USMLE World Notes-6

Sheehan syndrome
Develops due to ischemic necrosis of pituitary gland. Impaired ADH secretion casues full blown Dibetes Insipidus.

Shingles
After initial infection with VZV ( chicken pox ) latent infection is establised in the sensory dorsal ganglia. Characterized by vesicular eruption that occurs in a dormatomal distribution.

Shock - 4
From First Aid, How to Dx shock? 1-Look at CO, if <5, then look at PCWP, if its <18 Its Hypovolemic(Trauma,blood los,burns), if its >18 its Cardiogenic shock(Tension pneumothorax,CHF,Temponade,arrhythmia). 2-If CO is >5, look at fever, if there is fever its Septic, if there is no fever, its Neurogenic Shock(or Anaphylactic shock. Bee sting,medication, food alergy). *****Hypovolemic: Has 4 stages depending on degree of blood lost. 1-CLASS ONE: 10% loss of blood (about a unit). Pt is alert but a little lightheaded. BP is normal. Skin and organs are not affected. Pt respondes by tachycardia. This is the first response to compensate in hemorrhagic shock. Physiologically this response is affected by secretion of catecholamines and an insrease in sympathetic tone. 2-CLASS TWO:20% blood lostt. He is like to be confused anc combative. Althogh mean arterial BP is normal, Pulse pressure (systolic-diastolic) has narrowed. Urine output has decreased. Skin is cool and moist. His mental status reflects fight or flight. The change in PP is consistent with increased vasoconstriction. 3-CLASS THREE:35-40% blood lost and can no longer maintain BP. . He will maintain CO by further increasing HRand increasing after load. His mental status is stupor. 4-CLASS FOUR:if blood loss is >40%. pt goes to coma and BP is incompatible with life.**** 1-Septic: results from decreased systemic vascular resistance due to significant vasodialation. Hyperdynamic circulation leads to elevated CO. Normal MVo2 results from hyperdynamic circulation. So there is a)elevated co, b)low systemic vascular resistant, right atrail pressure and Pulmonary Capilary Wedge Pressure. c)Normal Mixed Venous oxygen concentration. 2-Cardiogenic : has increased PCWP (too much blood to pump due to shock). 3-Neurogenic: has low MVo2 due to increased oxygen extraction by hypoperfused tissues. Low left vent preload is also characteristic . 4-Hemorrhagic shock presents wth bleeding.***Hemorrhagic Shock: happens in trauma setting, most propabely from ruptured abdoinla organs bleeding. Either ER US or Diagnostic Peritoneal Lavage should be considered in UNstable pt, onve IV fluids are connected. CT is indicated in stable pts. with suspected solid organ injury. REMEMBER muffled heart sounds are common in severe hypovolemiaand DONT necessarily indicate Pericardial fluid, moreover Cardiac Temponade is unlikely in the absence of JVD. So problem is most likely ruptured abdominal organ.***Septic shcok:both RA presure and PWCP are low. Hypovolmic Shock:Both RAP and PWCP are low. ****hypovolemic shock, 1st parameter to change is pulse rate. *****Hemorrhagic shock: Pt presents with 70/0 BP and CVP of 0. If pt is Unstable with suspected intraabdominal bleeding the best dx procedure is Peritoneal Lavage. USG is actually the best option. The pt may ultimately need exploratory laparotomy but 1st step is DPL. If pt is stable then CT is the best option for dx.

Shoulder Dislocation
Tonic-Clonic seizures may cause posterior dislocation os the sholder. It presents with internaly rotated arm and pt can not do external rotation os the arm, and there is intact sensation and reflexes. Anterior dislocation occurs with sensory loss and Pt can rotate the arm externally. Axillary nerve is the mc nerve injured in this situation.

Shy-Dragger synd
Characterized by 1-Parkinsonism, 2-Autonomic dysfunction(Postural hypoension, abnormal sweating, bowel or bladder control problems, abnormal salivation or lacrimation, Impotence or gastroparesis). 3-Widespread neurological signs. Always suspect it when a pt w Parkinson experiecnes postural hypotension, impotence or incontinence. Anti-parkinson druga are ineffective, and tx in aimed at intravascular volume expansion. DDXM Neuropathy, can cause the symptoms but it happens in a pt who is not controlling blood sugar and it takes a while to develop.

SIADH - 3
Asso w small cell carcinoma of the lung. Severe hyponatremia(specialy when pt has CNS symptoms like disoriented and irritable) requires aggressive mgmnt with IV 3% saline w/wo Furesamide. Rapid correction should be avoided cause it can lead to pontine myelinosis. Summary of the mngmt of hyponatremia due to SIADH : 1-Mild(Asymptomatic w Na 120-130) = Fluid restriction, 2-Moderate(Asymptomatic w Na 110-120) =Loop diuretic+Normal saline, 3-Severe(CNS symptoms) = Hypertonic saline(3%).*****HYpotonic hyponatremia with euvolumia, Low plasma osm and high urine osm. before the dx of SIADH is entertinaed, hypothyroidism and adrenal insuficiecny should be ruled out. One of the causes of SIADH is NSAID therapy. DDXI, polyuria,polyduspsia, hypernatremialow urine osm and high serum osm. *****Tx steps:1-Water restriction is the 1st step in managing hyponatremia. 2-If the pt sodium is below 120 or if he is seizing, emergency tx is administration of 3% Sodium Chloride solution (solution of hypertonic saline) to raise serum sodium to 125 . 3-If the pt has evidence of fluid overload, Hx of CHF or is resistant to tx then Furesamide maybe added. 4-Chronic tx may involve Lithium or demeclocycline, which inhibit ADH action.

Sialolithiasis
Sialolithiasis or calculus in the ductal system of salivary gland is mc in Submandibular gland followed by sunlingual and parotid. Pt will have recurrent Sialoadenitis (infection of salivary gland). Sialolithiasis presents as postprandial pain and sweling. Stones in Wharton duct are radioopaque, so xray is dx. Tx is dialation and incision of involved duct to remove the calculus.

Sick Euthyroid syndrome
Pts with any acute severe illness may have abnormalities of throid hormones and TSH in absence of any underlying thyroid abnormality. This is called SES. The mc pattern is a fall in total and free T3 and normal T4 and TSH levels.

Sick sinus syndrome
Test#6. Q=22. Tx is permanat pacemaker.

Sickle cell disease - 6
Sicke cell trait is most commonly Asso with Painless hematurea in black male. *****Suplementation of Folic acid is recommended in ALL pts to prevent occurance of aplastc crisis. Aplastic crisis happens for two reasons, 1-Folate def, 2-Infection with Parvo virus. Note:Hydroxyuria is used when painful crisis happens frequesntly, it produces its effect by increasing HbF levels.*** May cause acute painful crisis. adequate hydration and oxygen therapy is necessary to terminate the episode. Hydroxyuria is used when frequent painful episodes interupts life. Acute Vasoocculsive crisis is an important complication that may cause Stroke, PRIAPISM. Exchange transfusion is indicated whenever Oclussive crisis occurs.****Pts with SC encounter constant clumping of sickled cells, leading to repeated microinfarctions in the spleen. By 2-3 of age, they have functional Asplenia. Since one of important functions of spleen is to remove CAPSULATED organism, like Pneumococcus, and H.Influenza, pts will be at risk of infection with these organisms. For this reason, antibiotic prophylaxis and vaccination against Pneumonoccal and H.Inf are given standardly to pts. with functional Asplenia. So if a 5-yo boy persnts with high grade fever, hypotension, altered mental status, elevated WBCand Bandemia, its sepsis due to Pneumococcus.****Acute painful Crisis:is due to vasoocclusive events. First step is hydration and opiod analgesics. If pt has frequent acute crisis, then Hydroxyurea is indicated. This is a cytotoxic agent that increases Hb F by simulating erythropoisis. Since the function of HbF is to retard sikcing leading to decresed sicking and less occlusion of vessels by sickled cells. Now Folic acid is helpful in all SC pts, becuase it helps with eryhtropoasis, its helpful in preventing aplastic crisis. If aplastic crisis happen, blood transfusion is indicated. *****when pt present with acute severe anemia, they may be Aplastic Crisis, Splenic Sequestration Crisis or Hemolytic Crisis. Aplastic crisis result from transient arrest of erythropoesisand mf asso w infections, the mc is B19. Hay sudden drop of Hb concentration and absent reticulocytes. Tx is blood transfusion. Splenic Seq occurs in pts who have not yet had splenectomy. Characterized by vaso constriction and pooling of blood in spleen. Hay marked decrease in Hb concentration but persistant reticulocytosis. Pt develops rapid splenomegally, severe hypotensive shock. Tx is spleenectomy to prevent recurrences. ****Acute Chest Synd are chest pain, fever, and infiltrate in cxr. It is one of the mc complications of SC.

Sideroblastic Anemia
Results from defective heme synthesis, most commonly due to Pyridoxine-dependant impairment. Specially if pt is taking Isoniazide. It manifest as hypochromic microcytic anemia simulating iron def anemia. But iron studies reveal elevated iron and increased TIBS (DDX). Tx is pyridoxine (B6). MCC is Chronic Alcoholism. Smear shows Iron granules in blue around the nucleus.

SIDS
Sudden Infant Death Synd. Infants should be put on their back(SUPINE) while sleeping to reduce mortality. They are the leading cause of infant mortality from 1mo-1yr.

Sinusitis, Acute Bacterial
MC Pediatric bacterial agent is Strep pneumonia, then H. Influenza, then Moraxella catarrhalis. Dx in children <6 is based on clinical rather than radiological criteria. For uncomplicated sinusitis, Amoxicillin. Presents with persistnat thick nasal discharge, nasal congestion, HA, cough, low fever, maxillary sinuses are tender. Complicated sinusitis could present with orbital complications and abscess. Do a CT to Dx or rule out complicax.

Sjogren- 6/8
An autoimmune chronic dysfunction of exocrine glands. Pt devlops dental carries due to salivary insufficiency. Xerostomia leads to difficulty swalowing and talking. Eye show keratoconjunctivitis. Lab shows, anemia,leuukopenia,eosinophelia and elevated ESR. Lip biopsy is the ONLY specific dx technique.

SLE - 8
MCC of death is chronic renal fialure. ****DDx b/w SLE and RA: Arthritis in SLE is non erosive and in RA its erosive. Kidney is damaged due to immune-complex deposition (type II). "Goodpasteur" damage is caused by type III. "Methicilin interestitial nephritis" caused by IgE (Type I). "DM & Hypertension" are caused by non immune reasons. When there is evidence of kidney failure in SLE, the next step is to do renal biopsy and therapy is directed to the pattern of the glomerular involvement. There are five patterns. Type I & II no need for tx. Type IIi&IV need immunosuppresants. Mainstay of tx is IV methyprednisone. If it didnt responde then Immunosuppresants (Cyclophosphamide) is given. In SLE pt with active Nephritis OCP should be avoided. ****SLE presents with 5 types of renal involvements:1-Mesangial, is the earliest and least severe. 2-Focal, is more severe than Mesangial, there are proliferative changes and areas of necrosis. 3-Diffuse proliferative, is the mc type and the severest type. It has the worst prognosis. There is Hematuria, proteinuria, renal insufficiency, hypertention, hypocomplementemia, marked elevation of anti-DSDNA. 4-Membraneous GN, renal function is preserved, basement membrane is thickened, and subepithelial deposits are present, it has a better prognosis than Diffuse. 5-Sclerosing type, presents healing of previous inflamatory damage, urine is normal and immunosupresive drugs are not effective since hay no inflamation.****Tricky Q, if the vgnette says no anti-sm antibodies that does not rule out SLE because 30-40 of pt dont have it. SLE pt could have: muskuloskeletal hematological, skin,lungs,kidney and serous membran problems. If a pt has 4 or more its dx. DDX with Mixed CTD is Anti-RNP antibodies.****Renal involvment in SLE is due to immune complex mediated glomerular injury. These complexes are primarily composed of Anti-DsDNA antibodies. Remember Anti-Sm antibodies remain elevated even when dis is no longer actve. Anti-RO antibodies are asso with Neonatal Lupus.*****DDX b/e RA and SLE is that SLE has non erosive arthritis.****Scarring Alopecia is the skin related problem in SLE pts.

Sleep Apnea
First line of tx is Weight loss,avoidance of sedatives (benzos) and alcohol, and avoidance of supine posture during sleep. Other options are Positive Continues Airway Pressure. If all fails then Tracheostomy is the optin. Dx is with polysomnography.

Sleep terror disorder
episodes of sudden fearful waking . Later they dotn remmeber it. DDX:Nightmare dsorder, pt remembers in detail the dream.

Slipped Capital Femoral Epiphysis - 2
SCFE Is a result of failure of the growth plate b/w femoral neck and femoral head, resulting in displacement. Its seen in adulescence with overweight problem. Pain & limp are presenting complains. Dx is by Xray. Must contain Hip, and both front 'AP' and Lateral 'frogs' views. SCFS can progress to Avascular Necrosis if untrearted, xray will show bone cyst or sclerosis. If AN is in advanced stages, xray shows collapse of the bone.Pt needs urgent surgery in SCFE.****Its a medical emergency the prompt surgical intervention is needed to prevent the two cmoplications of Avascular necrosis of the femoral head and Chondrolysis. Surgical fixation of the hip with screws is the tx of choice.

Small Cell Carcinoma Lung
Asso with SAIDH. SCC has usually metastacised by the time its discovered.

Smoking cessation
Use Bupropion.

Social Phobia
pt is isolated because he is afraid of being in public, He can speak infront of people and gets anxous evenin small parties. Tx of choice is Assertiveness training (Cognitive&Behavior Therapyor CBT) plus SSRI.

Solidary pulmonary nodule
T9Q8

Somatization disorder - 2
Pt presents with pain and symptoms in : 2 GI, sexual or reproductiive symptoms, and one pseudoneurological symptom (HA,blindness, deafness, weakness.). It presents before age of 30 and in mostly females.*** If pt asks for CT, tel her you woud like to see her on regular basis before CT scan.

Specific Phobia - 2
Pt is afraid of swimming pool. The besr approach is Systemic Desensitization. Beta blockers are for Performance anxiety. Benzodiazepin is for acute panic attack. Cognitive-Behavior therapy is for chronic Panic attack and GAD.****Pt 9 yo doesn’t go tro shcool and he says he s afrid of Dark clouds. Tx is CBT (congitive-behavioral therapy) that repeatedly exposes th ept to the object.

Spherocytosis - 2
Due to RBC membrane defect mostly from Spectrin deficiency. In PNH defect is in Decay Accelerating factor. In Thalasemia absence Beta chain synthesis is the problem. Malabsorption results in B12 and Folate def which is the cause for Macrocytic anemia. In Sickle Cell there is substitution of Glutamin for valine amino acid in polyeptide chain. ****Autoimmune Hemolytic Anemia: Pallor,Jaundice,elevation of indirect bilirubin & reticulocye count & LDH are all indicative of AHA. Splenomegally is asso with ExTRA-vascular hemolysis, while descreased level of Haptoglobin is indicative of INTRA-vascular hemolysis. AHA pt have decreased Haptoglobin and Intravasculat hemolysis. Hereditary Spherocytosis pt have Extravasculat hemolysis. Its an aduto dominant so there MUST be family Hx in vigniette. MCHC is elevated, Osmotic Fragility test is positive, but its ALSO positiv ein AHA. . Now in AHA Coomb's test is also positive. But since its not always positive in all cases of AHA we do Micro-Coombs test to confirm the dx of AHA. So bottomn line, spherocytosis may also be seen with AHA and Negative family hx and positive Coombs test , thes DDX AHA from Spherocytosis.

Spider bites - 2
1-Black Widow spider: causes acute abdomen that is tx with combination of Muscle relaxant+Calcium Gluconate. 2-Brown recluse spider: Produces extensive localized skin necrosis resembling Pyoderma Gangrenosum. Dapsone is used to reduce the extent of local necrosis in pts who have been screened for G6PD deficiency. ****Brown spider bite, pt has an ulcer on the thigh, the mc complication is deep ulcer with necrotic center and erythomatous halo. Local excision is the tx of chouce. In BLACK WIDOW spider ther mightbe abdominla rigidityand muscle cramps. Pts develop N&V and initial site of bite is not seen. Tx is Calcium glucanate and muscel relaxants.

Spinal Cord Compression
Or Cauda Equina Synd. Pt presens with absent rectal tone, urinary incontinence, motor and sensory loss in extremities. This is a surgical emergency. Do MRI to determine the site of compresion. It may occur in males repeatedly due to prostate cancer that has metastasized to spinal column.

Spinal Cord Injuries
1-Anterior Cord Synd: Asso with BURST fracture of the vertebra characterized by total loss of motor function beloe the level of lesionwith loss of pain and temperature. On both sides below the lesion. MRI is the best dx method. 2-Central Cord Synd: Burning pan and paralysis in upper extremities with relative sparing of lower extremities. Seen in elderly due to hyperextension of the neck injury. 3-Brown Sequard synd: Ipsilateral motor and proprioception and loss of contralateral pain below the level of lesion.

Spinal Stenosis, Lumbar - 2
It can present with Neurogenic claudication. The pt presents with calf pain when he stands up and walks. . Neurogenic claudication from spinal stenosis. Its POSITIONAL Intermittant Claudication , pain does not occur at rest while standing or in certain position, it happens only pt walks. Dx is MRI. DDX1:Cada Equina synd (tumor), causes urinary retention or overflow incontinence. DDX2: Leriche Snd, presents with atherosclerotic vascular dis, impotence and intermittent claudication. DDX3: Arterial Insufficiency is not positional. Dx is Arteriography and Doppler.

Spleenic Contusion:
Asso with fracture of the left lower ribs. Breath sounds are normal and no respiratory distress.

Spleenic Trauma
The immediate mngmnt caused by blunt abdominla injury depends on hemodynamic status and response to IV fluids. If initilay he is Unstable, but improves with fluid, Next best step is to get a CT. If initialy Unstable and iv fluid doesn’t help, Emergent Exploratory laparotomy is indicated. If CT shows no operation is required, then admit him to surgical ICU for monitoring.

Spondylolesthesis:
Is a developmental disorder characterized by a forward slip of a verebra, that usually manifest in pre adulescent children, Back pain, neurological dysfunction (urinary incontinence) and a palpable “step-off” at the lumbosacral area are present if the disease is severe.

Spontaneous Bacterial Peritonts
Always suspect SBP in cirrhotic pt with fever and ascites. SBP is peritonitis in the absence of an apparent source of infection. SBP is almost always seen in adults 2ary to severe cirrhosis especially alcoholic cirrhosis. It almost always occurs in pts with ascites. Its characterized by growing a single bacteria in ascites fluid, usually E.Coli. Clinical features include unexplained fever in a pt with cirrhotic ascites and abdominal pain. Ascites fluid containing PMN>250/L, SAAG(Serum to Ascites Albumin Gradient) >1.1 and G- bacili in a cirrhotic pt is highly suggestive of SBP. Presence of >10000WBC/L ,multiple oraganism, or failure to improve after 48 hr therapy is suggestive of 2ary Peritonitis. Suspected SBP should be reated empiricaly with Cefotaxim or an Ampiciline with an aminoglycoside. Recurrence is very common.

Sporotricosis
Garderners dis, postules and painless ulcers at finver tip.Tx is ????

Squamous CC Lung
Hypercalcemia nd hillar mass in a smoker of more than 45 yo is most likely SCC of lung. Even though hypercalcemia usually develops due to metastatic bone involvement , its also because PTHrP (r=related, p=protein). Its like PTH and bind to same receptor and increased absorption of Ca in distal tubules.

Squamous CC Skin - 5
The single most important factor is sunlight exposure. Its associated with Leukoplakia (a whitish patch in tongue that is hard to remove and its granular, an incisional biopsy or cytology should be done). Appears as an ulcer that does not heal, on the LOWER lip. Characterized by invasive cords of squamous cells with Kerai pearls. Differential diagnosis includes many types of benign and malignant lesions, including basal cell carcinoma, keratoacanthoma, actinic keratosis, verruca vulgaris, and seborrheic keratosis.***Whenver an open ulcer fails to heal after a period, you need to biopsy to ensure that it han not degenerated into SCC. These ulcers are known as MARJOLIN's ulcer. Also remember Aktinic Keratosis is a recursor to SCC.**** When ulcer dosnt heal, suspect SCC, nest step is PUNCH biopsy. If SCC, WIDE excision is the Tx of choice.****Actinic Keratosis turns into SCC.

Statin intolerance/Toxicity
CPK elevation of more than 10 times in presence of myalgias/myopathy. Rhabdomyalysis in an Acute renal failure could be a consequence. Tx is stop the drug and supportive therapy for Rhabdo.

Status Epilepticus
An emergency. Mgmnt step are: 1-Place pt lateral with mandible pushed forward. 2-medication started. 3-if medication failed after 30 min , then general anesthesia and intubation is indicated.

Stevens Johnson's
Target shaped mucocutanous lesions and systemic signs of toxicity. Pathology involves immune complex mediated hypersensitivity.

Still's dis, Adults
Is a variant of RA. Pt presents with 20-30yo, high spiking fevers with CHARACTERISTIC salmon colored rash, arthralgias, arthritis, Leukocytosis. DDX1:Parvovirus (Slapped cheek dis), malar,eryhtomatous rash, arthralgia or arthritis. DDX2:Henoch-Schonlein purpura, in children, rash,abdominla pain,arthralgias and renal dis. Rash is pruritic and involves lowerlegs or Buttucks.DDX2:RF, PECCS. Erythema Marginatum is Evanescent(tending to vanish)erythomatous non pruritic mostly on the trunk.

Stomach cancer
The only malignany that has decreased universaly. The reason is not known.

Strabismus:
The mcc of amblyopia (decreased visual acuity) is strabismus. The mc type of strabismus is esodeviation (medial deviation of th eye). Tx is to cover the normal eye.

Stranger Anxiety
When a child is left in unfamiliar places (day care). From 6-8 months and peaks in 12-15 months. DDX:Seperaion aniety is with older childs when seperated from a love one.

Stress Fracture
Bone pain at rest, worsens with exercise, swelling and point tenderness, Xray is normal at initial stage and MRI is dx, Tx is restrictive weight bearing along with short leg cast, healing takes 3-4 weeks. It occurs in young dancers's legs.

Stroke - 6
Stroke can be 2 types, Hemorrhagic (intercerebral or subarachnoid) or Ischemic (secondary to thrombosis, embolism, or systemic hypoperfusion). Blood supply of the brain is 1-Anterior vasculature, internal carotid A and its branches Anterior and Middle cerebral A. 2-Posterior vasculator, paired Vertebral A and they join to make Basilar artery, which divides to make Posterior cerbral Artery. Now Deficiencies produce: 1-ACA:Contralaterla motor and sensory deficit wich is more pronounced in the lower rather than upper limbs.Urinary incontinence, gait ataxia. 2-MCA: Contralateral motor and sensory deficitwhich are more pronoucedin the Upper rather than lower limbs, and homonomous hemianopia. If the dominant lobe (left) is involves hay aphasia, and if non-dominant (right) is involved hat neglect syndrome and anosognosia(pt cant tell is there has been an injury to the body). 3-PCA: Homonomous Hemianopia, ataxia w/o agraphria, visual hallucination(Calcarine cortec), sensory symptoms (thalamus), third nerve palsy with paresis of vertical eye movement and motor deficit (mid brain). 4-LACUNAR infarcts: are small non cortical infarcts caused by occulsion of a branch of a cerebral artery. Risk factors are hypertension, DM or Polycythemia. They usually dont produce both motor and sensory symptoms but rather have well recognized syndromes, like pure motor hemiparesis, pure sensory stroke, dysarthria-clumsy handor ataxic hemiparesis. *If a pt presents w/i 3 hours of ischemic attack, thrombolytic therapy with tPA (after CT scan) should be started. Dont try to regulate BP first, it might impair autoregulation and make it worst. Streptokinase does not help either. tPA is tx of choice. * THALAMIC stroke:Involves VPL part of thalamus that transmits sensory info from contralateral part of body. Presents with hemianesthesia accompanied by hemiparesis, ahtetosis. Dysesthesia (numbness and tingling burning feeling) of the area affected by the sensory loss is chracteristic, and is called thalamic pain phenomenon.****HT has the highest risk factor for Stroke, more than smoking,alcohol,hyppercholesterol.....****If pt presents with hemiparesis and speech difiulty like broken words then its Expressive aphasia related to Dominant frontal. But if he cant understand what is being said to him then it is Parietal dominant(Dyscalculia,Dysgraphia). ****If a pt comes in with hemiplasia, you need to first ddx b/w Hemorrhagic and Ischemic stroke and then give medication. To DDX you need to do CT WITH OUT contrast, if its ischemic (thrombi) then we give aspirin and then we do carotid Doppler and TEE to evaluate source of embolism.

Stuge-Webber Synd:
A neurocutanous condition. Its auto dominant therefore doesn’t affect multiple generations. Pt will have a cerebral lesion on the same side as facial nevus. Also exopthalmus due to ICP. Dx is CT. The cerebral lesions are nevi involving the leptomeninges and are thus similar to the facial lesions.*****Caverness unilateral hemangioma is another presentation. Skull Xray after the age of 2 years shows gyriform intracranial calcifications that resembles the tramline. Tx ia aimed at controlling seizure and reducing ICP. Laser therapy w Argon to remove skin lesions.

Subacromial bursitis
It refers to inflamation of the subacromial bursa. It occurs in athlets as pat of impingment syndrome. Its characterized by shoulder pain, which is absent at rest but present at overhead activity. Range of movement is limited by pain. Neer sign (pain on passive internal rotation and forward flextion at shoulder) is present. US or MRI confirms Dx. Tx is conservative with NSAID, physical therapy. DDx is Tear of long head of bicept tendon, which will lead to bulging muscle mass in the middle of the arm.

Subacute Combined Degen
T9Q42. Tx is B12

Subarachnoid hemorrhage –4. 6/3
Rupture of aneurysm is the most frequent cause. Hypertension is the mcc for Intracerebral Hemorrhage. They are most prone to rupture when they’re >7mm. Pt should be evaluated with cerebral angiography and treated surgically. Pt should be evaluated by cerebral angiography and treated surgically. AVM is the mcc of SAH in children, the hx of seizure and migrain like headache is characteristic.****Vasospasm is the major cause of morbidity and mortality in pts with SAH. Calcium channel blockers (Nimodipine) are used to prevent spasm in these pts.****SAH or "cerebral-salt wasting syndrome". Patholgy involves 1-SIADH (inappropriate vasopressin secretion) which causes water retention. 2-an increased secretion of an atrial/brain natriuretic peptide. SIADH also results in hyponatremia for which water restriction is the tx of choice. So Hyponatremia is one of the important complications of SAH.

Subcunjuctival hemorrhage. Ophthalmo. 6/3
Redness in the eye, due to hard rubbing or trauma. Its benign and heels spontaneously.

Subdural hematoma
Tear of bridging veins. Picture shows semi lenticula rhematome. MC in Elderly & Alcoholics. Tx is conservative if no midline shift is present in CT. Tx is centered on prevention of ICP by head elevation, hyperventilation (causes vasoconstriction and thus decreases cerebral blood flow), and if needed acetazolamide and mannitol. If there is a midline shift then Craniotomy is indicated but its asso with grave prognosis. DDX1:Epidural hematoma where Middle Meningeal A. is injured. Biconvex hematoma in CT, non contrast. Lucid interval. DDX2:Hypertensive hemorrhage, putamen & thalamus. DDX3:Subarachnoid hemorhage, rupture of aneurysm.

Sublimation:
A mature defence mechanism that allows for unacceptable impulses to be channeled into more acceptable activities. Like aman w fiery temper who channels his anger into athletic pursuits.

Sumatriptan Tox
CI include Printzmetal Angina, CAD, Pregnancy. So is a femlae of child baring age wants it make sure she is not pregnant.

Superficial thrombophlebitis:
Dull pain in the region of the affected vein, eryhtema, induration and tenderness along the vein. High fever and chills and rigor is suggestive of septc phlebitis. Presence of edema and deep calf tenderness is characteristis of DVT. ST is not risk factor for Pulmonary Embolism. Localized ST is treated wth bed rest, heat and NSAID

Superior Vena Cava Synd
Pt presents with Venous congestion of face and arms. The mcc of superior vena cava onstruction is Bronchogenic carcinoma(Small cell tumor) (smokers). Today Angioplasty with stenting is choice.

SVT:
Narrow QRS, HR>140, regular, loss of P wave. If pt is unstable, cardioversion. If stable, vegal maneuvers initially, if failed then IV Adenosine. Verapamil is 2nd DOC.

Supraclavicular fracture:
It compromises brachial artery resulting in bradial artery pulse loss.

Symptomatic Bradycardia
Pt has HR of 40, dizzy,lightheaded, clamy extremities, but no dyspnea or chest pain and no hypotention. He is having severe symptomatic bradycardia dn the tx is iv Atropine.If that didn’t work net step is Transcutaneous pacing. If pt has bradycardia AND Hypotension, then tx is Epinephrine. Reember Adenisine is used for SV tachycardia.

Syncope - 3
Know basic pathophys mechanism and different types of Syncope. The most common pathophysiologic basis for syncope is an acute decrease in cerebral blood flow (with resultant cerebral hypoxemia) secondary to decreased cardiac output; arrhythmias, including conduction abnormalities, are the most frequent cause. 1-Exertional (effort) syncope suggests cardiac outflow obstruction, mainly due to aortic stenosis. 2-Syncope of cardiac etiology typically begins and ends suddenly and spontaneously. It is most commonly due to an arrhythmia. 3-Vasovagal (vasodepressor) syncope is typically precipitated by unpleasant physical or emotional stimuli (eg, pain, fright, sight of blood), usually occurs in the upright posture, and is often preceded by vagally mediated warning symptoms. 4-Syncope due to seizures is abrupt in onset and is associated with muscular jerking or convulsions, incontinence, and tongue biting. 5-Syncope due to pulmonary embolism usually indicates massive pulmonary vascular obstruction and is often associated with dyspnea, tachypnea, chest discomfort, cyanosis, and hypotension. 6-Syncope of gradual onset (with warning symptoms) and slow clearing suggests metabolic changes, eg, hypoglycemia or hypocapnia of hyperventilation. ***7-Situational syncope, Typical senario would include a man middle age who looses consiousness immediately after urination or during coughing fits. The pathophysiology involves autonomic dysregulation, which can be explained by staining or rapid bladder emptying. ****Vasovagal syncope dx is with upright tilt table testing which includes Carotid sinus massage.

Synovitis of the hip joint
Bed rest with the hip joint in a comfortable position is the tx of choice.

Syphilis - 4
Once Dark field microscopy shows the spirochet and its positive, no need to do VDRL or FTA-ABS. But since the pt is at risk of HIV we need to do Elisa for HIV screening.****PRIMARY: Presnts with Painless, shallow CHANCRE ulcer WITH PUNCHED OUT BASE AND ROLLED EDGES and painless bilateral lymphadenopathy. The best dx test is Dark field microscopy. **Secondary: presents with Condylomata lata, highly contagious.****** In pt who is allergic to Penicillin, give Oral Doxycycline.

Syringomyelia
Suspect in a pt with upper extremity areflexia weakess and associated anesthesia in a "cape" distribution. When syringomyelia is associated with Arnold-Chiari malformation, there is caudal displacement of cereberal tonsilsthrough the foramen magnum

Systemic Sclerosis
The cause of pulmonary complication is interestitial fibrosis not tighning of the skin. Prolonged oral administration (> 1.5 yr) of penicillamine (0.5 to 1.0 g/day) can reduce skin thickening. For renal disease, ACE inhibitors are the drugs of choice.

Tachycardia, Vent
Regular (Wide Complex) Ventricular tachycardia has 2 types of tx. 1-If pt is hemodynamically stable (BP is normal, K normal, no bleeding) then DOC is IV Amiodarone, or alternative is Lidocaine. If pt is not stabalized then cardioversion is choice. Digoxin is CI in VT, Its used for Atrial Tachy. For SVT Carotid massage is chioce.

Tamoxifen - 3
An antiestrogen drug used for breast cancer. When used as adjuvent therapy for early stage disease it reduces the risk of recurrence of original cancer and new cancer in other breast. However it increases the risk of 2 types of cancer, 1-endometrial (lining of Uterus) and Uterine Sarcoma. ***It reduces the risk of breast cancer in those who are at increased risk for developing breast cancer, ITS PROVEN. SEE RALOXIFEN.****It increased the risk for endometrial cancer by 1% and ONLY in postmenopasusal women. It decreased risk of breast cancer, so overall it reduces mortality rate. It also decreases risk facto in the opposite breast. It protects against osteoporosis. However it does cause hot flashes and vaginal dryness due to its antiesterogenic effect. Remember its mixed agonist-antagonist on estrogen receptors.

Tay-Sachs dis:
Def of Hexosaminase and accumulation of GM2 gangliosidase, particularly in CNS. Pt presents with hyperacusis, MR, seizure, chery red macula but NOT hepatomegally or lymphadenopathy.

TB -2
1-Induraation of 5 or > is + in: Close contacts of TB pt, HIV pt, Organ trnasplant, chronic steriod therapy. 2-Induration of 12 or > is + in : Immigrants recent, IV drug users, homeless person, prisoners and healthcare workers. Once PPD is positive, it does not mean pt has TB, they have to undego Cxr. If TB is diagnosed then full therapy, if TB is excluded then 9 months of Isoniazide prophylaxis. TB is the mcc of Constrivtive pericarditis in immigrants. It should be considered in pt with unexplained elavation of JVP and hx of predisposure.*****Erythema induratum are nodules in the sheen and calves. They are small tender erythomatous nodules.

TCA intoxication - 4
T9Q15. tx is sodium bicarbonate prevents arrythmia by alleviatng cardio-depressant action on sodium channel. Asso with QRS widening on EKG. It also helps correct acidosis. If pt presents with seizures that need tx we give Diazepam.

Tennnis Elbow
Or Laterla Epicondylitis, is condylitis about the origin of extensors of forearm. Characterized by point tenderness over the lateral epicondyle of humerus and exacerbation of pain by extention of the wrist agaisnt resistance (hitting the ball). DDX with Radial tunnel syndrome which could coexist, pain is produces by simultaneously extending the wrist and ringers while the long finger is passively flexed by the examiner.

Testicular cancer - 2
1-Seminoma: elevated Placenta Alkaline Phosphatase. 2-Embryonal: elevated Alpha Feto Protein (AFP). 3-Choriocarcinoma: elevated beta-HCG. Once the dx of carcinoma is made, US shows solid nodule, then initial mngmt is Orchiectomy. Trans scrotal biopsy and FNA is CI becauseit might spread lymphatically or hemotgenously. ****Leydig cell tumors are the mc type of testicular sex cord stromal tumor. Testosteone and Estrogen are markedly increased with 2ary inhibition of FSH & LH. Pt prestns with Bilateral Gynecomastia. DDX1:Choriocarcinoma, bHCG is increased. DDX2:Seminomas contain Syncytiotrophoblastic giant cells.DDX3:Yolk sac tumors show increased AFP.

Testiclar feminization:
Defect of absence of androgen receptors resulting in feminine phenotype with 46XY genotype. The MIF is produced by the gonads, so th euterus, vagina and tubes are absent. Breasr develop due to peripheral production of estrogen, whereas axillary and pubic hair does not. Tx is to resect testicles and make Vagina.

Tetanus guideline
Hx of Tetanus Immun Clean Wounds Dirty looking wounds
<3 doses of tentanus toxoid in past TT:Yes, Tig:No TT:Yes, TIg:Yes
>=3 dose of tet toxoid in past TT:Yes if last dose >10y ago, TIg:No TT:yes if last dose>5y ago, TIg:No

Tetracycline Toxicity
A5- Photosensitivity.

Tetralogy of Falot - 2
Most prominent feature is cyanosis that rarely improves with oxygen. A Classid presentation is Squanting that improves cyanosis. "Tet" spells are hypoxic episodes characterized by rapid breathing. Immediate tx is Oxygen and put the child in a Knee-Chest position. followed by fluids,morphine,propranolol. TOF is a Cyanotic (early) condition. ASD & VSD aren't cyanotic (late).****Pansystolic murmur, Hepatomegally.

Tetsticular feminization
defect or absence of androgen receptor results in feminine phenotype with 46XY genotype. MIF is produced by gonads, so urtus and vagina are absent. Breat develop because peripheral production of estrogen , whereas axillary hair and pubic hair does not. Tx is testicular resection at puberty and creation of aneo vagina. Pt prestns with amenorrhea, developed breasts, absent pubic and axllary hair , absent internal reproductive organs and a 46XY karyotype.

Theophyline toxicity
1-CNS stimulation (headache, insomnia), 2-GI (Nasea, Vomitting), 3-Cardiac toxicity (arrhythmia).

Thiazide SE
Hyper GLUC= Hyper 1-Glycemia, Lipidemia, Uricemia, Calcemia. HypoK and HypoNa.

Thioridazine toxicity - 2
Unlike other antipsychotics, thioridazine is asso with cardiac arrythmias. Symptoms of thio overdose include deep sleep, coma, abnormal involuntary movements, hypotension, tachypnea and arrhythmias. EKG reveals prolong QRS. Pt needs sodium bicarbonate.****Antipsychotics like Thioridazine, galactorrhea 2ary to Dopamine blocking effect. Pt presents with lactation and menturation irregularity.

Thoracic outlet synd
refers to compresion of neuro-vascular structures supplying upper extremity. Pain wakes up the pt from sleep. There is paresthesias ans weakness of fingers. Vascular involvement presents with palor pulslessness and coldness.Cxr, MRI and angiography helps to dx the cause f compression. Conduction velocity studies identify the site of compression and overhead pully excercise helps to releif the compression.

Threatened abortion - 3
Hemorhage before 20week . Cervix is closed,no fetal tissue pasage,feal heart if normal, 25% of women have this. When th pt comes to you first step is to make sure fetus is alive. Once that is fullfiled, mngmt is reassurance and performance of USG one week later. Tx is Reassurance and outpatint follow up. DDX1:Incomplete abortion,sometissue is evacuated, cervix is dialated. DDX2:Complete abortion,whole concep passes theough cervix. Cervix is closed. USG shows empty uterus. DDX3:Inevitable abortion, low abdominal cramp radiated to the back, dialated cervix. USG shows ruptures or collapsed gestational sac with absence of fetal cardiac motion.****Complete abortion is when produce has come out and cervix is closed with blood in vaginal vault.****Cerclage is used to tx or prevent first trimester abortions when the cause is incompetent cervix.

Thrombophlebitis:
Characterized by palpable, indurated, cord-like, tender, subcutaneous venous segments, low fever.

Thymoma - 2
Is seen with CT in ANTERIOS midiastinum. All Neurogenic tumors (Neuroblastoma, are in POSTERIOR mediastinum. Pericardial cyst is in the MIDDCLE mediastinum. Esophageal Leomyomas are in POSTERIOR midiastinum.****Is asso with Red cell aplasia which is eveything except RBC,ESR,Hct,Hb and reticulocyte are normal.

Thyroid carcinoma
MC cancers 1-PAPILLARY(Papillary carcinoma is the most common thyroid cancer (60 to 70% of all thyroid cancers). Females are affected two to three times more often than males. It is more frequent in the young, but is more malignant in the elderly. It is more common in patients with a history of radiation. Hurtle cells exist. Psammomma bodies are characteristic.FNAB shows large cells with groung glass cytoplasm, and the pale nuclei with central bodies and central grooving. The prognosis is excellent even with metastasis.). 2-FOLLICULAR cancer(Follicular carcinoma accounts for about 15% of thyroid cancers and is more common in the elderly. ddx with ADENOMA is that cancers demonstrate invasion of capsul and blood vessels. It is more malignant than papillary carcinoma, spreading hematogenously with distant metastases.). 3-MEDULARY(Medullary (solid) carcinoma may occur as sporadic (usually unilateral) or as familial (frequently bilateral), transmitted as an autosomal dominant trait. Pathologically there is a proliferation of parafollicular cells (C cells) that produce excessive amounts of calcitonin, a hormone that can lower serum Ca and phosphate (PO4), Total thyroidectomy is indicated, even if bilateral involvement is not obvious. Hurtle cells exist.). 4-ANAPLASTIC(Anaplastic carcinoma accounts for 10% or less of thyroid cancers and occurs mostly in elderly patients and in women slightly more than in men. The tumor is characterized by rapid and painful enlargement, and about 80% of patients die within 1 yr of diagnosis). Do FNA for Dx, but FNA cant ddx b/w Follicular cancer and Follicular Adenoma.

Thyroid Nodules - 2
The mc is COLLOID (benign), 2nd mc is FOLLICULAR adenoma (benign). The first step in Dx of a thyroid nodule is is measurement of TSH, the subsequesnt steps (T4, T3) are all dependent on TSH levels. ***** FOLLICULAR Adenoma:histologically demonstration of invasion of the capsul and blood vessels is required. FNAB shows large numbers of normal-appearing follicular cells. Its almost impossible to ddx Follicular ADENOMA from Follicullar CANCER. Unlike PAPILLARY cancer, FOLLICULAR cancer is encapsulated and doesnt have dstinctive nuclear features. Lymph node involvement in Follicular cancer is rare, unlike papillary.

Thyrotoxicosis
one of the mc causes of thyrotoxicosis with reduced thyroid uptake is Subacute lymphocytic (painless) thyroiditis. Leakage of thyroid hormones into the circulation due to inflamatory damage to the thyroid follicales results in Thyrotoxicosis. Most cases happen postpartum. Other causes of TT with low radioactive iodine uptake are 1-Subacute granulomatous (De Quervain)thyroiditis (Asso with intense pain in thyroid), TX is just NSAID. 2-levothyroxine overdose, 3-Iodine induced TT.

TIA - 4
1-Embolic TIA are prolonged and single, they last for hours. EKG shows Atrial Fibrillation or MI. Tx includes avoidance or correction of risk facor like smoking, HT and Hypercholesterolemia. Anticoagulation is considered when TIA is caused by Emboli that arose from the heart. Heparin is administered followed by Warfarin. Transesophageal Echi is performed to clots or vegetations. 2-Atherothrombotic TIA are recurrent and shorter in duration., minutes. MRI and CT shows the site of injury. All pt should get antiplatelet therapy if there is no CI. Aspirin is the initial agent of choice. Clopidegrol is used if pt is intolerant of aspirin. Aspirin is used in combinatinon with Dipyridamole if pt has a hx of TIA despipte being on Aspirin.**** Presents as focal neurologic deficits (right-sided weakness, expresive aphasia) (MS might show same way but CT shows it). There are 3 pathophy for TIA, 1-Blood vessel abnormality(atherosclerosis, inflamation), 2-Embolic source(heart), 3-inadequate cerebral blood flow. Atherosclerosis & Emboli are the mcc in Elderly pt. in Young pt Emboli is the mcc. usually from the heart, due to arrythmia, IE, valvular dis or Myxoma. Less common are venous emboli that reach arterial circulation via ASD or patent foramen ovali. Transatlantiv flights increse the risk for Venous Thrombosis.. To identify the cause Transthoracis Echo is performed. If Echo is normal work up for hypercoagulable conditions should follow. ****All pt with atherothrombotic TIA should get antiplatelet tx if there is no CI to it. Aspirin is the initial agent of choice. If CI exists, Clopidegrol. If CI still exist then Ticlopidine.Now if TIA was caused by Emboli from the heart then anticoagulants ar considered.****In TIA asso focal symptoms resolve in <24 hr. DDX1:Reversible Ischemic Neurological Deficit, cahracterized by a transient ischemic attack followed by resolution of the symtoms in 24hrs to a week. In Hemorhagic or Complete IA, symptoms dont resolve as quickly.

Tic Borne Diseases
1- Lyme, 2-Ehrlichinosis (RMSF):Fever,malise,HA &Vomit. 3-Babesiosis:endemic in Long Island. Occurs in pt >40, SPLENECTOMIZED, or immuncompromised. Parasyte enters RBC and cuases hemolysis. . Progression is Jaundice, hemoglubinuria, renal failure and death. Unlike othe rtick diseases RASH IS NOT a symptom.. Hay intravesculr hemolysis, anemia, abnormal LFT, elevated ESR. Dx is with blod smear. Tx is either Quinine-Clidamycin or Atovaquone-Azitromycin.

Tinea Corporis
Ring shaped scally patches with central clearing and distinct borders, topical tx with 2% antifungal lotions and creams (terbinafine) or systemic tx with Griseofulvin (for extensive disease).

Tinea Versicolor
Velvety pink or whitish, hypopigmentaed macules that don’t tan and don’t appear scally, but scale on scraping. Agent is Malasezia furfur. On KOH shows "spagetti and meatballs", Topical Selenium sulfide lotion or Ketokonazole shampoo is recommended.

TMJ Dysfunction
Always think of refered talgia when pt presents with ear pain and no hx. TMJD is a cc of refered otalgia, and pain aggravated by chewing, with psychogenic grinding (bruxism).

Torret Synd - 2
Tx is TYPICAL antipsychotics, like Haloperidole or Pimozide. *** Pts are at risk of developing OCD (keep repeating the same gestures and obsessed about counting the same numbers).

Torsade de pointes - 2
Could be caused by Quinidine. Tx is first stop the drug, then increase the heart rate by Magnesium. Torsade de pointes (see Fig. on DT), or twisting of the points, causes symptoms and death in patients with the rare congenital long QT syndromes. Its importance in everyday practice is its provocation by drugs (especially antiarrhythmics, which are contraindicated in its further management) or electrolyte imbalance. Management is to stop all cardioactive drugs (eg, antidepressants, antiarrhythmics, phenothiazines), normalize electrolytes (particularly K and Mg). ***TDP is also termed Polymorphic VT. its a very rapid VT characterized by gradulay changing QRS, prolonged QT. The mcc is Quinidine. In the acute setting Mg replacemnet is the tx.

Torus palatinus
is a benign bny mass on the palate. Its basically an outgrowth of the hard palat. No medical or surgery is required. Cause is unknown. So in a young person who present with a fleshy immobile mass on his hard palateits most likely Torus Palatinus

Toxic Adenoma - 2
Increased thyroid hormones with suppressed TSH are indicative of Thyrotoxicosis. Furthermore if radioactive Iodine uptake increased only in one lobe, that confirms Toxic Adenoma. DDX with Grave's is that in Graves iodine uptake is diffusly increased not just a specific area, also have exophthalmos. DDX with Multinodular goiter, uptake is patchy. DDX with Painless Thyroiditis, uptake is markedly reduced.***** Increased hyperthyroid pt like TA are at increased risk of rapid bone loss. Direct effect of thyroid hormone on th ebone cells eventually leads to increased OsteoClastic bone resorption.

Toxic epidermal necrolysis
A life-threatening skin disease in which the epidermis peels off in sheets, leaving widespread denuded areas. Primary manifestation is an erythomatous morbilliform eruption that rapidly evolves into exfoliation of the skin. Patches of skin slides off with slightest pressure (Positive Nikolsky sign). Oral mucosa shows painful blisters. Could be caused by Sulfanamides, barbituates, phenytoin, NSAIDS. Tx is supportive. Sulfanamides could also cause Stevens Johnson's syndrome (Erythema multiform major), but typical lesions are "target" shape. Same with Erythema multiform minor.

Toxic shock Syndrome
symptoms include sudden onset of flu-like syndrome, high fever, hypotension, erythomatous rash. 1-2week after onset skin peels. Tx: Pt should be hydrated and debridment of the wound should be performed. All source of infection should be removed and anti staph antibiotics should be started.

Trachoma
MCC of blindness in the world. Dx by presents of lymphoid follicales on the conjunctiva , scarring and limbal follicles. Tx is erythromycin or tetracycline.

Transient Sinovitis of the Hip:
Inflammation and swelling around the hip joint. Cause is unknown but could be due to virus. Bed rest with the affected joint in a comfortable position is the treatment of choice. Pt gets better in 3-4 days. DO NOT give aspirin due to the fear form Reyes Syndrome.

Transplantation
Oral Trimethoprine-Sulfamethoxide is the DOC for preventing PCP in transplant pts. If hay allergy then Dapsone.

Transposition of great vessels
The mc cyanotic heart disease that presents with cyanosis w/I the first 24hr of life. TOF chows cyanosis after few years.

Trichomonas Vaginalis
T. vaginalis is a flagellated protozoan found in the GU tract of both men and women. The organism is usually pear-shaped .Copius Malodoros vaginal Greyish-green color, thin and frothy. Also vaginal pruritis, dysurea and dyspareunia. Petechial pathes on the cervix show "strawbery cervic". Dx by microscopic obervation of flagellad organism in wet mount preparation. Tx is either one dose 2000mg or 250mg 3X a day for 7 days, for both partners. Metronidazole is teratogenic avoid using in 1st trimester.

Tricuspid Atresia:
Is a cyanotic congenital heart disease characterized by cyanosis early in life and left axis deviation. Most cases, 90% , are asso with VSD. DDX is TOF.

Tricuspid Regurgitation
A pansystolic murmur at the left sternal border

Tricuspid Stenosis:
A mid diastolic rumble, best heard along the left lower sternal border

Tricyclic Antidepressant drug tox:
Is the mcc of hospitalization and death due to excessive ingestion of prescription drugs. Pt with TCA overdose presents with anticholinergic, CV and neurological symptoms. CV se is proonged QRS and AV block. Also dry mouth dilated pupils, decreased bowel sounds, urinary retention, constipation, tachycardia, flushed skin and hyperthermia. Its been realized that QRS interval more reliably predicts the level of toxicity than the serum or urine drug levels.

Trigeminal Neuralgia - 2
At surgery or autopsy, intracranial arterial and, less often, venous loops compressing the trigeminal nerve root where it enters the brain stem have been found, suggesting that the tic is a compressive neuropathy. Paroxysmal lightning pain on the face, tx is carbamazepine.

Trimeta-Sulfa Toxicity
In African-Americans it cann cause acute hemolysis, back pain due to G6PD deficiency. NOTE:vigniette says that "G6PD I snormal", Don’t fall for that because in these pts it is normal but the cuase is still G6PD def. This also happens with Primaquine.

Torus Palatinus:
Is a benign bony mass on the hard palate. No medical or surgery is required. Cause is unknown. Tx is reassurance.

Tropical Sprue
Blunting of the villi and hx of travel is DDX with CELIAC disease. A common presentation is the triad of sore tongue, diarrhea, and weight loss. All features of a malabsorption syndrome may develop. Steatorrhea is common, and D-xylose absorption is abnormal in > 90% of cases. Folic acid and vitamin B12 deficiencies lead to megaloblastic anemia. shortening of the villi and lengthening of the crypts, with changes in the surface epithelium and an inflammatory cell infiltrate of lymphocytes, plasma cells, and eosinophils. The best treatment is tetracycline

TTP
presents with Pentad of 1-severe thrombocytopenia, 2-Microangiopathic hemolytic anemia (RBC fragments), 3-Neurological signs, 4-Renall failure, 5-Fever. LDH is elevated, PT & pTT are normal. HUS is like TTP w/o neuro signs. Both need Emergent Plasmaphoresis. DDX:I T P, a dx of exclusion, pt presents with isolated decreased in platelet count. Hb and WBC are normal, Pt & Ptt are normal. DDX3IC, RBC fragments, PT,PTT and BT are elevated. Renal failure is not a feature.

Tuberous Sclerosis:
Initial presentation is seizures. The cutaneous anomaly is called adenoma sebacum, which appears b/e 5-10 yrears of age. TS occurs in first year of life with clusters of brief symmetrical contractions of the neck , trunk and extremities known s ‘infantile soasms, demonstrating EEG patterns. There is also hyperpigmented lesions (Ash leaf) and cortical tubers on head CT. The DOC is IM ACTH.

Tubo-varian abscess
Is seen in 10% of pt w PID. Admit the pt, Broad spectrum antibiotics should be started immediately AFTER taking cultures. Gentamycin+Clindamycin+Ampicillin. In absence of obvious response w/i 48 hours , drainage should be considered. If there is doubt re Dx we do Laparoscopy. If hay rupture we need to do exploratory Laparotomy.

Tumor Lysis Synd - 2
Is characterized by Hypreuricemia. Seen in pt undergoing chemotherapy, with high nucleic acid turn over such as Leukemia dn Lymphoma. Prophylactic Allopurinol is the most effective method to prevent gout in these pts. Hysration is also good but alone is not enough, it should be used with Allopurinol.****Tumors which have high cell turn over are frequently ass with TLS, like Burkitts, ALL and AML. There is Hyperphosphatemia, Hypercalcemia, HyperKalemia and Hyperuricemia. The reason is both K and PO4 are intracel so they increase, PO4 causes HypoCa and Degradation of cellular protein causes increased Uric acid.

Turcot synd
It refers to an asso b/w brain tumors (primarily medulablastoma and gliomas) and FAP ( Familial Adenomatous Polyposis) or HNPCC (Hereditary Non Polyposis Colorectal Cancer. Its autosomal recessive and occurs mostly in teens. DDX1: Gardner, An auto Dominant, colonic polyps are seen with extraintestinal lesions, like Desmoid tumors, sebacious or epidermal cysts, lipomas, osteomas (mandible) gastric polyps and nasopharyngeal angiomas. DDX2: Peutz-Jeghers, an auto dominant dis, intestinal hamatomatous polyps with cutanous melanocytic macules. DDX4:Multiple Hamartoma synd, asso of GIT hamartomas and breast cancer, thyroid cancer and gingiva hyperplasia.

Turner synd
Since all ova are lost by atresia before menarchi, pts have streaked ovaries. There are no estrogen production, as there are no functinal filicular cells in streak ovaries. Absence of follicular cells results in absence of estrogen and inhibin from the ovaries as a result of loss of feedback inhibition of estrogen on LH & FSH causing their elevation. Inhibin only causes feedback inhibition of FSH, so in the absence of inhibin, serum FSH are more than LH, which is pathognomonic for Primary Ovarian Failure. **** Variation are possible, as in one X and one Y Ch. In this case the pt needs a bilateral gonadectomy due to increase risk for gonadoblastoma.*****Cxr shows rib notching due to coarcation of the aorta.

Ulcerative colitis - 3
Toxic Megacolon is a complication of UC. Its an emergency and prompt admin of IV steriods, nasogastric decompression& fluid management is required. Pt presents with diarrhea and bloddy stools, Dx is established clinically and colonoscopy. As it progresses, the rectum looses its elasticity and lumen collapses. Once tx is sarted some pt remit but some go on and manifest wieght lost and fever, when this acute colitis symptoms are associated with radiologic evidence of coloninc dialatation its called toxic megacolon.****Pts with UC that have pancolitis, should begin surveilance colonoscopy after eight years of diease.

Ulcerative Esophagtis
CMV is the most frequent cause in HIV pt. Triad of focal substernal burning pain with Odynophagia, shallow superficial ulceration and intracellular incluisons are dx of CMV (tx is gancyclovir). If ulcers are caused by HSV(tx is Acyclovir) they are multiple, well circumscribed and look like Volcanos.

Ulnar Nerve entrapment
Decreased sensation to 4 & 5 digits, and weak grip. The mc site is the elbow, in medial epicondyl groove.

Umbilical cord compression
is asso with Variable deceleration. Fetal sleep presents with decreased logn term variability. Fetal Head compression is asso with EARLY deceleration. Uteroplacential insufficiency presents with LATE deceleration. Intrauterine infection presents with tachycardia.

Umbilical Hernia
Is due to imperfect closure or weakness of the umbilical ring. Commonin low weight and Black infants. Its covered with skin and is easily reduced. > most disappear by one year. Surey is advised if hernia persists to the age of 3-4, exceeds 2cm in diameter, causes symptoms, becomes strangulated or progresily enlarges after 1-2 years.

Urethral injury, posterior - 2
Hallmark of Urethral injury is triad of 1-Blood at urethral meatus. 2-Inability to void, 3-Distended bladder. We have two types of UI: 1-Anterior, urethral inury anterior to perineal membrane. AUI are mc due to blaunt trauma to perinuem (saddle injuries). An immediate surgert is tx. 2-Posterior urethra, consists of prostate urethra and membaneous urethra. PUI are mc asso with pelvic fracture and high riding prostate. Initial mgmnt is retrograde urethrogram and then suprapubic catheterization. Remember Urethrogram with post void film is for Bladder injuries.

Urethritis
A/01/03. Tx for uncomlicated infections, Tetracycline, Azithromycin. For Pregnant women Erythromycin.

Uric acid stones
Are visualized via CT of abdomen, or IV pyelography.*****Needle shape crystals on urine analysis indicate urc acid stones. Uric acid stones which are radiolucent have to be evaluated with either CT of abdomen ar IVP. The stone can cause Ileus, possibly due to vagal reaction due to ureteral colic. The result will be absent bowel sounds, constipation, signs of obstruction, no gas passing. Ileus will be over once ureterolithiasis is tx. Stones

Uterine Rupture - 2
Presents with intense abdominal pain asso w vaginal bleeding, ranging from spotting to massive hemorrhage.****Risk in transverse line is 0.5% and in Vertical its 5.0%. If pt does not want any more children, total hysterectomy is the Tx of xhoice. If she wants more kids then Debridment and closure is indicated.****difficult to ddx from abrupta placenta. UR is preceeded by agitation, rapid breathing, tachycardia.

UTI in females - 3
The mcc in order are: 1-Shorter urethra compare tomen, 2-Contraceptives, 3-wt periuretral envoronment, 4-close proximity to anus.*****E.Coli is the mcc but it dos not produce uease so it doesn’t alter the normal Acidic pH of urine. Proteus is a urease producing bacteria and a frequent cause of UTI. Protease makes the urine Alkaline. ****In a female that there is no response to trimetasulfa and yellow/green mucopurulent endocervical dischage and edematous friable cervix, suspect C.Trochomatis. Dx is cervical culture. Asingle doze of Azithromycin for both partners is tx of choice. DDX is Chlamydia Urethritis, suspect in sexulay active pt with prolonged dysuria (7-10) days unresponsive to therapy for Chlamydial CYSTITIS. In Chlamydia, Gonocoal prophylaxis in not needed, but in Gonococal infection, empiric tx of chlamydia is recommended. Hospitalization and IV tx is recommended for severe PID (abdomial pain, uterine.adnexal tenderness on bimanual exam, and cervical motion tenderness).

Uveitis
Is the mcc of red eye in pt with Ankylosing spondolytis.

Vaginismus - 2
Involuntary spasm of the perineal musculature that interferes with sextual intercourse.****Unlike Dysparunia, Vaginismus is not due to any medical cause. In ALL cases its due to ignorant of women's anatomy, ahuge apprehention about penetration, and an uncontrolable fear of pain. Tx includes relaxation, Kegel excercise (to relax vaginal muscle), and graduation dialation (penetration).

Vaginitis, Candida
Its not an STD. It may appear in presence of risk factors like DM, OCP, pregnancy and immunosupresive therapy. It can also trigger by Alkaline pH of the vagina during menses that is favorable for growth of Candida. Symptoms are vaginal and vulvar pruritis, burning and dysparunia. Discharge has cottage cheese appearance. Its NOT malodorous and pH is 4-4.5. Dx is by KOH wet mount preparation and visualization os pseudohypha and spores. Tx is Imidazole cream or 10 day oral Ketoconazole (especially if recurrent). Fluconazole is the new drug with fewer SE. Give 2 doses, a week apart. Most recurrences are due to non-compliance. If that is OK, then suspect anoterh oraganism and culture on Sabourausd. 50% of reccurence is due to other organism like like T.Glabrata and Candida tropicalis. In addition, 35% of pt with recurrent yeast infection and who have negative cultures, have HPV on biopsy. DDX1:Trichomonas (Metro) DDX2:Gardenella Vaginitis (Metro).

Varicose Veins
Symptoms are fatigue, tiredness in the leg, aching swelling. They are worsend by prolonged sittingor standing.The sweeling and pain rapipdly goes away when leg is elevated. The edema is asso with perforator incompetence. Ulcers occur in medial aspect of the leg. DDX Arterial insufficiencyresents with claudication that is worsened by leg elevation. Pulse is weak or absent and the ulcers are deep and at the distal parts of the leg. There is NO SWELLING in arterial insuff but hair loss and muscle atrophy is noted. DDX2 DM ulcers are like arterial but they are at the pressure points. DDX3 DVT related ulcers take years to develop and they are unlikely in active pts.

Vasa Previa - 2
Hemorrhage w fetal heart rate changes, progresing from tachycardia to bradycardia to a sinusoidal pattern. "Apt" test distinguishes maternal from fetal blood. Mortality risk is 75%. Dx w transvaginal US in combination w Doppler. VP necessitates emergency C section.

Ventricular Tachycardia
When a pt has recurrent VT first thing to do after stabilization(Amiodarone) first thing to do is to look for the cause, Most probabelt its due Diuretics (ie Furesamide causes HypOkalemia). So order electrolytes and correct them if needed.

Ventriculat Fibrilation.
Tx is defibrilation with 200-360 joules. If it fails, lidocaine or Amiodarone (DOC) can be loaded and pt shocked again. Epinephrine can sensitize and lower the treshold for conversion.

Verapamil poisoning
May cause bracardia, hypotension, AV block and cardiac arrest. Like hypotension caused by other poisons, IV saline is the first thing. Then Calcium Chloride is useful in reversing the effect of Calcium channel blocker including bradycardia, AV block and hypotension.

Vesicoureteral Reflux:
Is retrograde flow of urine from bladder to ureter and renal pelvis. It’s a risk for recurret UTI and renal scarring ultimately. Renal scaring is the major cause of end stage disease in children. Reflux exists in all children with renal scars and renal scars are in 60% of children with gross reflux. Dx is made with voiding cystourethrogram.

VIPoma
Is a Pancreatic tumor. Produce Vasoactive Intestinal Peptide. It causes diarrhea, hypokalemia resulting in leg cramp, and decrease in amount of acid in stomach. Woman are more affected. Other symptoms include weight loss, facial flushing and redness. Dx is high VIP in blood. CT or MRI find location. Tx: first goal is to treat dehydration. Next is to slow the diarrhea with Octreotide. If tumor has not metastasized, surgery is indicated.

Vitami K def - 2
Vit K def presenting as hemorrhagic dis of the new born occurs in infants born at home with no prenatal care. Its given to all infants after birth. Newborns are suseptible due to low fat stores, low vit K breast milk and liver immaturity. It can present as intracranial bleeding as well as skin and GI. In adults it is seen in pts with chronic small bowel disease, after small bowel resection or prolonged anbiotic therapy. Dx is elevated Pt or decreased clotting factors. BT is normal. Platelet in normal, PTT may or may not be elevated. DDX1:Von Willerbrand, Auto Dom, BT & PTT are elevated, PT is normal. Factor VIII is low. DDX2:Hemophilia ia X-link, PTT is elevated, BT and Pt are normal. DDX3:Liver disease, Pt is elevated, PTT & BT are normal. DDX4:ITP, platelets are low.

Vitamin D Def
Most commonly due to MALABSORPTION causes reduced plasma Calcium and Phosphorous. DDX w Hyperparathyroidism and Pseudoparahypothyroidism is that they cause decreased in Ca but increase in phosphate.****In infants: presents with bone abnormality like softness or deformity. Typical pts ar low birth weight, Unsupplimented dark skin infants, infants with inadequate exposure to the sun, and breast fed infants.Pthology is defective mineralization of the bone.*****Rickets is developed due to Vit D def in children who stay indoors all the time and eating is not blanced. Presents with costochondral junctions are enlarged, wrist and ankle are thick and xray shows cupping and frying of the distal end of radius and ulna, large anterior fontanel.

Vitamin D Toxicity, Misc. 6/2
Confusion, HA, nausea from hypercalcemia. Mental status changes. Constipation is the mc GI SE. Renal SE is nephorolithiasis, ARInsiff and CRI. Tx is stopping the vitamin, low Ca diet, keep urine acidic and giving corticosteriods.

Vitamine Def
1-Riboflavin Def (B2) is unusual in industrialized nations. Symptoms are Photophobia, Dermatitis and Anemia. 2-Vit C : Ecchymosis, petechia, bleeding gums, Hyperkeratosis, Sjogren's. 3-Niacin (B3) presents with Diarrhea, Dementia, Dermatitis. 4-Thiamin def (B1) asso with infantile and adult Beri Beri as well as Werneki-Korsakoff. Dry beri beri is symetrical peripherla neuropathy with sensory and motor involvment. Wet beriberi is includes neuropathy in addition to cardiac involvment.

Vitiligo - 2
Presents with pale patches of skin, symetrically around themouth and areola. Borders are well circumscribed and hyperpigmented. Pathology is destruction of melanocytes. Few experience spontaneous remission. ***Its asso with Pernicious anemia, Grave's dis, DM-I, alopecia areata.

Vitreous Hemorrhage -2
Sudden loss of vision with floaters in the visual field. Diabetic Retinopathy is the mcc. Fundus is hard to visualize. Basically there are 3 types of Ophtalmological Hemorrhages:1-Conjunctival, cause is minor trauma,cough, sneeze or strain, no tx needed, resolves w/i 2 weeks. 2-VH, produces blavk reflex in exam, cause is DM and retinal vein occulsionretinal tears,its absorped slowly, bleeding is controlled with photocoag. 3-Retinal Hemorrhage which is flame shaped in HT and dot&blot in DM or septic infarction, its always significant.

Volkman’s Ischemic Contracture:
Displaced anterior fat pad is a radio-G sign of Supracondylar fracture which may be complicated by VIC

Volvulus, midgut
Present in a child <1 month old with billus vomit, abdominal distension and passage of blood stained stools. Child is irritable but no signs of pain. DDX1:Pyloric stenosis is non bilus vomit. Duedal Atresia has no blood in stool. In Down synd infants. Hirshprung fails to pass stool. Meconium Ileus, fails to pass meconium, asso with CF.

Von Willerbrand disease:
Vwf is decreased.

VSD
Harsh and hollosystolic murmur heard at the left lower sternal border, is the mc cardiac congenital defect. If its small and causes no symptms for the infant, 40% of the times it closes spontaneously by 3 years and 70% chance of closure by 10years. Risk of Infective endocarditis is increased so peophylaxis for dental is indicated. If the defect is large (Soft murmur) then it might turn in to Eisenmenger syndrome and reverse of the blood flow which is irreversible. Medx and surgery is then indicated prioe to irreversible stage.

Vulvar Hypertrophic Dystrophy
Thick and hyperkeratotic due to long term scratching. Mostly seen in PM women.


Vulvar Papillomatosis
or Condylomata acuminata. Caused by HPV 6,11. Present as exophytic lesionswith araised papilloatous or spiked surfacemay grow into a calliflowerlike formation.

Waldenstrum Macroglobulinemia
is a rare chronic plasma cell neoplasm. Plasma cells multiple and invade BM,spleen and lymph nodes. They produce excess IgM that causes thickening of the blood, Hyperviscosity. Major S&S are: 1-Increase size of spleen, liver, lymph node, 2-Tiredness (from anemia) 3-Bleed easily(little platelet), 4-Night sweats, 5-HA and dizzy, 6-Visual problems, 7-Pain and numbness in extremities. DDX:MultipleMYeloma, there is IgA/G not IgM. Also No hyperviscocity (Engorgment of the retianl vein) like in WM.

Warfarin induced skin necrosis - 2. Dermo. 6/3
Ita a serious complication of oral anticoags. Sometimes its asso with protein C deficiency. Female are more prone. Its a hypercoagular state.Commonly affected sites are breast, thighs, buttucks and abdomen. Initial complain is pain followed by bullae and skin necrosis. It occurs w/I weeks of starting therapy. VitK should be administered in the early stage and Warfarin discontinued if lesion progresses. Heparin should be used until necrotic lesion heals. **** Note os the dise: Warfarin treated pts should be given FFP instead of VitK when emergency surgery is to be performed. DDX with Cholesterol Embolic synd, dont be fooled with Bruit, see the whole picture.

Washing cells
Febrile reaction is a common transfusion reaction that is caused by antibodies in the pt's plasma reacting with donors leukocytes. Leukocyte depletion technique, like cell washing , decreases the probability of febrile, NON-hemolytic transfusion reaction.

Waterhouse-Friedrichsen
Or Adrenal Glands Hemorrhage is a very serious complication of Menigococcial meningitis caused by Nisseria. Its bilateral bleedng into adrenal gland due to DIC, carries 100% mortality. So in an infant with Meningococcemia watch out for WFS, which is characterized by a sudden vasomotor collapse and skin rash due to adrenal hemrr.

Wegener granulomatosis - 2
Hematuria+Hemoptysis+Sinusitis. Underlying pathology involves Necrotizing vasculitis with granuloma formation. Postive C-anca. Typical Xray shows nodular cavities. ****Demonstration of Anti Neutrophil Cytoplasmic Antibodies confirm dx. The Cytoplasmic pattern (C-ANCA) is highly specific. Cxr shows infiltrates, nodule, cavities and masses.

Werdnig-Hoffman:
An auto recessive disorderinvolves degeneration of anterior horn cells and crnial nerve motor nuclei. It causes floppr baby synd (like Botulism)

Wernicke encephalopathy
Characterized by Ataxia, opthalmoplegia, nystagmus, and altered mental status. It's seen in chronic alcoholics due to B1 (THIAMINE) deficiency. DDx1:is Folate def which is common in alcoholics but wont prestn with B1 def symptoms. Remember B3(NIACIN) causes Pelegra, 3D, due to corn base diet. B2(FLAVIN) causes Cheilosis an Glositis.

Whipple's disease - 4
Caused by bacterium T. Whippelli, affects men 30-60yo. Presents with joint pain + abdominal pain + diarrhea + weight loss. PAS+ foamy macrophages containing a glycoprotein in intestine is Dx. Also skin Hyperpigmentation. Untreated dis is fatal and progressive. Tx is Procaine pencillin G followed by tetracycline. *Dx is by PAS staining, it can be confirmed with upper GI endoscopy with biopsy on the small intestine. ***D-Xylose absorption is abnormal in both Whipple and bacterial overgrowth. However, the test becomes normal after antibiotic tx.

Whopping cough - 2
B. Pertusis. Tx Erythromycin and cough suppresants. Hospitalize if serious. Pt might develop rectal prolapse, epistaxis and Pulmonary pathology.*****Its highy contagious. Presents with severe bouts of coughing spells after an URI. They are so severe that they can cause rectal prolapse, epistaxis, pneumothoraces and subconjunctival hemorrhage.


Wilms Tumor - 2
B/t ages of 2-5. It’s the mc primary tumor of renals in childhood. 80% have asymptomatic abdominal mass discovered by mother. In 10% massis bilteral. Tx is Nephrectomy. . If tx at early age majority have long term survival. DDX1:Neuroblastoma, if the child has <1 year suspect it. It presents with abdominal mass, fever, weight loss, hepatomegaly and HT. It usually crosses the mid line and dx is made by measuring urinary cathecholamine products. ****4yo with right flank mass, and both kidneys being palpable with stable vital signs is Willms. Thi stumor orignates from METANEPHRONS. DDX is Neuroblastoma, a unilaterla mss, w/o bilateral enlargment of kidneys. This tumor is a malignancy of neural crest cells. DDX2:Polycystic kiney dis presents with BILATERAL flank masses.

Wilson's disease - 2
Dx is decreased serum ceruloplasmin, increased urinary copper and slit lamp examination of the eye. There is also Mallory's hyaline on liver biopsy. Its recessive disease. Decreased ceruloplasmin leads to copper deposition in liver, cornea, basal ganglia (hepatolenticular degeneration). Disese starts in infancy, but since all infants have increased level of copper for the first 3 months, its best to diagnose it after the first year. f not treated thi disease is fatal.****Dx is finding Ceruloplasmin ,increased urinary copper and hepatic copper deposition in liver biopsy. Tx is Penicilamine . Fulminant Hepatitis needs liver transplantation.

Wiskott Aldrich
Characterized by recuurent Pyogenic infections, atopic eczema and thmbocytopenia. Presents w/I one year of age. First manifestationis hemorrhagic episodes followed by pyogenic infections. Its X-linked. IgM is decreased but IgA & IgG are normal. The defecy lies in inability to produce immune response to capsulated polysaccharide antigens. Pt are predisposed to ALL and Hodgkins. Thrombocytopenia is due to spleenic desrtuction of Platelets. Tx is continues antibiotics, spleenectomy and BMT. DDX1:CGD, presents under 2 years of age, defect is inability to generate oxydative burst to kill organism after being phagocytosed. Lack of NADPH oxidase. In lab, it can be confirmed with Nitro Blue Tetrazolium, which will be NEGATIVE. DDX2:Chediak-Hegashi is recurrent pyogenic infections. the defect is in neutrophils as their lysosomes fail to empty their contents. B&T cell function are normal. NBT is normal. Pt will have partial Albinism and neuropathies and Nystagmus.

Wrist fractures:
1-Colles: the mc fractureof distal radius in outstretched hand. Characterized by dorsal displacement & dorsal angulation.
2-Smith : reverse of Colles. 3-chauffer’s: fracture of radial styloid process. 4-galleizi: isolated fracture anywhere in radius with asso injury to radio-ulna joint.

Zenker Diverticulum - 2
Pt presents with orophareangeal dysphasia, neck mass and are >50yo. UES dysfunction and esophageal dysmotility (motor dysfunction and motility problem) are believed to be the cause. Barium exam helps to delineate the diverticulum, the surgical tx includes excision and frequently cricophareangeal myotomy. ****Zenker is defined as herniation of mucosa through the fibers of cricopharyngeal muscle. Barieum Esophagograpghy is the confirmatory test od choice, not Esophagoscopy.

Zinc Def
Alopecia, mental changes, diarrhea, dysgeusia, smell abnormalities, maculopapular rash around the mouth and eyes and impaired wound healing.

Zollinger Ellison (Gastrinoma) -4
Characterized by multiple severe drug resistant ulcerations in GI track. The mcc of ZE is a gastrin-producing pancreatic tumor. As a result of uncontrolled gastrin production, parietal cell hyperplasia occurs and stomach acid production is significantly increased. Multiple Duedenal ulcer are typical, and a Jejunal ulcer is almost pathognomic for this condition. Steatorrhea may develop, becuase increased production of stomach acid inactivates pancreatic enzymes. Tx of choice is K-H atpase inhibitor Omeprazole, indefenitely until surgery. If medx fails we have to go to toal Gastrectomy. *Is Asso with MEN-I, Hyperparathyroidism,Pancreatic carcinoma and Pituitary tumors