Erythromycine.

Leprosy
A chronic granulomatous disease that primary affects peripheral nervers and skin. Dx is by acid fast bacilli in the skin biopsy. Pt is from Asia, lesion on arm, dry cough. Lesion has no sensory feeling and muscle atrophy. Next step is to do skin biopsy for acid fast.

Lesch-Nyham synd
Def of HGPRT. Self mutilation and neulogic features, gouty arthritis (gout is for men over 50, so if you see a BOY with gout suspect this syndrome). Tx is Allopurinol.

Leukemia
1-Acute Monocytic (FAB M5) Leukemia. The onset is dramatic HA and fever are chief complains. , Also fatigue, weight loss, bleeding from mmouth and nose, Gingyval hyperplasia. There is leukocytosis with high proportions of blast cells. Chemically they are 'Alpha-Naphtyl Esterase' positive. DDX:Acute Myeloblastic Leuk with Maturation (M2) Myeloblasts predominant. DDX2:Acute Promyelocytic Leuk( M3) has lots of Promyelocytes. DIC is sometimes seen with ths type. DDX2:Acute Lymphoblastic Leuk, predomiant cells are Lymphoblasts. They are mostly PAS positive. DDX4:Acute Erythro Leuk (m6) characerized by erythroblasts.

Leukemoid reaction
is a marked increase in leukocytes by a severe infection or inflamation. CML and LR are indistinguishable. Leukocyte Alkaline Phosphotase increase establishes ddx b/w CML and LR (increased LAK). In CML , ALK is decreased and there is Philadelphia chrom.

Lewy Body Demntia
Characterized by fluctuating cognitive imparment and bizzare , visual hallucination. Parkinsonism is aldo seen. The central feature required for dx is progressive , cognitive decline tht interfers with normal social functions.

Lichen Sclerosis:
Is epithelial lining inflammation and dry skin . Usually occurs in postmenopausal women. Thr mc presentation is a severe itch and vaginal soreness. It might progress to vaginal cancer. Once diagnosed start superpotent steroid cream while awaiting biopsy results.


Lithium Toxicity - 4
Presents with tremulousness, headache, confusion, GI disturbances, fatigue, seizure, coma, hyperreflexia and opisthotonus. Lithium exacerbate or precipitate Psoriasis.***Lithium exposure in the 1st trimester of pregnancy causes a 20 fold increase in the risk of Ebstein anomaly, a CARDIAC malformation. Its characterized by a malformed and inferiorly attahced tricuspid valve that causes decrease in size of right ventricle.****SE are Nephrogenic DI, Hypothyroidism, Ebstein anomalyin fetus. So test the pt for TFT, Creatinine and pregnancy before perscribing.*****if a pt presents with refractory mania despite therapy with a mood stablizer, a urine toxicology screen and mood stablizer drug levels should be obtained in initial evaluation.

Liver Cirhosis
T6Q=30. Liver functions can be divided into the following categories: 1-Synthetic:Synthesis of clotting factors, cholesterol, proteins. 2-Metabolic: metabolismof drugs and steriods including detoxification. 3-Excretion of biles. So pts manifestations could include: A-Gynecomastia in cirrhotic pt is due to liver not metabolizing estrogen. Other manifestations of hyperestronism are testicular atrophy, decreased body hair in males, palmer erythema and Spider nevi (angioma). B-Caput meduda is due to portal HT, along with that hay hematemesis and hemmorhoids. C-Ascites is a result of 1-Underfilling theory: Sequestration(accumulation) of fluid in splanchnic circulation due to portal HT. 2-Overflow theory: Primary abnormality is inappropriate retention of salt and water by kidney. D-Asterixis is 2ary to hyperammonemia leading to hepatoencephalopathy. E-Pedal edema is due to hypoalbuminemia.

Liver disease criteria
Lab tests used to evaluate liver dis is cllasified into two claases: A-Tests to asses the function of liver which includes 1-PT, 2-Albumin, 3-Cholesterol, 4-Billirubin. B-Tests that assess structural integrity and cellular damage, 1-Transaminases, 2-Gamma glutamyl transferase, 3-Alkaline phosphatase. Now PT is considered the most important tst to asses functionofliver, since liver makes all clotting factors (except VIII). Elevated TransAminase are indictive of liver cell damages since this intracellular enzyme leaks out of damaged cells. A marked increase in TA is an indication of an ongoing tissue destruction. A progressive decrease in TA could mean either recovery from liver injury or that there is little tissue is left (as in Fullminant hepatitis), so this interpretation is dependant on functional test like PT. If PT is OK then TA decrease means recovery, if PT is increased, TA decrease means fulminant hepatitis.

Liver failure coagulopahy
FFP is the tx of choice. Liver makes all clothing factors, except VIII. Among these are vitK dependant factors, II, VII, IX and X. FFP has all cloting factors. VitK can reverse the bleeding problem if vitK def is the cause but if the cause is liver fialure it is of no use to hepatocytes, also vitK takes a while to work.

Liver failure, Acute
When PT is 20s it means hepatic failure. 1-ACUTE liver failure means development of lilver failure w/I 8 weeks of onset of hepatocellualr injury. 2-FULLMINANT hepatic failure means AHF+Encephalopathy. Acetaminophen toxicity is the mcc for both. AST will be very high ( >3000), ans hay 20% mortality rate. FHF has the most favoable prognosis. *****In the evaluation of Asymptomatic elevation of aminotransferases, FIRST step is to rule out Alcohol and drug abuse. and risk factors for viral hepatitis by taking detailed hx. The NEXT step is LFT. If only AST is elevated then ALT should be checked to rule out extrahepatic causes of AST elevation, because ALT is more specific for liver injury than AST.

Liver metastasis
Metastasis are the mc neoplasm in the adult liver and are 20 times more common than primary tumors. It’s the 2nd mc organ after lymph node that gets metastasis due to its big size and dual blood supply. Dx is by US, CT, MRI, however biopsy is confirmatory.

Liver pathology
1-Ballon degeneration w polymorphic cellular infiltrates:Acute Alcoholic Hepatitis. 2-Panlobular mononuclear infiltration w hepatic cell necrosis:Acute Viral Hepatitis. 3-Portal necrosis including piecmeal necrosis and/or bridging fibrosis: Chronic Hepatitis. 4-Inflamatory destruction of small intrahepatic billiary ducts: Primary Billiary Cirrhosis. 5-Extensive fatty vaculorization of the liver: Rey'e Synd (aspitin toxicity in children).

Lower extremity edema
The two important causes are 1-Liver disease (HepB favors it. Lower ext edema, ascites, hepato and spleenomegally. ) 2-Cardiac diease (Constrictive Pericarditis: TB favors it. Lower ext edema, ascites, hepatomegaly,splenomegaly. Hepato-Jugular reflex is a useful tool is the ddx).

Lower extremity nerves:
1-Tibial
2-Obturator
3-Common peroneal
4-Femoral

Ludwig Angina
is infection of sumaxillary and sublingual glands and souorce of infection is an infected tooth. Pt presents with inflamed mouth, drooling and fever and dysphagia. Tx is IV penicillin with coverage of anaerobics.

Lukemia
1-ALL: 2-CML:Leukocytosis, Anemia, increased granular cells like segmented neurophils and bands. Its mostly seen after 50 and presnets with fatigue, malaise, low grade fever, anorexia, weight loss, and bone pains. Night sweats and fever asso with increased metabolism due to granulacytic cell turn over . Examination of the bone reveals hypecellularity with prominant granulocytic hyperplasia. The Leukocyte Alkaline Phosphate is low, the only other diseaes that this may happen is Hypophosphatemia and PNH. Elevated Leukocyte Alkaline Phosphatase is characeristic of Leukemoid reaction. Presence of Philladelphia chromosome and LOW Leukocyte Alkaline Phosphatase makes CML more likely than Leukemoid reaction.

Lumbosacral strain
The mcc of back pain. Paravertebral tendernesspain after physical excertion, negative staight led sign.Tx is NSAID and early mobilization.

Lung Adenocarcinoma
t9q29. Least asso with smoking.

Luteal phase defect. - 2
A15.***LPD is suggested by short cycles, hx of spontanous abortion, abnormal Basal Body Temperature, or low levels of mid-leuteal Progesterone. The Dx is confirmed by Endometrial biopsy which demonstrates a lag in endometrial maturation of 2 days or more. LPD is tx with progesterone vaginal supository FIRST, if that didnt work then Clomiphene citrate or hcG (Human Menopausal Gonadotropin) is tried. They both increase serum FSH.

Lyme dis - 7 , 6/2
Tx for Pregnant women is Oral Amoxicilline, EVEN if there is no reaction give prophylaxis for anxierty. *Facial nerve palsy and classical Eryhtema migrnas indicate Lyme. DDX:Bells palsy, is the term used to refer to idiopathic facial nerve palsy. *Lyme dis prophylaxis (Oral Amoxicilline) is given to pregnant women who have been exposed to the tick and are asymptomatic or have anxiety about getting the diease.****Lyme arthritis is a late manifestation of Lyme infection , suspect it with a hx of travel to endemic areas, Rhode island, NY, conneticut, jersey,wisconsin. DDX:Septc arthritis, sudden onset of acute MONOarticular arhtritis in previously damaged joint, asso with Chills and fever. DDX2:Reactive arthritis, occurs 2-4 weeks after genitourinary or GI infection. Onset is acute, with malaise and fever. Symetrical joint involvement.*****By Ixodes tick. Antibosy crossreacts with T. Pallidium.****Remember that dx of early dis is Clinical and there is no need for serology. So the first thing to do is to give Doxycyline for 28 days.**** Remember in children <9 yo, dont give Doxy, give Amoxicilline.

Lymphoganuloma Venereum
It’s a STD caused by C.Trochomatis. Serotype L1L2L3. Initially there is headache and fever, then a papul apears that turns in to an ulcer typicaly in vulvovaginal region. Ulcer is painless and disease may go un noticed unti inguinal adenitis develops a month after. If untreated at this stage LGV becomes chronic causing ulceration, PROCTATITIS, rectal stricture rectovaginal fistulas and elephantiasis. Tx is Doxycycline or erythromycin . DDX1:Granuloma Inguinale is caused by Donovania granulomatis, Unlike LGV the ulcer and lymphadenopahty present simultaneously. Also the ulcer here has irregular borders and beefy red granular base. Recommended Tx include azithromycin, doxycycline, erythromycin.

Lynch synd
or HNPCC(Hereditary Non Polyposis Colorectal Cancer). Criteria includes 1-atleast 3 relatives with CC, 2-involvmnet of 2 or more generations, 3-At least one case dx before 50, 4-FAP is rules out.Its also asso with extra colonic tumors, the mc is Endometrial carcinoma.

Macular Degeneration
Age related. Progressive loss of bilateral CENTRAL vision. Due to degeneration and atrophy of the outer retina, retinal pgment epithelium. Laser photo-coagulation is tx. DDX with Open Angle Glaucoma in which PERIPHERAL vision is lost.

Malabsorption Syndrome
One cause is bacterial over growth could be assosiated with stomach surgery (peptic ulcer or spcially after billroth II surgery). There could be A(night blindness) D(tetany due to hypocalcemia) Neuropathy (due to B12 def) , dematitis, arthritis and hepatic injury.

Malaria
People travelling to India or Pakistan should get chemoprophylaxis against malaria. DOC is Chloroquine, but in case of chloroquine resistance P.Falciparum, Mefloquine is doc. Tx with Primaquine is for Plasmodium Vivax and Ovale. ****The most sensitive test for DX is Giemsa stain thick smear.

Malignant HT
BP > 200/140. The most consistant sign is Papilledema. The pathological change responsible for end organ damage is Fibrinoid Necrosis of the small arteries.

Malignant Melanoma - 7
Always suspect it in a changing mole. DDX is Keratoacanthoma which is the family of Squamous Cell carcinoma. Best protection is wearing protective clothing, because sunscreen with SPF 15-30 protects ONLY against non-malignant melanoma (Basal and Squamous) skin cancers. Excision biopsy with narrow margins is the preffered study for dx. If the depth is <.76mm the melanoma can be excised with a 1cm tumor free margin and they have 99% 5year survival rate. The MC subtype is "Superficial spreading melanoma, 70%), the least common is "Acral Lentiginous". ***Still the best way to protect fair skin individulas is avoidance of the sun in the middle of the day (10am-4pm). Better than lotion or clothing or what have you.****The strongest risk factor for MM is recent change (color, size).****It metastasizes YEARS later to the BRAIN.

Malingering
Intentional production of false symptoms to get secondary gain (money or morphine.) Factitious is production of false symptoms to get the sick role, no secondary gain.


Malory-Weiss tears
increased intragastric pressure during vomiting could cause tear in the mucosa of the cardia and distal esophagus.

Mania - 5
Manic episodes are characterized by DIGFAST. Distractability,Insomnia,Flight of ideas, Activity inrease,Speech(extreme talkative),Thoughtlessness(excessive gambling).**** Initial tx of choice is antipsychotic, Haloperidol****For general population risk Bipolar dis is 1%, but for first degree relatives its 10%. ****If pt shows signs of Mania, Bipolar is a good dx. For CHRONIN tx Lithium is first line but not for a pt with renal problems. Valproate or Carbamazepine is bette for those pts. Also remember that Haloperidol is the doc for ACUTE mngmnt of iniital agitation and agresiveness.****Lithium and Valproate first line, 2nd line cabamazepine.****If pt has renal problem don’t give him Lithium, give him valproate for long term treatment,

Marfan Sybd
Asso with Fobrillin -1 gene defect. Its auto Dominnat. Aortic root dilatation. Lens dislocation.

Marijuana tox - 2
Impaired concentration and conjunctival injection are important features.*** A cannabis group, causes dry mouth, tachycardia, increased appetite, and conjunctival injection.

March fracture of Stress fracture:
Is common amongs young active adults (female dancer) involved in vigorous and excessive exercise. Tibia is common.

Marjoli’s Ulcer:
Years after burn surgery pt presents with an ulcer that still hasn’t healed. Biopsy will dx it. Its asso w SCC of the skin

Massive Hemoptosis
Is greater than 600ml of blood per 24hrs. Its an Emergency. The Initial intervention of choice is RIGID bronchoscopy, cause it gives better faster vision and has laser for control of bleeding. FLEXIBLE is not good for ER but its good for diagnosis.

Mastitis
Infection of breast with S. Aureus. It must be ddx with Breast Engorgement (heavy,tender,firm and warm breasts bilaterallyin women who not nursing. Its manged with tight fiting bras, anagesics and ice pack, breast feeding should be resumed). Mastitis is tx with oral Dicloxacillin. Breast feeding should be suspended but milk has to be pumped until infection clears. If it onvolves abscess, incision and drainge is required.

Mastoiditis, ENT 6/2
Its very rare. It’s a complication of AOM. Pt presents with fever, otalgia and tneder mastitis. CT confirms fluid filled middle ear & demineralization of mastoid. Tx is IV antibiotics immediately.

Maternal Hyperthyroidism:
Seen in 2/1000 pregnancies. MCC is Graves disease. Pt may present with sudden onset of Atrial Fibrilation ( irregularly irregular rythem and tachycardia. Dx is best made with serum TSH and free T4. However the best screening test would be TSH only.

Maternal substance abuse
1-Herion abuse: Newborn will show tremors, increasd weakness, frequent loose stool, high pich cry, fist sucking, poor feeding and tachypnea, Hyperirritability. Symptoms manifest w/I 24/48 after birth, Exclude hypocalcemia and hypoglycemia. 2-Mthadone withdrawlresents at the 2nd to6th wek of life with seizure. 3-Cocaine: asso w IUGR, intracranial hemorrhages, and premature labor or abrupta placenta. Its not common. 4-Alcohol withdrawl: presents with tremors, agitation, lethargy and seizures .Its rare.

McCune-Albright Syndrome
Rare, characterized by precocious puberty, café au lait spots (large and irregular borders DDX w Von Reklinnghausen) & multiple bone deffects (Polyostotic fibrous dysplasia). Its responsible for 5% of female precocious puberty. Its been related to defect in the G-protein cAMP-kinase in the affected tissue. Remember three P's : Precocious puberty, Pigmentation (cafe), Polyostitic fibrous dysplasia. Tx for Precocious puberty: a GnRH agonist (an analog of GnRH)--such as Hist-relin acetate, sc; or Nafa-relin acetate, intranasally; or Leuprolide acetate.Remember the three Ps, Precicious Puberty, Pigmentation, Polycystic fibros dysplasia.

Measles:
Vitamin A is known to reduce mobidy and mortality in pts with measles.*****Includes koplik spots. It should be reported. DDX Fifth disease or erythema infectiousum, by Parvo virus B19, rash is slapped cheek appearance. Fever is not present or is very mild. DDX2 Scarlet fever, pharyngitis, fever and sandpaper like erythomatous rash . Strawberry tongue may be present.

Meconium Ileus:
Asso w CF. presents with failure to pass stool w/I the 1st 24 hour of life.

Meckel's Diverticulum - 2
Painless Melena (dark stool) in a 2-3 y child is most likely MD. It results from the failure of viteline duct to obliterate during fetal development . Dx is best made with Technitium 99m pertechnetate ( is uptaken with heterotropic gastric mucosa) . MD is the mc anomaly in GIT. Heterotropic gastric tissue may be present in the diverticulum,which resutls in ulcerating and bleding. ****In a pt with only abdominal pain and pale and hx of childhood meckle, do Pertechnetate scintigraphy to dx it. Angiography can document bleeding at a rate of 0.5ml/min so its not helpful for this situation.

Mediastinitis
Hemorrhage and large pericardial effusionmay accnt for widening of mediastinum. Antibiotic alone is not sufficient for this SERIOUS dis. Mediastinitis needs, Thoracotomy for debridement, drainge, and antibiotic therapy. Remember widening of mediastinum is not because of that little pericarial fluid shows in Echo, that will resolve spontaneously, its because of effusion.

Medulabelastoma
It’s the second mc posterior fossa tumor in children after Cerebellal Astrocytoma. 90% occur in Vermis of cerebellum.

Medullary cystic dis
Its not asso with renal failure or Hypertension. Pt presents with stone formation or is found incidentaly. IVP shows typical radial arrangment of contrast filled cyst. Adult form is Auto Dominant. There is no therapy to prevent progression of cysts. Stones are treated like regular stones, increase intake of water and salt. So suspect MCD in adults with recurent UTI or renal stones and contrast filled cyst shown in IVP.

Megaloblastic Anemia - 3
Alcohol abuse is the mcc of Folate deficiency in chronic alcoholics in US. ***

Memberoproliferative GN
Dense inttramembraneous deposits that stain for C3(only, no Ig) is a characteristic finding for MPGN type 2 (also called dense deposit diseae). Its unique because cause its caused by IgG antibodies directed against C3 convertase of alternative complement pathway.

Membraneous GN
is the most likely dx in pt with both HepB and Nephrotic syndrome. HepC is asso with MPGN. MCD is asso with Hodgkins. FSGN is asso with HIV. Diffuse proliferative GN I sht esevere form of GN seen in pt with SLE.

MEN I - 2
Type-I:Tumors od Parathyroid (hypercalcemia), Pituitary and Pancrease (Hypergastrinemia leads to recurrent peptic ulcers).

MEN IIA - 2
Total thyroidectomy is recommended. Hyperparathyroidism+Thyroid medulary carcinoma+Pheochromocytma. ***Thyroid C cell hyperplasia becomes Thyroid medullary carcinoma. Following helps to Dx: Increased Ca, Increased Calcitonin, decreased Phosphorus, elevated urine metanephrine, increased Alk Phosphatase, elevated catecholamine, normal thyroid hormones, MRI of abdomen shows mass, Thyroid biopsy shows medulary carcinoma, Adrenal bipsy shows Pheochromocytoma, , Parathyroid biopsy shows tumor, PTH is increased.

MEN IIB
Pheochromocytoma, Thyroid medulary cancer, Neuroma.

Meniere's Disease
Recurrect episodes of rotational vertigo, sensorineural hearing loss and tinnitus. Dx is clinically. Tx is not necessary or impiric. DDX is Acoustic Neuroma where Vertigo is CONTINUES, and may be asso w ataxia.


Meningitis
1-Meningococcemia:Suspect it in a neonate with signs of meningitis and petechial rash. Rash appears w/I 24 of sickness. 2-H. InfCauses meniggitis w/o rash. Epigolitis, rihnoehea. 3-Listeria causes meningitis w/o rash. 4-Strep group B is the mcc of meningitis in infants. acuired from mother during childbirth. No rash. *****When a child presents with signs of ICP and memingitis, CT should be done before LP, HOWEVER start Cefotaxim 1st.

Meningococcal Vaccine:
Recommended to people with Asplenia.

Menopause - 3
Peripferal FAT tissue has the enzyme aromatase that converts Androesteodion(androgen) to Esterone (Estrogen), this process helps fat post menopausal women not to feel many of post menopausal symptoms like hot flashes, dryness of vagina, dyspareunia. ****Estrogen replacemtn therpy affects metabolism of thyroid hormones. , The requremtn for L-thyroxine increases, probabely due to increase metabolism of hormones due to induction of P450. Rifampin,carbamazepine and phenytoin act the same way. Other causes might be increased TBG, increased vol of distribution. In pregnancy also, thyroid hormone requiremtn would be increased and pt should be monitored every 4-6 weeks for dose adjusmnt. ****Estrogen is responsible for 2ary sex characteristics, emotional and physical health. Progesterone, produced by corpus leutum at ovulation, prepared for implantation and maintaining pregnancy. MenoPause occurs b/w 40-55, average is 51. Before MP there is period of transition, it last 2-4 years before complete cessaion of themenses. First complain is of chanfge of floe and duration. Afterwards, menses become more irregularmarking occurance f anovulatory cycles,hotflashes,vaginal ddyness. A womeni sconsiderd menopaused when at least one year of no menses has occured. Hor flashes there after may become more frequent vaginal dryness more prominent and may result in dysparunia, infections vaginal, and UTI. Psychological problems may be less concentration, sleeping problems, mood swings.


Mesenteric Thrombosis:
It can lead to massive fluid sequestration in bowels, Hypovolemic shock ensues. Extreme elevation of Cksuggest massive ischemia, characteristic. Abdominal pain and diarrhea with blood further supports Dx. Pt presents with BP 60/0, CVP of 0. DDX is MI (EKG abnormality). DDX2 is AAA, which will show in US.

Metabolic Acidosis - 3
T10Q45. In case of MA the first step is to calculate anion gap. Normal anion gap is b/w 6-12. Some of the CC of AG-MA are Lactic acidosis, Ketoacidosis, Methanol ingestion, ethylene glysol ingestion, Salicylate poisoning, Uremia (ESRD). A pt is said to have a normal anion gap MA when he has decreased HCO3, but a normal anion gap. This is also called Hyperchloric metabolic acidosis. Some of the CC of normal anion gap MA are 1-renal loss of bicarbonate (RTA, Carbonic anhydrase inhibitors). 2-GI loss of bicarbonate ( diarrhea). Urine anion gap tells us if the loss is due GI or renal.

Metabolic Alkalosis – 10, 6/2
Hypochloric MAlk due to vomitting causes loss of water, H, K, Na and Cl. To treat it use IV normal saline and K. Also remember that there is MA in presence of uncompensated Cirrhosis. Also Diuretic use is one of the mcc of MA..ie Thaizides. ****NG tube placement may lead to loss of large amount of gastric acid leading to contraction metabolic alkolosis even in pt with preexisting metabolic acidosis. An example of MA after three days due to vomitting is pH=7.55, PCO2=50,HCO3=42. So CO2 is increased to neutralize alcolosis and make up for acid lost, and HCO3 is also increased because there is no acid to neuralize it. Metabolic Alkolosis can occur in Hemodialysis pt who receive Citrate.*****Met Alk can be divided into two broad category based on urinary chloride level: 1-chloride sensitive MA (Urinary Cl <20) that is suggestive of ECF contraction. The loss of gastric hydrochloric acid by suction or vomiting produces metabolic alkalosis that is perpetuated by concomitant ECF volume contraction (NaCl loss in gastric juice) and development of K deficiency, due more to secondary aldosteronism (i.e., renal K wasting) than to K loss in gastric juice.. It can be corrected with saline infusion and is called Chloride sensitive MAlk. Some causes are thiazide or Loop, loss of gastric secretion (Sureptitious Vomiting), acid ingestion, CF, Villus Adenoma ). 2-chloride resistant MAlk (Urinary Cl>20. due to persistant mineralocorticoid stimulation and HypoKalemia. Hay ECF expansion. They are characterized by HT and so are not corrected with Saline infusion. Some causes are Primary Hyperaldosteronism, Cushings synd, also Barret's and Gittermna Syndromes (both are kidney syndromes). When we give Kayaxelate it causes MAlk. *** MAlk is the mc acid base abnormality in hospitalized pts.

Metatarsus Adductus
Is a congenital foot deformity. In the first born only. Thre are 3 tyes, 1-feet over correct both passively and actively into abduction. These corrent spontaneouslt and no tx is neede. 2-foot that corrct to neutal position with pasiv eand active movemtns. this is corrected with orthosis or corrective shoes and sometimes plaster cast. 3-foot is rigid andis not corrected , these are manged with serila cast. Now surgical tx may be required if there is significant residual metatarsus adductus in children bythe age of 4.


Metformin
Is added to DM pt who needs a better control of glucose. Make sure pt renal function is good, because it causes Lactic acidosis if otherwise. Also it helps to reduce weight in borderline obese pts. ****CI in dye procedures and hospital stays.****Most Serious but rare SE is Lactic Acidosis, Most Common SE is GI Distress.

Methanol alcohol Tox
Blindness. Tx is Ethanol. Pt also has Anion Gap Met Acidosis. Its Asso with renal fialure and Crystalluria (rectangular)

Methyphenidate Toxicity
Its used for ADHD. Its SE is nervousness, decreased appetite, weight loss, insomnia and abdominal pain.

MI - 24
T9Q21. T9Q43. RV infarction: Presents with JVD, kusmmaul sign, hepatomegaly and hypotension in presence of clear lung fields. Sometimes Tricuspid regurg is present. The mechanism for these findings is that RV becomes less compliant resulting in decreased filing ad stroke volume with a resulting elevated central venous pressure. RV also becomes dialated and tricuspid regurgitation may develop. Loss of LV diastolic function gives rise to the symptoms. Manage a pt with ST elevation MI with immediate PTCA and angiography is sublingual thrombolytics are CI (hemorrhagic stroke a < 1 yr ago). Thrombolytics therapy is indicated when there is ST elevation >1mm AFTER nitroglycerine rules out Coronary artery spasm (by persisting after Nitro admin). Another indication is a new LBBB. Its NOT indicated for ST depression or Unstable Angina. Absolute CI for thrombylitic therapy is internal bleeding, stroke w/i a year, intracranial neoplasm, BP>180/110, or suspected Aortic Aneurysm. Thrombolytic therapy with t-PA requires co-admin of Heparin and aspirin, for Streptokinase heparinis not needed. MI Complications: LV Aneurysm, is a late complication of MI, usually occurs after anterior wall MI, could present with either asymptomatic or with CHF. Precordial exam shows Double apical beat, a murmur of Mitral regugitation exist due to papilary muscle dysfunction, CXr shows characteristic prominence of the left border of the heart, EKG shows persistant ST elevation. DDX1 VSD & Papilary muscel rupture, present w/i the first week after MI, with cardiogenic shock. Drugs that reduce mortality in MI are Betablockers, Aspirin, Aceinhibitors. Lidocaine is not given prophylactically to MI pts, althought it might decrease the risk for VF, it may increase the risk for Asystole. In post MI hypetensive pt beta blockers and ACE inhibitors are preffered over diuretics and calcium channel blockers. Beta blockers decrease myocardial oxygen demand by reducing heart rate and contractility. ACE inhibitors are indicated when EF is decreased. *ANTERIOR wall MIs are asso with high risk of ARTERIAL thmboembolism, so pts need full dose of Heparin when hospitalized, followed by 3 mo of Warfarin therapy. *Ventricular wall rupture:hypotention, pullsus paradoxus, pulsless electrical avtivity in a pt w recent MI, due to Cardiac temponade. Occurs the first week after MI. DDX is Papilary muscle rupture:It also occurs first week after MI. It will lead to acute mitral regurgitation and a pansystolic murmur is audible.****Ventricular Septal rupture:Pt presents with 4 day post MI, low BP, JVD, harsh pansystolic murmur at the lower sternal border. with wide radiation. Dx can be made if there is evidence of L-to-R shunt on Swan Ganz cathater, when a 2-D Echo is not available.****Pain that radiates to arm should make you think of MI, so u need to rule out MI wth Echo.****In a pt with acute heart failure, ACUTE INFERO-LATERAL MI, Pulmonary Edema (Bilateral crackles, edema, JVD) can set in Even though beta blockers decrease mortality in MI they are CI in presence of Pulmonary Edema. Diuretics are DOC in this setting. The most commonly used in Furesamide.***Reentrant Ventricular arrythmia (Ventricular Fibrillation) is the mcc of death in pt with acute MI.**** In case of ST elevation MI, reperfusion therapy with PTCA (PCI) with or w/o Stent should be done asap. PTCA (PCI) is prefered over Thrombolytics(tPA).****The earliest EKG findng in MI is Peaked T waves, followed by ST elevation, followed by T inversion, followed by Q waves.****All pt who had MI sould receive 2ary prevention. The follwoing drugs have shown to have mortality benefit:1-Aspirin, 2-Beta blocker, 3-ACE inhibitors, 4-Lipid lowering Statis drugs. In addition, Clopidogril should be prescribed to all pt with unstable angina /non ST elevation, as well as pts who are post PCI(percutaneous Coronary Intervention). Clopidegrel is preffered over Ticlopidine due to less toxicity. ***Chest pain in an MI pt a few days after the attack, that presents with friction rub is either Acute Pericarditis or Dressler's Synd. Knowing the Dressler is a LATE complication of MI that occurs b/w 2-10 WEEK post MI, tells us that this is Acute pericarditis. Fever is not a must for the Dx.***Post MI is pt is on Heparin an embolifrom heart can block supply to the leg and pt can presnt with Cold pulsess leg. Pt has to go to surgery for the leg, but we have to do an ECHO to rule out thrombus in LV.****Drugs tht improve survival in Acute MI are : Thrombolytics, Beta blokers, Aspirin, ACE inhibs. Ca chanels DONT.****Pt with ST elevation in lead II,III and aVF means Inferior wall MI. Now if this pt later in ER presents with low cardiac output (cold extremity adn BP) and low arterial pressure MI has resulted in RV infarction. RVI leads to reduced filling and so reduced stroke volume of RV and then to reduced LV stroke volume and CO and reduced BP. Therefore any medication that reduces Preload, like diuretics or nitrates shold be avoided. Severe RV failure dould lead to cardiogenic shock, initial therapy for acute RV infarction, who has hypotension is imediate volume expansion with normal saline. to increase RV filling pressure. If fluid resusitation alone is insufficient then inotropic and Chronotropic stimulation with Dobutamine should be initiated. *****The most important enzyme for evaluation of RE-infaction (MI) is CK-MB.****St elevation in lead II,III and aVF is indication of Inferior wall MI. It results from occulsion of either RCA or Left Circumflex artery. witha ratio of 5:1. Also if pt has bradycardia and hypotension suggesting involvment of SA node and right ventricle. ******A pt who develops a cold leg after an MI episode should be suspected of an emboluls. An Angiography should be done and Embolectomy performed.****Dressler Synd occurs 2-4 weeks post MI with low grade fever and malaise, and pleurtic chest pain. ECG reveals non specific ST elevation and maybe pericardial effusion. Once oyu suspect it start pt n NSAIDs, dont need ECHO or CT or Xray.

Migrain HA
Tx Steps: First start with NSAID, if that had a minor effect then use Acetaminophen, if that didn’t work either then give Ergotamine. Ergotamin is CI in pregnancy. Give Ergotaimn if attack last more than 48 hours or its recurrent. Prophylaxis: Betablocker, if pt has asthma Amitryptaline.

Migratory Thrombophlebitis - 2
Or Trousseau's Synd. Is indicative of chronic DIC, most probabely due to cancer. Lung, pancreatic,stomach, prostate malignancies are the mcc. CT of the chest, abdomen and pelvic is indicated for complete work up of malignancy along with age appropriate cancer screening such as digital exam, mamography and colonoscopy.****Pt have occult tumor which is not always detected when they come in. The mc tumor is Adenocarcinoma . The thrombophlebitis of ATYPICAL sites like ARMS and CHEST are good clues. Tumors are 24%Pancreatic carcinoma, 20% lung, 13% prostate. 12% stomach.

Minimal Change disease - 2
In general "membraneous nephropathy" is the mc nephropathy asso with carcinoma, however, nephrotic synd is a well known complication of Hodgkins lymphoma and is usualyy caused by "MCD".*****In Children we don’t do biopsy, once we suspect it we start Prednisone.*****Light microscopy is normal but electron microscopy shows effacement of foot processes of podocytes.

Missed abortion - 2
Once the dx is made, surgical evacuation (dilatation & cuertagge) of the uterus has to be performed to avoid complications such as DICand sepsis and to minimize hemorrhage.**** Missed abortion involves a dead fetus that is still retained in th e uterus. Dx is suspected when there is disappearance of the nasea and vomiting of early pregnancy and arrest of uterine growth. Urine pregnancy test would still be Positive.

Mittelschmerz:
It’s a mid-cycle (LMP was 2 weeks ago) abdominal pain that typically presents in young females. If there is no fever its not PID.

Mitral regurgitation - 4,
Mitral valve prolapse is the mcc of isolated MR( It sounds like soft S1 and a blowing high pitched pan-systolic murmur, that radiates to axilla.) Other causes of MR are:1-RHD, acounts for 1/3 of cases, more common in males. 2-IE, by causing damage to leaflets or chorda tendina, 3-HCM, causes MR by systolic anterior motion of mitral valve, 4-Mitral anual calcification, due to aging in elderly, 5-Ischemic heart dis, MI can cause it by papilary muscle.****Papilary muscel rupture inn the MI setting is the reason for MR a few days after MI.***Subacute IE usually involves previously damaged heart valves. The mc predisposing factor to native valve endocarditis is MVP. Mitral valve is mc-ly affected in endocarditis pts who are not IV drug abusers , and MR is the mc valvular abnormality observed in these pts. ****Causes of MR: 1-MVP is hte mcc, Pt prstns with DCM, Apical impuse is displaced. 2-Myocardial Ischemia, is the 2nd mcc, ischemia leads to papilary muscel dysfunction or infarction. 3-Rheumatic Heart Fever. 4-IE, pt prsents with fever. 5-Mitral Annular Calcification, usually in elderly.

Mitral Stenosis - 3
Hallmark is elevated left atrioventricular pressure gradient that ultimately leads to left atrial enlargement. Excertional dyspnea and later pulmonary hypertension and right heart failure. Very common Atrial fibrilation is due to atrial dilatation. S&S: 1-RHD, 2-L&R side failure, 3-MidSystlic Rumble w opening snap at apex, 4-AF, Pulm Rales, Increase intensity of S1, RV heave, 5-TXiuretics, Anticoag, Digitalis, Ballon valvuloplasty.****Tapping apex beat and malar rash are in MS.

Mitral valve prolapse - 2
Late systolic click, may or may not be followed by late systolic crescendo-decrescendo murmur. The click and murmur occur with maneuvers that decrease LV volume such as Valsalva and standing. Both are delayed with squatting and exercise(increase LV volume).****Beta blockers are used to treat chest pain, palpitation, autonomic sysmtoms of MVP. If pt prestns with TIA then Aspirin is given, if no response then Warfarin is given. MV repair is indicated when pt with MVP develops symptomatic or svere MR.

Mittelschmerz
Abdominal pain in a young female in the middle of her cycle with a benign hx and clinical exam is most likely this.

Mixed acid base disorders - 2
MA disorders are defined as independently coexisting and not merely compensatory responses. In order to Dx them first look for pH to determine status. Second see if the changein PCO3 or PaCO2 can explain the change in pH. Thirs step to see the degree of compensation possible for the disorder and if the values are not matching with the observed values, pH=7.4, PaO2=51, PaCO2=32, HCO3=18. . ExampleM pt with Metformin has pH=7.23, PaCO2=40, HCO3=16. OK first there is acidosis, then we see decreased HCO3 so its Metabolic Acidosis (Metformin induced), then use Winter's formula [1.5 x (16) + 8]=32, so Co2 must be 32 (compensated value) but its 40, so there is also a respiratory acidosis. Pt with Lobar pneumonia (tachypnia leads to Res Alk, Alk pH and low PaCO2), with N&Vomit (Met Alk, with Normal HCO3 of 24), and DKA (AG Met Acid). This pt will have Res Alk+Met Alk+AG Res Acidoosis).

Mixed Cryoglobulinemia - 2
80% of the cases are asso with Hepatitis C. So always do HCV RNA assay. Suspect in a pt with palpable purpura, hematuria and proteinuria, non specific systemic symptoms, peripheral neurapahty and hypocomplementemia. MERCK:Cryoglobulinemia is characterized by the presence of immunoglobulins that precipitate when plasma is cooled (ie, cryoglobulins) while flowing through the skin and subcutaneous tissues of the extremities. Monoclonal immunoglobulins formed in WaldenstrÃm's macroglobulinemia or in multiple myeloma (see Ch. 140) occasionally behave as cryoglobulins, as may mixed IgM-IgG immune complexes formed in some chronic infectious diseases, most commonly in hepatitis C. Cryoglobulinemia can lead to small vessel damage and resultant purpura. Cryoglobulinemia can be recognized after clotting blood at 37° C (98.6° F), incubating the separated serum at 4° C (39.2° F) for 24 h, and examining the serum for a gel or precipitate.END MERCK

Mixed CT disease
Ovelaping symptoms of SLE+Scleroderma+Myositis. Asso with antibody to RiboNuclear Protein. Occurs in much younger generation. DDX with Dermatomyositis, Polymyositis

Mobitz-I heart block
Mobitz-I or Wenkebach. Charaterized by narrow QRS, progressive increase in PR until a ventricular beat is dropped. It’s a benign arrythmia and unless pt is asymptomatic, no tx is needed. If pt is symptomatic Atropine is needed, and rarely pacemaker. Mobitz-I is seen with Digitalis tox, increased vagal tone and inferior wall MI.

Moluscum contagiusom - 2
Pic. It’s a POX virus family. Its asso with AIDS when CD<100. It resovles spontaneously in one year. Tx options are excision and cryotherapy.

Mongolian spots - 2
it found in dark skined population, presents at birth and usually disappear in several years. No tx is neccesary. Its caused by entrapment of melanocytes. The lesion is a bluish-grey, mostly located at lower back buttucks. The lesion does not fade in to surrounding skin. DDX:Salmon patch, a falt salmon colored lesion commonly seen over the eyelids, and neck and glebella(forehead bone). Its a vascular lesion that diappears at early childhood.

Monteggia & Galeazzi Fractures:
Monteggia is isolated proximal third Ulna fracture with anterior dislocation of radial head. May be asso with radial nerve injury ro neurovascular exam is mandatory. In adults its treated with open reduction and internal fixation. Galleazzi is isolated radial shaft fracture asso w disruption of radial and ulna distal joint needs open reduction and internal fixation.

Monoclonal gamopathy
MG of Undetermined Significance should DDX with Multiple Myeloma. There is only increased IgG. Plasma cell is <10% and no anemia or other signs of Multiple Myeloma. Tx is Asurance. MERCK: Low M-protein levels in serum, normal levels of other serum immunoglobulins, and no lytic bone lesions or Bence Jones proteinuria

Mucopurulent Cervicitis
By C. Trochomatis is asymptomatic in 50% of pts. Presents with scant vaginal discharge, abdomen is non tender, Yellow mucopurulent discharge is seen.

Mucormycosis
Pts with DM are prone to it. Pt has fever, dull facial pain, bloddy nasal discharge, diplopia, , nasal turbinates are necrotic. Requires aggressive surgical debridment and early systemic chemotherapy with IV amphotericine B,

Multiinfarct Dementia:
History of heart disease and hypertension is suggesting, however, if there is no indication of focal neurologic defects, this dx is ruled out and AD is the more probable cause.

Multiple Myeloma - 5
A malignant proliferation of plasma cells mainly in the bone marrow. characterized by marrow plasmacytomas (plasma cell tumors) and overproduction of an intact monoclonal immunoglobulin (IgG, IgA, IgD, or IgE) or Bence Jones protein (free monoclonal or light chains).. MC presentation is bone pain and old age, also anemia, renal failure and hypercalcemia. Pathologic fractures may occur and vertebral collapse may lead to spinal cord compression. Bone lesions are osteolytic. Serum and urine electriphoresis is used to detect monoclonal protein. Skull xray rerveal punched out lesions. Hypercalcemia is a characteristic of MM, it manifests as Constipation, anorexia, weakness, renal tubular dysfnction and neuro sysmptoms. DDX1:Osteoporosis, is reduction of bone density, Bone density scan (DEXA) is dx. DDX2: Pagets disease, excessive resoprtion of bone mediated by osteoclast, followed by replacement of normal marrow by vascular fibrous connective tissue. Pt presents with elevated alkaline phosphatase, bone deformity, large skull and pain. Hearing loss and nerve palsy may occur. Sarcoma is a long term complication. ***MM is caused by the proliferation of a single transformed plasma cell usually producing IgG. Following are the classic findings: 1-Lytic bone lesions, 2-Marrow Plasmacytosis, 3-Urine and serum monoclonal proteins. MM presens in old age and bone pain is the mc presentation. Complications include Renal failure, Hypercalcemia, hyperviscosity syndrome. Complete work upincludes CBC with differencial and morphology, serum electrolyt, kidney and liver screening, skeletal survey and serum electrophoresis and BM biopsy which shows over production of plasma cells. BM DDX1:Essential Thrombocytopenia, increased marrow cellularity with megakaryocytic hyperpplasia. DDX2:Aplastic Anemia, Hypoplastic fat-filled marrow with no abnormal cells.****Any elderly with bone pain,renal failure and hypercalcemia has MM until proven otherwise. Hay obstruction of distal and collecting tubules by large laminated cast containing Paraproteins (Bence Jones).

Multiple Sclerosis - 9
For acute symptoms ONLY steriods ( IV Methylprednisolone) are indicated. For relapsing-remitting episodes use Interferon B or Glatiramar acetate.MS is assosiated with Trigeminal neuralgia. Asso with MLF. MS is asso with Glosophareayngeal Neuralgia, sharp pain asso with swallowing, chewing, talking and yawning. * Dx of choice is MRI which shows white matter disease.****Pt might present with patchy neurological problems(right upper extremity, right lower extremity, optic neuritis) which is characteristic of MS.****Csf shows Oligoclonal bands but its not specific. However seeing Plaques in periventricular regions on T2-Weighted MRI is Dx.

Mumps
Asso with Orchitis.

Munchausen Synd by proxy
Is when a family member recieves satisfaction by making another member sick. Like the mother who gives her baby insulin to make her hypoglycemic.

Murmur
1-Diastolic and loud systolic murmurs should always be investigated with Transthoracic Duppler Echo. 2-Midsystolic soft murmurs in a young pt are benign and no further work upis needed.

Mutations
1-Silent: does not effect the structure of protein. 2-Nonsense is very severe. 3-Missense is mild structural changes.4-Frameshift is also very severe.


Myasthenia Gravis - 8
Hallmark is decreased acetylcholine receptors due to antibodies. DDX with botulism is that in MG pupils are spared. There are 3 TX options available for MG, 1-Anticholinesterase, 2-Immunosuppresive agents, 3-Thymectomy. Anticholinesterase, Pyridiostigmine, is the first line of tx, SE of abdominal cramps and fasciculations is treated with Atropine. Immunosuppresive agents, prednisone, azothioprine and Cyclosporine. Thymectomy is the best tx to induce remission and provide long term benefit. *****Once the dx is established (EMG and antibody t acetylcholinereceptor) the next step is to locate Thymoma ( CT os the chest) especially in pt <60yo. It rakes a 3-4 years to notice the difference after thymectomy.****The resolution of weakness with rest is the hallmark of MG. Pt presents with Dysarthria(speech difficulty),dysphagia,ptosis, diplopia.****Determination of evel of antibodies to Ach receptors is Dx. TENSILON test is not used anymore.****Myasthenia Crisis is a lifethreatening situation. caracterized by weakness is respiratory and pharyngeal mscles. The tx includes endotrachial intubation and withdrawl from anticholinesterase for a few dadys. The most important cause is an infection, pt has high fever. ALL pts should have bed side PFT done. ****DDX MG with TRICHONOSIS which is GI complans followed by muscle pain, swelling and weakness. Presence of subongul splinter hemorrhages , conjunctival and retinal hemorrhages, periorbital edema and Chemosis should make oyu think of Trichonosis. *****Level of lesion is in Neuromuscular junction.

Myelodysplastic Syndromes
Are clonal stem cell disorders, which may progress to Acute Leukemias. They are characterized by Pancytopenia.

Myositis, Dermato & Poly - 3
Polymyocitis and Dermatomyocitis are both inflamatory myopathies, charcterized by proximal muscle WEAKNESS, and ultimatly wasting. Dermatomyocitis involves typical skin changes:Helitrop rash around the eye asso w periorbital edema, and Gotrron's papules (red scally papules over metacarpophalangeal joints). These conditions may occur alone or with cancers: breast, ovary, lung, prostate, colon. Unlike Myasthenia ocular muscle weakness is UNCOMMON. Unlike Sclreoderma whic affects lower SMOOTH muscle, these affect STRAITED muscle of upper pharynx. Spcefic Dx is with muscle biopsy. They both responde to corticosteriods (Prednisone). If pt does not respond or CI to it, then immunosupresants (Methotrexate) is choice. *Polymyositis is not as generalized as SLE. Dermatomyositis, skin eruption is dusty red and may occur in the same proportion as SLE. DDX1:Mixed Connective Tissue Disease, Dx is made when Anti.RNP antibodies and clinical features of SLE, polymyositis and Systemic sclerosis are present simultaneously. These features include swollwn hands. Synvovitis, myositis, and Raynauds. If three of these are present with anti-RNP antibodies the dx of MCTD is made. DDX2:SLE, has musculoskeletal, CV, hematological, skin ,lungs, kidney, and serous membrane. If four or more are present dx is made.

Myotonic Muscular Dystrophy
Is the 2nd mcc of muscular dystrophy, after Duchenes. ALL muscle in body atrophy, lip looks like a V. Its Auto Dominant. Its defined as delayed mucle relaxation, characteristic is not being able to release the hand after hand shake.

Narcolepsy
Tx is Methyphenidate or Modafini (Psychostimulants)

Nasal Polyps
Are the MC nasal tumors, mostly malignant. Cause is either alergic or infectious. Usually a Hx of Asthma is present. Signs are recurrent rhinittis, nasal obstruction, postnasal drip, altered taste sensation and reduced sense of smell. Tx is with steriods or decongestants. If not sufficient then surgery is indicated. In pts with Asthma and Nasal Polyps, Aspirin is CI, may lead to severe bronchospasm. DDX:Angiofibroma, localized mass that causes bony erosions and epistaxis.

Nasoethmoidal fracture. Surgery 6/2
Are very common in auto accidents and trauma to the face. There is sweling of soft tissue, ecchymosis, gross bleeding. Dx is made with suspicion, and CT (more sensitiv ethan Xray). Injuries ar to ethmoidal roof, lacrimal system, cribiform plate and vasculatureof nose. Nasal packings are CI due to possible intracranial injury. Most of the injuries are managed b surgical reduction and fixation of unstable fragments. Remember Clear fluid discharge from the nose is due to CSF rhinorrhea 2ary to fracture of the base of the skull not ethmoid system.

Nasopharyngeal Carcinoma
Higher incidence in Asians. Mosr frequent presentartion is a painless neck mass. Other signs are Nasal blockage, epistaxis, hearing loss.They are benign and caused by EBV.

Neck SC Carcinoma
This is very commonin people who smoke and drink a lot of alcohol.The first manifestation maybe a palpable cervical lymph node. The best test is PANENDOSCOPY (Triple Endoscopy=Esophago,Broncho,Laryngo) to detect primary tumor or in most cases tumors. Then we do biopsy to confirm. Then we choose one of following: 1-radical neck disection,2-Tumor resection, 3-Platinum based Chemotherapy, 4-Radiotherapy, 5-Palliative mgmnt.

Neck Trauma
Zone1(lower):from clavicle to cricoid cartilage. Zone2(middle):from cricoid to angel of mandible, this is an important zone, All GUN shot injury should be surgially explored, but stab wounds in asymptomatic pt can be safely observed. Zone3(higher): from mandible to base of skull. Cervical spine should be assessed in all pts with severe blunt trauma to the neck.*****Angiogram is done following neck trauma to rule out carotid a. damage. In case of an intimal flap finding, surgery has to be done to prevent strokes.

Necrotized Surgical Infection:
Is characterized by intensive pain in the wound, decreased sensitivity at the edges, cloudy-grey discharge & crepitus. Early surgical exploration is essential.

Necrotizing Enterocolitis - 2
Should be suspected in any preterm or low birth weight infant with fever, vomiting, abdominla deistension, and pneumatosis intestinalis (ddx with malrotaiton of the gut). MERCK: The cause of NEC is not clear. It is believed that an ischemic insult damages the bowel lining so that mucus is not produced, leaving the bowel susceptible to bacterial invasion. Once feedings are begun, ample substrate is provided for proliferation of luminal bacteria, which can penetrate the bowel wall; there they produce hydrogen gas that collects, producing the characteristic appearance of pneumatosis intestinalis on x-ray. MERCK END.****Newborn with abdominal distention, blooody diarrhea, and leukocytosis. usually after formula feeding. Radiologic finding of penumatosis intestinales (intramural air) in infants is Dx.Tx is Aggressive resusitation is caried out w/o antibiotics. DDX is duodeal Aresia, there is no abdominal distention, Classic radiologic sign is Double buble sign (dilated stomach and duedenum). Asso with Down and Polyhydramnions.****increased gastric residues in a preterm neonate is highly suspicious.

Necrotizing Fasciitis
Caused by Group A strep and/or Staph aureus. Sudden onset of pain and swelling after trauma or surgery. Systemic signs. CT identifies site involved and gas. Aggressive treatment and surgical debridement is the focus of tx. Suspect DM. Ampiciline & Sulbactam + Clindamycin.

Neonatal care:
Early neonatal care in an uncomplicated pregnancy include initial PE, removal of airway secretion, drying and keeing warm, Silver nitrate for gonococcal and vitamin K supplementation.

Neonatal EYE infections: Peds, 6/2
1-Gonococcal conjunctivitis: Extremely purulent and presents b/w 2-5 after birth. 2-Chemical conjunct- ivitis: is 2ndary to prophylactic drops of silver nitrite, it resolves in 24 hr w/o tx. 3-Congenital Rubella infection: is more serious and may have micropthamia, cataract, glaucoma and retinopathy. 4-Adeno Virus infection: conjunctival secretion and respipratory symptoms of UPPER RT. Discharge is serous rather than mucoid or purulent and asso w mild itching. 5-Congenital Chlamydia infection: Presents w conjunctiva and respiratory problems. Transmitted from the birth canal. Its MCC of congenital neonatal conjunctivitis. Few days to weeks after birth. Conjunctival edema and mucoid or purulent. Pneumonia is b/w 3-19 weeks after birth, symptoms are cough, tachypnea, rales, there is no fever and wheezing is rare (the last 2 features DDX from RSV bronchiolitis). Tx is Oral Erythromycin for 14 days ( not topical).

Neonatal Jaundice:
Naonatal jaundice with conjugated hyperbilirunimia is suggestive of neonatal cholestasis and warrants furthur evaluation. Hx of jaundice in asso with light colored stool, hepatmegaly, and direct (conjugated) hyperbiliruninemia is indicative of neonatal cholestasis and impaired hepatic excretion of bilirubin, either by extrahepatic obstruction or liver cell injury. BILLIARY ATRESIA is the cause in this case. The purpose od the question was to keep in mind that conjugated hyperbilirubinemia , >2mg/dl, is an indication for evaluating neonatal jaundice, even if the infant is otherwise normal.

Nephrolithiasis - 8, 6/2
1 -Calcium oxalate/phosphate (75%), they are envelop shaped and seen under microscope. Etiology: small bowel dis or gastric resection or chronic diarrhea can lead to malabsorption of fatty acids and bile salts, this predisposes to formation of calcium oxalat stones ( fat malabsorption leads to increased absorption of oxalic acid becuase the unabsorped faty acids chelate or bond calcium and making oxalate acid free for absorption). 2- Uric acid (10% of pt, seen in pt with unusually low pH urine like 4.5 when normal is 5.6, this low pH could be due to defect in renal amonnia secretion, these are radiolucent but can be seen in USG & CT. Tx includes hydration and alkalinization of urine and a low purine diet, Since uric acid stones are highly soluble in alkaline urine alkalinization of urine to pH of >6.5 with oral sodium bicarbonate or sodium citrate is indicated). 3- Struvite/triple phosphate (10%), alkaline urine, by proteus and Klebsiela, . 4- Cysteine (1%). **** Consider 3 possibilities when flat film of the abdomen (KUB) does not show stones in a pt with typical signs. 1-radiolucent stone dis (Uric acid stones), 2-Calcium stones <1-3mm and 3-Non-stone causes (obstruction by blood clot or tumor). **** The way to treat Idiopathic hypercalceuria is not to decrease the Ca intake or increase excretion, because that what causes the problem to begin with (excretion of too much Ca in Urine). The way too tx is to increase aborption in Kidneys, by increasing ca intake, Thiazide diuretics (which causes decrease urinary Ca excrtion by inducing mild volume depletion which leads to compensatory rise in proximal reabsorption of Na and Calcium) and prevent precipitation of calcium in urine. So Tx in the order of importance is 1-Increased fluid intake 3L/day, 2-normal or increased calcium intake, 3-Dietry sodium restriction, 4-Oxalate restriction (dark roughage, chochlate,VitC), 5-Decrease dietry protein(beef,fish,egg,poultry).*****Cystinuria is an inherited discasing recurrent dis. Look for personal hx of recurent dis and family hx. Stones are hard,radiopaque,hexagonal crystals. Urinary cianide Nitroprusside is positive.****Managing step are:1-CT is choice forhigh specificity and sensitivity, Its advagne over plain xray(KUB) is detecting radiolucent stones. 2-Narcotics and NSAID, in pt with normal renal function NSAIDs are prefered because narcotics exacebate N&V. 3-Size of stone, <5mm passes spontaneously, manage conservative with fluid intake of greater than 2L/d. 4-Urology referal, urgent urological evaluation is warrented in pt with anuria,urosepsis and ARF. ***Oxalate stones are due to excesive gi absorption of oxalate. Hyperoxaluria occurs in pts with small bowel resection, like IBD. Increased dietry fat binds dietry calcium, which is then unavaliable to bind oxalate. Therefore increased absorption of exalate in large bowels occurs and precipitates in the kidney. Increased Oxalate can also occur in people with large cunsumption of tea, coffee, beer and choclate. DDX1:Calcium phosphate is asso with hypercalciuria, conditins that may cause it are sarcoidosis, immobilization, cushing and RTN. Tx includes Thiazide, Furesamide is CI. DDX2:Struvite stones, become infected wit Urea spliting organisms. Conditions requried for this are high pH urine, Mg, ammonim and carbonat levels. DDx3:Uric acid stones, occur in pt with Gout, diarrhea. Tx is fluid, alkalinization of urine and allopurinol. DDX4:Cystine stones are due to defect n transportstion of cystine and excess excretion of Cystine. It starts in Childhood and are rare cuase of Staghorn calculi. ******Nephrolithiasis durgin PREGNANCY:requires special consideration. Becasue we dot want to put baby at risk of radiation,USG if the procedure of choice. If USG is not informative, Transvaginal USG sould be tried next to help locate stones. If this too is inconclusive, there are two options, 'LIMITED' IVP and Ureteroscopy. ****Diagnosis: Kidney stones pt urine analysis in normal, except hematuria and US shows dilated collecting system. Next step is Dx with IV pyelography (not urineanalysis in morning, it looks for protein), however Non Contrast CT has replaced IVP.

Nephrotic Synd - 4 , GU 6/2
Hypercoaguable state. **** I could not dx it!!! Pt presents with Proteinuria, Hypoalbumnemia, Edema, Hyperlipidemia and Lipiduria. Pt with Nephrotc synd are at increased risk of developing Hypercholesterolemia, Hypertriglyceridemia and Hypercoagulable state. **** Amyloidosis is a cause for NS. Pt has Hx of RA, enlarged kidneys, and hepatomegaly. Typical finding on renal biopsy are amyloid deposits that show apple green bifringence under polarized light after staining with congo red. DDX1, Cresent formation under light microscopy is due to RPGN. DDX2, linear immunoglobins on immunofloresence are typical for anti glomerular baseent membrane dis, Goodpasteur. DDX3,Granular deposits on immnofloresence microscopy are in SLE or PSGN. DDX4, Normal microscopy is due to MCD.****FSGS: is the mcc of Nephrotic synd in blacks,HIV and IV drug users and morbid Obese people. MCD:is the mcc in children. Membraneous Nephropathy may be secondary to HBV , autoimmune dis or medication,like penicilamine.IgA nephropathy causes a nephritic synd aith active urine sediments, It usually follows upper respiratory tract infection. ****NS presents as high range proteinuria, hypoalnuminuria, and edema and is a well known complication of Hodgkin’s Lymphoma. Thr mcc of NS in Lymphoma pts is MCD. NS resolves with treatment of Lymphoma. Glomerular disease is seen in pts with carcinomas of lung, stomach, breast and colon. In general glomeroulus nephropathy is the mc nephropathy associated with carcinoma.*****Nephrotic syndrome has many causes: MCD (mc in kids and adulescent. Its either idiopathic or follows URT infection. Asso w cancers), Membranous nephropathy (Could be primary or 2ndary to HBV, autoimmune or drugs like penicillamine and gold. Its mc in adults, FSGN (mc in BLACKS, its either idiopathic or 2ndary to IVDU), Amyloidosis (primary or 2ndary to inflammatory process) and Diabetic Nephropathy (increased extracelluar matrix, basement membrane thickening, mesangial expansion, fibrosis

Neuroblstoma:
Is the mc extracranial solid tumor of children. Mediam age is 2 yo. It arises from Neural Crest cells which are a;sp precursor of Adrenal medulla. The mc site is abdomen either form Adrenals or retroperitoneal ganglia. Mass is firm or nodular. Calcifications or hemorrhages seen on plain xray or CT. Up to 70% have metastatic dis to long bones, skull liver and skin. Hay increased serum HMA and VMA but w/o fainting spells, palpitaiotns or hypertension as in Pheochromocytoma.

Neurocysticercosis
is the mc parasitic infection of the brain and highest prevelance seen in rural areas where pig farmers raise pigs in insanitary conditionss. Pt will develop headache and cns symptoms and will die w/I weeks.

Neurofibromatosis - 5
Axillary freckling and café au lait spots. Asso w Optic Glioma, nodular sweelings are hamartomas. DDx1:Tuberous sclerosis is asso w Hamartoma. DDx2:Optic Neuritis is asso with MS. ****There are few Neurocutanoues Synds, 1-Neurofibromatosis: Type-1 presents w cafe au lait, freckling, Lisch nodules (IRIS),neurofibromas ans bony erosions. Type-2 presents with Bilateral Acoustic Neuromas. 2-Sturge-Weber Synd that presents with port wine stains, angiomatous malformation of brain, seizures, hemiparesis. 3-Tuberus Sclerosis presents with ash leaf hypopigmentation, cardiac rhabdomyomas, kidney angiolyimiomas, mental retardation. ****ts auto Dominant***Infant with Cafe au lait spots, FEEDGIN PROBLEM SINCE BRTH, learning disability(cant speak or walk).

Neurofibromatosis type II - 2
Caused by Nonsense mutation. The mild variant, Gardner, results from missense or splice mutation. Silent or Same sense mutation does not change the protein. Suspect it in a young pt with acoustic neuroma and multiple café au lait spots. MRI with Gadolinium is the best method for dx. Tx is to remove the turmor. ****Bilaterla acoustic neuroma and Cataract.

Neuroleptic Malignant Synd. - 2
Characterized by marked hyperthermia, muscular rigidity and tremors, altered mental status and diaphoresis. Tx is with dopaminergic agonist like Bromocriptine and Dantrolin. ****Is a SE of Haloperidol. Causes elevated CPK. Rhabdomyolysis followed by myoglobinuria can cause renal failure. Tx is discontinuation and supporting care (aggressive cooling, antipyretics, fluid and electrolytes, and alkaline diuresis in case of Rhabdomyolysis). Specific drug Tx is Dantrolene sodium (muscle relaxant), or Bromocriptine.

Niacin SE
Is given to increase LDH level. It causes pruritis and flushing due to activation of protaglandins. That’s why we also give pt Aspirin to counteract. Flushing and pruritis improves w/I 2 weeks.

Nieman Picks:
Is due to def of sphingomyelinase. It’s a fatal disease of infancy. Clinical manifestations are failure to thrive, hepatosplenomegaly, and a rapidly neurodegenerative course and death by 2 years. Pt presents with hypotonia, hepato-splenomegaly, cervical lymphadenopathy, protruding abdomen and chery red spot.

Nitrates CI
Nitrates should should not be given to a man within 24 hrs of using Sildenafil.

Nocardia
Pts with immunocompromisd status, lymphoma aids, Transplant, are at risk.Pt presents, after penomonia, with cough,spectoration, fever, chills. Empyema is present in 1/3 of pts. 50% of pt have extra pulmonary dissemination, mainly to brain. Histological, there is an abscess that after acid fast shows Crroked, Branching , Beaded, G+ Filaments on the RED back ground. Sulfa-Trimeta is doc.

Non-Alcoholic Hepatic Steatosis -2
Or Non-Alcoholic fatty liver disease. Looks like alcoholic statosis but ALT/AST is not 2:1. Risk factors are obesity, DM, hyperlipidemia, TPN and bypass surgery. Tx is aimed at the cause and also Urodeoxycholic acid might help reduce Transaminase levels.*****Insulin resistance is the most lkely mechanism. Insulin resistance leads to increased accumulation of fat in hepatocytes by increasing the rate of lipolysis and elevating circulating insulin levels. Intrahepatic fatty oxidation then leads to increase in oxidative strss thereby causing a local increase in the proinflamatory cytokins, TNF-Alpha, with consequent liver inflamation fibrosis and ultimately cirrhosis.

Norepinephrine
Is a powerful vaconstrictor, used for pt with hypotention. Sometimes it will cause the hand to become cold & blue acutely. That’s why its only used in ICU setting. Thrombosis of the forarm could cause bluish discoloration but not coldness and not in acute setting.

Normal P Hydrocephaluls
Triad of: Gait disturbance, Dementia and Urinary incontincence. Memory impairment is very slow. CT or MRI shows dilated ventricles. CSF opening pressure is normal. If repeated spinal tap results in improvement then ventriculo-peritoneal shunt is definitive tx. DDX1:Multi infarct dementia, does not show dilated ventricles. DDX2 Alzhemier does not cause gait or urinary incontinence. DDX3:Pseudomotor Cerebri, seen in young , obese females and presents with HA, NOT memory impairment. and enlarged ventricles ARE NOT seen in MRI. In fact ventricles are shrunken. CSF pressure is increased, but the fluid is normal. papilledema is present.

Normal pregnany
Respiratory alkolosis.

Nosocoma infection
E.Coli and Staph aureus are the mcc of NI. UTI is the mc type os NI. Risk factors are Femlae sex,not under antibiotics, prolonged cathaterization and improper cathater care. Surical site infection is the 2nd MC type. Nosocomal Peuomonia is the 3rd MCC. Its the leading DEATH causefrom NI. Seen in intubated pts. Major organism is Pseudomoa.


Nursemaid elbow
Occurs in 3-5 yo children. Its subluxation of head of radius. At elbow. Can be caused by swinging a child or pulling her hand in a hurry.Child doesn’t want to move the arm, she is not distresed at presetation but will cry if you try moving it. Dx is clinicaly, cause xray is normal tx is Gentle passive elfow flextion and forearm supination.

Obstructive Jaundice
Obstructive or Cholestatic jaundice.Presents with elevated direct billirubin and disproportionate elevation of serum alkaline phosphotase. It maybe due to gallstones or carcinoma of head od pancreas for which CT is the best initial test. CT is used when US can ot explain th Dx.

Obstructive Sleep Apnea
Is common among obese population. Pt presents with 1-Habitual night time snoring, 2-Day time Somnolence, 3-Hypertension. Usually obese, middle age man, Investigation of choice is Nocturnal polysomnography. Lateral Cephalometry is only indicated when pt is scheduled for surgery to relife obstrution. MRI is also used only in presurgery pts. Multiple Sleep Latency Test is used only if Nocturnal Polysomnography is not conclusive. ****HT is a complication, weight loss helps, Apneic symptoms increase with age, cor pulmonale can develop, and Benzodiazepines are CI in these pts.

OCD - 3
Is asso with Serotonin levels that regulates mood, aggression and impulsivity. First line tx is SSRI, 2ndline Clomipramine.****Pts with Touret who keep repeating the same gestures are at risk of developing OCD tht makes them keep repeating the same habits.

OCP:
Chronic OCP can cause hypertension, discontinue it and problem goes away.*****SLE pts with increased risk of thrombosis (antiphospholipid and nephritic synd) and pts with active renal involvemnt should avoid OCP.****Pt with Migrain should avoid OCP due to increased risk for Stroke. Breast cancer has NO asso with COP. Endometrial and Ovarian cancers risk is decreased with use if OCP****When you 1st start taking it it could cause irregular bleeding and that is the mcc of incompliance. Tell the pt to keep taking it and it will be OK.

Olanzapine SE
an atypical antidepresant for Schizofrenia. Also for Bipolar disorder alone or with mood stabalizers (Valproate). Weight gain is the mc SE. Agranulocytosis is fro Clozapine not Olanzapine.

Open fractures
Should not be closed primarily because of increased risk of infection and subsequent osteomyelitis. So dress the wound and plaster it.

Opiod toxicity
Pinpoint pupils and respiratory depression are hallmarks. IV Naloxone is Tx of choice.

Oppisitinal Defiant disorder
Children that fight and argue with parnts and other eldely.

Optic Neuritis
Central scotoma (an area of blindness or lowered vision involving the central area of the retina), afferent pupilary affect, changes in color perception, and decreased visual acuity. Its asso with MS. Usually occurs in adult women. Pain on eye movements.

Orbital Cellulitis
Characterized by abrupt onset of fever, proptosis, restriction of extra ocular movement and pain, swllen and red eyelids. Causative agents are S. aureus, S. Pneumonia and H. influenza, tx is immediate IV antibiotics. MC in children.

Osgood-Schlater:
Typical pt presents b/w 10-17 yo male with knee pain at tibial tuberosity which is the site for insertion of quadricept tendon. The exact cause is unknown but repeated stress and trauma is an important factor. It’s a self limited condition****Its also called osteochondrosis of tibial tubercle, seen in young teens due to overuse.

Osteoarthritis - 5, Rheumo 6/2
Obesity is a risk factor, so the single best step in the mgmnt of pt is to loose weight. ****Xray of handS shows Narrow joint space and sub chondral cyst at distal interphalangeal joints. Heberden nodes are seen at DIP joints. Boucher nodes are at PIP joints. Xray was not clear. I missed Dx.*****Once the pt has been given NSAID and even had arhtroscopic shave of articular surface, if she still has severe restriction in walking and nocturnal and rest pain, the next step is total knee replacement. Rehabilitation takes a long time but functional recovery is excellent. ***ALWAYS Acetaminophen is the FIRST line of tx for pain control. If they fail then NSAD, like Indomethacin is used. If pt is at risk of Upper GI bleeding or no respond to Analgesics then COX2 inhibitor like Celecoxib is used. ****Xray shows narrowing of the joint sace and osteophyte formation, RA shows narrowing of the space and juxta articular erosions. DDX:Gouty arthritis has punched out erosion with a rim of cortical bone, RA has narrowing of joint space and juxta articular eerosins. Infectious and Gonococcal arthritis have normal joint space and tisue swallowing. Psoriatic arthritis has marginal bony erosions and irregular joint destruction.

Osteogenesis Imperfecta
An inherited CT disorder caused by mutation in gene coding for Colagen type 1.

Osteogenic Sarcoma:
Present with painful swelling around the knee. ESR is normal and Alk Phosphatase is elevated. Xray shows osteolytic lesion with periosteal reaction. There maybe a hx of trauma.


Osteomalasia -2
Defective mineralization of BONE in adults. In children, Rickets is defective mineralization of BOTH bone and cartiladge. In Osteogenesis imperfecta there is defective collagen formation (type 1). Low ca, low phosphate, high PTH.

Osteomyelitis - 6
Generally, S.aureus is the mcc. However in Sickle cell pt, Salmonela is mcc. Group B strep is the mcc in children <1 yr. And Pseudomona is the mcc in puncture wounds ( tx is with oral or parenteral quinolone & aggressive surgical debridement. Now Spinal OM: Lumbar area mostly affested, low fever and elevated ESR, paravertebral muscle spasm in PE, its important to Dx early because epidural abscess and spinal cord compression may develop. MRI is modulity of choice for Dx. * Its common in young children secondary to hematogenous spreading of organism mc from upper respiratory infection or partially treated distnt infection. It occurs in metaphysis of lung bones. Infection in the bone lead to formation of dead tissue called sequestrum. Periosteum is elevated and forms a periosteum new bone called involucrum. Pr presnts with pain tenderness and warmth over the involved bone. Fever, sweeling and elevated esr is seen . Dx is done cliniccally but bone scan can be done to localise it cray is typically normal in the begining. If xray is negative technetium bone scan is test of choice. Bone biopsy is the gold standard. In case of suspecting Osteomyelitis, blood cultures must be taken to ID the organism and and pt should be on IV antibiotics. If blood culture are negative, then needle biopsy is done.****S. Epidermitis is a frequent cause asso with prosthetic devices. ****Hx of IV drug user, high grade fever, and bony point tenderness is always OM unless proven otherswise. Pt should revieve antibiotics immediatly after blood cluture obtained. Three phase TECHNITIUM SCAN is the test of choice for acute OM and its very sensitive. Plain xray is usually normal in first 2-3 weeks.

Osteoporosis - 4
Test to check for OP and Osteopenia is Dual Energy Xray Absorptiometry (DEXA) of spine and pelvis. CT is most sentitive but not the test of choice. Risk factors include: 1-Thin body habitus, 2-smoking, 3-alcohol, 4-steriod use, 5-menopause, 6-malnutrition, 7-family history, 8- Asian or Caucasian. Numbers 1,7,8 are non-modifiable risk factors. Dx is by DEXA. Tx is 1000mg/d Calicium for 31-50yo. 1200mg for >50yo plus vitamin D. Pt should be encouraged to modify life stype, like weight bearing excercise, smoking cessation and alcohol abstinence. *****DOC for osteoporosis pts with HT is Thiazides, they are asso with decrease in the unirany calcium excretion. ***** Compresion Fracture of the vertebrae is a common complication of advanced OP. Local tendernes is present. Remember that Bilateral decreased ankle reflex has little significance for pt that are old due to normal aging process. Older pts on Glucocorticoid are at increased risk.

Osteosarcoma
Classic Codman triangle (sclerotic lesion in distal femur with periosteum lifted) and SUNBURST appearance are the two radiographic features. The mc initial symptom is pain. Tx is Surgery.

Otitis Externa Malignant – 4, ENT 6/2
Hallmark is pain on traction of pinna. By Pseudomina, swimmer's. Tx is systemic ciprofloxacine is the most appropriate initial therapy. Malignant OE is seen in DM and immunocompromised pt, malodor green discharge, granulation, CT should be done to seek damage, Tx is in-hospital admin of parenteral Ciprofloxacine and possible surgical debridement.****Fungal ones have whie fibers in canal and Bacterial ones have nothing.

Otitis Media – 2, ENT 6/2
Usually follows URT infection. Boggy nasal mucosa, postnasal drip. Pt present with earahce, fever, decreased hearing. Inflamation of tympanic membrane and diminished movement of the membrane with air insufflation (blowing into) are halmark of the disease. Amoxicilline is DOC.****Acute Otitis Media, The mc pathogen is Strep pneumonia (40%), 2ns is H. influenza (25-30%). and third Moraxella (10-15%). The first line of tx is Amoxicilline. If it fails then Amox+Clavulininc acid.*****Chronic OM: presents as purulent discharge. Tympanic membran appears thicker with calcific patches but there is no exudation of debris or granulation tissue, ***** Serous OM: results due to prolonged blockage. The tympanic membrane is dull and hypo mobile. Air bubbles are seen in the middle ear. Hay conductive hearing loss. *****the most specific for Dx is Immobile tympanic membrane.

Otosclerosis
Autosoma dominant, osseous dyscrasia limited to temporal bone. It presents as hearing loss by third decade of life. Audiometry shows hearing loss and loss of stapedial reflex. Tinitus is also a sign. More common in women. Tx is oral sodium chloride.

Ototoxicity
Furesamide, Aminoglycosides, vancomycin, quinine and chloroquine.

Ovarian Cancer
Screening for CA125 and vaginal US are good eough for pt at risk of OC. Althout there is no evidence that US of abdomen can help decrease mortality from OC.

Ovarian failure, chemo induced
chemotherapy causes failure of follicular cells of the ovary resulting in decreased production of estrogen and inhibin. This result in loss of feedback inhibition of estrogen on FSH and LH , causing their high levels. Inhibin causes feedback inhibition of FSH only, so in the absence of inhibin, FSH levels are higher than LH which is pathognomonic of ovarian failure.

Ovarian HyperStimulation Synd
Major complications of ovulation induction are multiple gestation and OHSS. OHSS occurs in 1-3% of pts. It develops 5-7 days after administrationof hMG or hcg and refers to acute increase in vascular permeability of enlarged ovaries. Symptoms include abdominal pain, distension, nasea, vomiting diarrhea, weight gain,hypotension and pleural effusion. Ovaries are large in US. OHSS maybe complicated with oravian torsion, ovarian rupture, renal insufficiency. Symptoms resolve in 1-2 weeks, but may persist longer is pregnancy is successful. Tx is supportive