USMLE World Notes-1

Abrupta Placenta - 4
Pt presents with vaginal bleeding, ABDOMINAL PAIN, and uterine tenderness. The absence of hemorrhage DOES NOT rule out this Dx. DDX:Placenta Previa, absence of bleeding RULES OUT this dx.****Risk factors are:1-HT and preecclampsia, 2-Placental abruption in previous pregnancy, 3-trauma, 4-short umbilical cord, 6-COCAINE abuse. AP is the mcc of DIC in pregnancy, which results from a release of activated thromboplastin from the decidual hematoma in to maternal circulation.****Risk factors are smoking and,Folate def. It can progress rapidly so careful monitoring is mandatory. Once dx is made, large-bore IV , as well as Foley cathater is inserted. Pts with AP in LABOR should be managed aggressively to insure rapid vaginal delivery, since this will remove the inciting cause of DIC and hemorrhage. Now if pt is stable tocolysis with MgSO4 is considered, but remmeber Ritordin is CI in pt with HT. ***Again, once we dx the next step is Vaginal delivery with augmentation of labor if necessary. Now if mother and baby are not stable or if there is CI, then Emergency C-section is indicated. Now if there is Dystocia ( narrowing of the birth passage) then Forcepts can be used.

ABCD of Homeostasis:
1-AIRWAY: An airway is needed for all unconscious pts, in the ER best method is Orotrachial intubation and in the field its needle cricothyroidectomy. For consciouns pt the best airway is chin lift with face mask. 2-BREATHING: Cervical spine injury should be analyzed but the first step is to establish ABC. 3-CIRCULATION: It needs control of bleeding and restoring the BP. In most external injuries pressure is enough to stop bleeding but in case of scalp laceration suturing is needed. Also all pts with hypotension should receive rapid infusion of isotonic fluid like ringer lactate to prevent life threatening hypotension. If IV line is not good for adults do saphaneous vein cut down and for children intraosseous membrane cannulation.

Absence seizures - 3
Ethosuximide is tx. Now remmeber that Phenytoin and Carbamazapine are first line drug used for primary generalized tonic clonic sezure or partial seizures, both work by blocking Na channels voltage dependent, Phenytoin is a second drug line for myoclonic and tonic clonic seizure, its available in both IV and oral forms, SE is gingivial hypertrophy, lymphadenopathy, hirsutism and rash, Both Phenytoina & Carbamazepine can cause Steven Johnson synd and Toxic Epidermal Necrolysis.*****Tx is Ethusuxamide or VALPROATE. Classic EEG is symetric 3mhtz spike and wave .

Acarbose SE
It blocks carbohydrate break down in the intestinal tract. The most significant SE is GI disturbance due to increased undifested CHO in the stool.

ACE inhibitor SE, Respira, 6/2
CAPTOPRIL (Cough, Angioedema, Pregnancy, Taste change, hypOtention, Proteinuria,Rash, Increase renin, Lower AII) and HyperKalemia. Cough is caused by accumulation of Kinins possibly by activation of arachadonic acid pathway. Kinins are degraded by ACE, when there is noACE they increase.*****Angioedema that is seen in ER. Pt presents with non-inflamatory subcutaneous edema and laryngeal edema due to bradykinin stimulation.

Acetaminophen toxicity - 2
Acute alcoholic intake can reduce the risk of hepatic injury by Acetaminophen because it competes with CYP2E1, so there is less production of toxic metabolites. Chronic alcohol intake increases risk of hepatic injury by stimulating P450 system and decreasing the amount of Glutathione (used for metabolism of acetaminophen). Management process: 1-4-hr post ingestion AA levels are determined to decide whether the pt will benefit from NAC or not. 2-On the other hand if the pt has ingested >7.5 gr AA and levels will not be available w/i 8 hours of ingestion, he should be given the antidote.

Acetazolamide Toxicity
Causes normal anion gap metabolic accidosis due to renal loss of bicarbonate. Anion Gap is 140-(114+116)=10 which is normal anionic gap metabolic acidosis.

Achalasia - 3
Dx 1-Barium studies, 2-Esopgaguscopy 3-Manometry. ** the CONFIRMATION test is Manometry. We also need to do Endoscopy to rule out malignancy.

ACL Injury
It prevents gliding of tibia under femur. Injury is seen after Hyperextension. A poping sensation is felt at time of injury. Commonly asso with Medial Meniscus and Medial Colateral Ligament (TRIAD). Lachman test is a test for ACL tear. Flex and pull tibia. Drawer sign also test ACL but its less sensitive. Posterior Drawer sign tests PCL. Mc murry's sign tests Meniscus injury. Valgus test is for MCL.

Acne - 2
1-Comedons (black/white heads): cuase minimal inflamation and tx is topical retinoids. If reactivation occur add topical Erythromycin or Benzoyl peroxide. 2-Papular and inflamatory acne: with moderate-severe inflamation: Oral Doxycycline. 3-Nodular or scaring acne: Oral Isotretinoin.

Acromegaly

Actinomycosis
Cervicofacial actinomycosis presents as slowly progressing , non tender, indurated mass, which evolves into multiple abscesses, fistula, and draining sinus tracts with sulfur granules, which appear yellow. Actinomyces israelii is the agent, Tx is high dose IV peniciline for 6-12 weeks. Surgical debrement comes after penicillin therapy.

Acute adrenal insufficiency:
Acute onset of naseau, vomiting, abdominal pain and hypoglycemia and hypotension after a stressful event (surgery) in a pt sho is steroid dependant is typical. A clue is preoperative steroid use. Exogenous steroids depress pit-adrenal axis and a stressful situation can precipitate AAI. DDX: insulin induced hypoglycemia does not cause naseau and vomit and abdominal pain and hypotension.

Acute Alkali ingestion
When a pt takes Lye (alkali substance for suicide), upper GI contrast studies should be performed as eary as possible, to assess the damage and posible perforation of esophagus. Normal x-ray does not rule out a perforation. Once you know there is no perforation then you can do Diagnostic peritoneal lavage if necessary. But the first thing is to rule out perforation.

Acute Appendicitis - 3
Pt who comes to hospital after 5 days of initial symptoms must be hospitalized with IV hydration and IV Cefotetan. If threre is abcess with CT, percutaneous drainage is an option.****Most pelvic abscesses are due to perforation of AA. Pt might have a 24 hour RUQ pain that resoves spontaneously and then later on in a few days he might come with anal abscess symptoms. Drainage of the abscess is tx of choice.****Experiecne has shown that right hemiclectomy with ileo-transvers anatomosis has best postoperative results when resection of part of ascending is requires. And that is when pt has shown gangrenous rupture of appendix with questionable necrotized colon.

Acute Bacterial Proctatitis:
MCC in young is Chlamydia and Gonococcus, in old E. Coli. To diagnose do culture of mid-stream urine sample and start empiric therapy. Prostatic massage is contraindicated due to septecemia chance.

Acute GI bleeding
There are three causes: 1-Diverticulosis (Painless. can be ruled out with Barium Enema), 2-Angiodysplasia (Painless. maybe seen as cherry-red sopts that maybe coagulated, dx with labeled erythrocyte scintigraphy). 3-PUD (Painfull. Dx with endoscopy, if there is Hematochezia, red bright blood,due to lower GI bleed, then there is no need for endoscopy, the blood is from lower UGI bleeding).

Acute renal transplant rejection
Renal transplant rejection in the early post-operative stage can be expained by, ureteral obstruction, Acute rejection, Cyclosporine tox, vascular obstruction and ATN. To determine the cause we do US, MRI and Biopsy. If biopsy shows infiltration of lymphocytes and vasular swelling and there is increase Crt and Bun and oliguria, then the cause is Acute Rejection. Tx is high dose IV steriods.

Acute Tubular Necrosis
Prolonged hypotention due to any reason (Hypovolemic shock) can lead to ATN. Hallmark finding on urin analysis is Muddy brown granular cast. DDX1:RBC cast, GN. DDX2:WBC cast, Interstitial Nephritis and Pyelonephritis. DDX3:Fatty cast, NephrOtic Synd. DDX4:Broad and Waxy cast:Chronic renal failure.

Acyclovir Toxicity
Can cause crystalluria with renal tubular obstruction during high dose parenteral therapy, especially in inadequately hydrated pts.


Addison's Disease - 2
MM-101. Aldosterone def leads to non-anion gap hyperkalemic, hyponatremic metabolic acidosis. ***80% of pt have primary adrenal deficiency due to Autoimmune adrenalitis. These pts also present with autoimmune involvement of other glands as well, like thyroid,parathyroid, ovaries.*** 70% of the Causes of Primary Adrenal Insufficiency autoimmune, mostly in developed countries. In underdeveloped countries TUBERCULOSIS, Fungal infection and CMV infection are the mcc, TB is the MCC in undeveloped countries. Adrenal Calcification is a typical feature of TB PAI. Pt presents with no rise in serum cortisol following injection of Cosyntropin (ACTH analog), CT shows calcification of adrenal glands. Tx of TB does not result in normalization of adrenal gland. PAI in HIV pt is common, mcc is CMV. Sometimes Ketoconazole can cause it. PAI is very rare with adrenal tumor metastasis, even then calcification is not seen.

Adenomyosis
Is defined as presence of Endometrial glands in the uterine muscle. MF in women above 49, , presents with severe dysmenorrhea, and menorrhagia. The typica lexam reveals enlarged sysmetrical uterus. If Adenomyosis is in one side of uterus then enlargment is asymetrical. DDX includes Myomatous Uterus , Leomyoma, Endometrial carcioma. For women above 35, its mandatory to perform an Endometrial curetage or even hysterectomyto rule out endometrial cancer. DDX1:Endometriosis is a benign condition, where foci of endometrial glands are found OUTSIDE of endometrium. They increase in size throgh out menstrual cycle. Asso with Adenomyosis occurs in 15% of cases. DDX2:Leomyomas, are difficult to ddx from Adenomyosis, except that consistency of Uterus is softer in Adenomyosis. DDX3:Endometrial Carcinoma, occurs in women after menopause . DDX4:Endometritis manifest with fever, and enlarged and tender uterus, asso with vaginal discharge . It usually occurs after a septic abortion, and the mc oranism responsible is Strep.

ADHD
Short attention span, impulsivity, hyperactivity for >6mo. Tx is Methylphenidate, se is decreased appetite.

Adjustment Disorder - 2
Emotional or behavioral symptoms that develop w/I three months of exposure to an identifiable streesor and raely lasts more than 6 months after the stressor.The tx choice is Conginitve or Psychotherapy, not drugs. DDX is GAD where pt worries about many things , AD pt worry about one thing. DDX PTSD is when pt relives the trauma that she experienced, nightmare, flashbacks. FOR >1 month. DDX Acute Stress Disorder is PTSD but FOR <1 month

Adrenal insufficiency, 2ary
Is caused by Pituitary tumor. There is Hypothalamic-Pit failure. There is Glucocorticoid def (weakness, fatigue, depresion,irritability,hypotention, lymphocytosis,eosinophilia), and Hypothyroidism(cold intolerance,constipation, dryskin), while Normal K level indicated Aldosterone production is not impaired, and absence of Hyperpigmentation(characteristic of Primary adrenal insuff), all suggest 2ary adrenal insufficiency. Other causes of Primary adrenal insuff are:Autoimmune destruction,adrenal CMV, adrenal TB and adrenoleukodystrophy.

Adrenal insufficiency, Acute
Pt presents with nasea and vomitting, abdominla pain , hypoglycemia and hypotension. Preoperative steriod use is the main cause.

Adrenal Tuberculosis: Endo, 6/2
Adrenal insufficiency plus adrenal calcifications. It’s the primary cause of Primary Adrenal insuff in developing countries. In contrast autoimmune adrenalitis is the mcc of Primary Adrenal insufficiency in developed countries.




Airway assess
An airway is always patent(SECURE) when a pt is conscious and able to speak. If he is tachypnea and noisy respiration he needs chin lift and face mask. An airway is needed in ALL UNCONSIOUS pts. In the FIELD best option is needle Crricothyroidectomy. In ER best option is Orotrachial intubation. Nasotracheal is time consuming. Surgical cricothyroidectomy is a good choice for Apneac pts with head and spine injury.

Alcohol withdrawl
It might occur after surgey when pt has not had drinnk for a few days. Prestns with fever, HA, N&V and TREMORS. Tx is Chlordiazepoxide.

Alcoholic Gastritis
Pt presents with epigastic pain, vomitting dark brown blood after alcohol binge, and has a hx of PUD. A BUN level >40 in a presence of normal creatine is highly suggestive of upper GI bleed, its due to bacterial break down of Hb in the GIT and the resulting absorption of urea. Another place that causes increase BUN w/o Crt is in administration of steriods.

Alcoholic liver disease - 2
T9Q9. The three major pathological findgins of ALD are: 1-Fatty liver (steatosis). 2-Alcoholic Hepatitis. 3-Alcoholic Fibrosis/Cirrhosis. Fatty liver is the result of short term alcohol ingestion, where as Hepatitis and Cirrhosis require long,sustain alcohol use. Alcohol Hepatitis is manifested by Mallory bodies, infiltration by neutrophils, liver cell necrosis, and a perivenular distribution of inflamation. Fatty liver, Alcohol Hepatitis and even early fibrosis can be potentially reversible if the pt stops alcohol consumption. ****Females are more suseptable to ALD. The most characteristic manifestation is ALT/AST > 2 . ALT & AST are almost always <500, if >500 this raises the probability of injury from drugs. Fatty liver exist in 80% of alcoholics but only 15-20% develop alcoholic hepatitis, and only 50% of pts w alchoic hepatitis develop Cirrhosis. Malory bodies are NEITHER specific NOR required for dx of Alcoholc Hepatitis.**** Pts with Alcoholic Cirrhosis should have Esophagoscopy to prevent varices.

ALL - 2
Presence of more than 25% lymphoblast in BM and the Positive Periodic Acid Shiff reaction (PAS) makes the Dx. ****First symptoms are non specific, fatigue, palor, fever, anorexia, petechia and lymphadenopathy. Dx is suggested by thrombocytopenia and blast cells, but confirmed with BM bioposy. DDX1: Hodgkins, presents with painless, firm cervial adenopathy, sign and symptms are similar to ALL but LYMPHOBLASTS make ddx of ALL. DDX2: AML, occurs in adults, main dx is >25% MYELOblasts in BM biopsy. DDX3: Aplastic Anemia, can present lilke ALL BUT lab shows decrease in ALL cell lines including WBC. DDX4: ITP, children with ITP present with sudden onset of bruising,petechia and occasional Epistaxis. The only cells that are very low are Platelets and their size is LARGE. DDX5: Infectious mononucleosis, presnts with lymphadenopahty, fever and pharyngitis, due to EBV. ATYPICAL lymphocyte are seens on peripheral blood smear and MONOSPOT test is positive. ***** If parents refusing treatment, obtain court order for chemotherapy. ****TX meds.

Allergic Bronchopulmonar Aspergillosis
ABPA is characterized by transient recurrent pulmonary infiltrates, peripheral eosinophilia, asthma and immediate wheel and flair reaction to Aspergilus fumigatus and presence of antibodies in serum against AF. Other characteristics are Hx of Brownish plug in the sputum and high IgE levels. Glucocorticoids are used to tx this dis. Whenever an Asthmatic pt is suspected of having ABPA, skin testing with Aspergillos antibody is first dx step, if its negative ABPA is tuled out. If positive serum precipitants agianst Aspergilos and IgE levels are checked. ABPA is excluded if IgE is <1000, or if serum precipitants against Aspergilus are absent. DDX1: JOB SYND, a recurrenct bacterial infection and markedly elevated IgE. Infections are due to Staph and are SKIN infections. Neutrophils exihibit impaired chemotaxis. Other feaatures are eczema, asthma, allergic rhinitis. Tx is antibiotics. DDX2: Wiskot Aldrich, X-link, Triad of eczema,thrombocytopenia, pyogenic recurent infections. IgA & IgE are high while IgM is low, DDX3:Chronic Eosinophilic Pneumonia , is the mc eosinophilic pneumonia in US. Pts presents with systemic signs of fever, malaise, anorexia, weight loss. Eosinophils >40% is suggestive of this dis. Tx is Glococorticoid. DDX4: Churg-Strauss is a multisystem vasulitic disorder of unknown etiology hat affects skin,kidney, CNS, lungs, GI and heart. There is asthma, , fever, marked Eosinophilia. Tx is glucocorticoids.

Allergic Conjunctivitis:
Is an acute hypersensitivity reaction that is caused by environmental exposure to allergens. Characterized by intense itching hyperemia, tearing, conjunctivla edema and eyelid edema.

Allergic Contact Dermatitis -3
Caused by Nickel and poison IV. Type VI hypersensitivity reaction. It mostly occurs in adults. DDX1: Atopic Dermatitis, presents as pruritic lesions in infants <6mo. Prevention is the mainstay of tx. Everywhere is involved but diaper area apears spared. Give infant warm bath and moisterizers. Acute attack maybe helped with low dose corticosteriods.

Allergic Interestitial Nephritis
Its secondary to Nafciline use. It’s a type IV hypersensivity reaction. Nephrotoxic agents are antibiotics (pencilline,cephalosporine, sulanamide, rifampine, cipro), thiazides, omeprazole, NSAID. Triad of fever,petechial rash and peripherla eosinophilia in an azotemic (Increased Urea) pt is highly suggestive. DDX: Acute Tubal Necrosis is mostly seen in ischemic or nephrotoxic renal failure. MUDDY brown casts are characteristic.

Allergic Rhinitis - 2
Dark puffy eyelids is called allergic shiners. The red crease over the nose causes constant rubbing, called allergic salute. Tx is avoidance and decongestants. ****If rhinitis is not clear if its allergic or infectious, then next step is Nasal cytology. Demonstration of neutrophils in nasal secretions suggests infectious cause. Predominant of Eosinophils suggest allergic cause. Other cause of nasal eosinophilia include Nasal Polyposis (Aspirin sensitivity).

Allergy, Drug
for mild reactions just use antihistamines. For systemic reactions, like anaphylactic use Adrenalin or Steriods

Alpha Feto Protein
The mcc of its deficiency is gestational age error. HIGH levels are seen in Gastrochisis and omphalocele, as well as 'false positive' causes like fetal demise, multiple gestation, inacurate gestational age. In case of increased MSAFP should first do US to rule out false positive causes and to detect presence of any anomaly. Afterwards, Amniocenthesis must be ordered for confirmation by measuring amniotic level AFP and AchE. AchE is a protein that increased only in neural tube defects. LOW levels of MSAFP are seen in chromosomal abnormality especially Down's synd. The screening is more acurate when MSAFP is coupled with b-hCG and Unconjugated Etridiol (UE3) levels, Its called TRIPLE TEST. Combnation of Decreased MSAFP + Increased b-hCG + Decreased UE3 is typical for Down's. In trisomy 18, ALL three are decreased. Likewise, US has to be perfomed to rule out inacurate dates and fetal demise, then amniocenthesis to confirm the Dx. MSAFP and triple test should be performed by 16-18 week of gestation. ****AFP is produced by Yok sac and fetal liver, some passes to maternal circulation. Other procedures: CVS- is indicated in women who are known to have genetic abnormality or previous affected children. Its done 10-12 weeks and offers advantage of 1st trimester testing.

Alpha-1 Antitrypsin Deficiency
It’s a protease inhibitor synthesized in liver. Pts w homozygous def are at risk of Panlobular Emphysema in adult life. The mc manifestation in adults is Asymptomatic cirrhosis, and maybe complicated by Hepatocellular Carcinoma. Hepatocytes contain granules that are PAS positive and Diastase resistant. DDX1: Whipple's, which is PAS positive but doesnt cause cirrhosis.

Alport Synd
Recurent episodes of Hematuria, sensoryneural deafness and a family hx of renal disease. Alternating areas of thinned and thickened capilary loops with spliting of GBM.

Alprazolam:
Abrupt cessation is asso with significant withdrawl symptoms like generalized seizure and confusion.

ALS - 2
Tx is Riluzole (glutamate inhibitor. Side effects are dizziness, nasea, weight loss, elevated liver enzymes and skeletal weakness.) Both upper (spasticity, bulbar symptoms, hyperreflexia) and lower motor neuron (Fasciculation) damage. Muscle wasting of all body muscles. "Tuesdays with Morrie" Jack Lemon.

Altered Mental status in elderly
Major causes include: 1-Hypo/Hyper natremia. 2-Hypo/Hypercalcemia. 3-Hypomagnesemia. 4-Hypophosphatemia. 5-Hypoglycemia. 6-Stroke. 7-cardiac events. 8-infections.


Alturism
Alturism is minimizing internal fears by helping other who have same problem (Alcoholic volunteering in AA). DDX: Sublimation, turning unacceptable behavior to a more acceptable ones.


Alzheimer's Disease - 4
Diffused cortical atrophy. Tx is Donezapin, Tacrine, rivastigmine, galantamine. **** Elderly gradual memory decline with Apraxia (Loosing the ability to do routine acts), Aphasia and Agnosia (not recognizing familiar objects). *****DDx it from Picks by MMSE, which is decreased in AD. In picks you need to see more than just one indication of behavior changes(urinating is not enought).

Amaurosis Fugax
Amorosis Foo-Gacs: Visual loss that is monocular, transient "dropping of the curtain". Opthalmoscopy reveals zones of whitend, edematous retina, following retinal artery distribution. Seen in pt with atherosclerosis and CV disesae. Its caused by retinal emboli from ipsilateral carotid artery. It last about 15 minutes. Tx of atherosclerosis is important to reduce the risk of stroke. Dx is with Duplex of the carotid.

Amebic (liver) abscess - 2
More common in tropical males. After intestinal infection with Entameba Histolytica. Transmission by water or food. Dx of liver abscess is by CT. When aspirated has "Anchovi-paste" appearance, Tx is Metroniddazole, orally, given one to two weeks. ****Hx of travel to endemic areas followed by dysentry and RUQ pain with a single Cyst in right lobe of liver is indicative of ALA. Primary infection is i the colon, but then it goes to portal vein and liver. Dx is made by stool examination of trophozoit serology and liver imaging. Tx is Metronidazole. DDX:Hydatid Cyst, caused by Echinococcus acquired by contact with dogs

Amenorrhea - 3
1-Secondary Amenorrhea: the first step is to rule out pregnany, then hyperprolactinoma, then hypothyroidism. The 2nd step should be determination of pt's estrogen status with progestine challenge test. A- If pt has adequate estrogen and a history of intrauterine instrumentation then suspect Asherman's synd (intrauterine adhesions. A hysterosalpingogram can show). Pts with no such hx are all anovulatory or oligo-ovulatory. B- If estrogen is inadequate, FSH should be ordered to determine gonadal or central origin.****Prolactin production is inhibited by Dopamine and stimulated by serotonin and TRH. An increase in TSH and TRH may lead to Hypothyroidism. Hyperprolactinoma may also affect GnRh and gonadotropin secretion and thus result in ammenorrhea. Other causes are dopamine antagonist (antipsychotics,TCA), hypothalamic and pituitary tumors. In the case of ammenorrhea-hyperprolactinoma , first rule out hypothyroidism by measuring serum TSH.***2ary Ammenorhhea in athletes is due to Estrogen deficiency because menstruation happens because of Estrogen.******Check out Table in Q41, Exam 12 0r 13.

Amiodarone tox - 2
1-Pulmonary, 2-Hepatotox, 3-corneal deposits, 4-skin reactions. *** If a pt needs rate control but has Restrictive lung disease Amiodarone is CI.

Amlodipine side effect

Amphetamine intox
pt might act like schizo but HT is not normal. Cocaine is the same as Amphetamine. DDX is Manic episode that has the mnemonic DIGFAST (Distractbility,Insomina,Grandiosity,Flight of idea, Activity increase,Speech talkative,Thoughtlessnes risky actions.).And Herion Tox: Triad of altered consciousness,respiratory depression and pinpoint pupils. Herion Withdrawl: muscel and joint pain , N&V, diarrhea,abdominal cramps, rihnorea,lacrimation,sweating. Amphetamine Withdrwal:depression, increased appetite ,fatig , irritability.

Amphotericine Toxicity
Hypokalemia.

Amyloidosis:
In heart is the end stage and next step is Transplantation.

Anal Fisure
They are most comonly caused by passage of hard, large constipated stool. The mc symptoms are severe pain and bright red rectal bleeding during defecation. Tx of both acute and chronic fisures starts with dietry modification (high fiber diet and lots of fluids) along with stool softner and local anesthetics.

Analgesic Nephropathy - 2
Clinical senario describes a woman with chronic HA, almost everyday, who presents for Hematuria. Several years of abuse leads to chronic tubointerstitial damage. Hematuria is due to Papilary Necrosis**** It’s the mc form of drug induced chronic renal failure. Most commonly in femlaes . Papilary Necrosis and Tubulointerestitial nephritis are the mc pathologies seen. Polyuroa and sterile Pyuria with WBC casts are early manifestations. In advanved cases you see Proteinuria and hematuria.

Anaphylactic shock
One HOUR After bee sting in ER the first thing to do is SC Epi, not removing the sting. If after oneminute then first remove the sting.

Anemia of Prematurity
is the mc anemia in premature and low birth weight infants. Pathology involves a diminished RBC production, shortened RBC life span. And blood loss. Iron supplementation doesn’t help falling Hb levels and iron def is not the cause of prematurity.

Aneurysms
Causes are: 1-TARUMA:Aneurism in a young pt who presents with Desending Aortic aneurism. Pathophy is acceleration trauma. It might show in Cxr by wide midiastinum, 10% will have normal cxr so if you suspect it do CT or MRI. Tx is surgery to prevent rupture. 2-ATHEROSCLEROSIS:Is the mcc of Descending Aorta aneurism. Pts are older, smokers. They are generaly asymptomatic and are seen on Cxr. Majority of pts also have significant CAD. 3-MARFAN:nomonic is 'm.A.AR.f.A.n". Pts present with Ascending aneurism of Aorta. Asso findings are Aortic regurgitation Surgery is required to replace both aortic valve and entire ascending aorta. They also have a higher chance of Aortic Dissection than genral population. 4-MYCOTIC:result from localized infection , Its mc in Femoral artery and 2mc in Ascending aorta. The mc pathogen is S. Aureus and 2mc is Salmonela. 5-SYPHLYTIC:Occur in Ascending Aorta. Pt presens with fever,chills, spliner hemorrhages. CT is dx.

Angina, Prinzmetal or Variant - 2
Classis picture is a pt with absence of risk factors of CAD, night pain waking her up, transient ST elevation, absence of Q waves and negative cardiac enzymes. The disease results from coronary vasospasm of the artery that causes "Transmural Ischemia" and hence ST elevation on EKG. Other things to know is: "Subendocardial ischemia" in Angina pectoris causes ST Depression. "Transmual Infarct" causes ST elevation followed by development of Q waves and increased cardiac enzymes. "Subendocardial infarcts" cause ST Depression that are not followed by Q waves and elevation of cardiac enzymes. Summary: TM-IS=Elevate ST-Q-Enz. TM-IN=Elevate ST+Q+Enz. SE-IS=Suppresed ST-Q-Enz.and SE-IN=Suppresed ST+Q+Enz. *** Propranalol and Aspirin are CI in these pts. The initial tx is with Nitrates and Calcium channel blockers. Second drug is only added when there is no response to the first drug. DOC for initial mgmt is Calcium channel bloker, Diltiazam.

Angina, Stable - 4
EKG stress test is the initial test for dx. Rbbb is not a CI. But when a pt has Lbbb,WPW, ST depression >1mm at rest then stress testing with imaging is done. Dobutamine stress test is for those pt who cant exercise sufficiently. Coronary Angiogram is done if stress test fails. Myocardial Perfusion is for those who are at risk of develoing complications with excercise or Dobutamine. *****Medications that has to be withheld prior to EKG Exercise test are Anti ischemic mdeciation, Digoxin and medications that slow the heart (B-Blockers, Atenolol).****In pts with stable angina and HT, B-blocker is tx of choice. CCB(Verapamil) is indicated if BBs are CI or dont work. They both have BOTH anti HT and anti anginal effect. Enalapril has ONLY anti HT effect. ****Stress EKG or an Excercise Echo should be done for risk stratification in pts with stable angina. Pharmocological stress testing is an alternative if pt cant do excercise. Coronary angiography is done when pt is refractory to medical tx or when excercise tesidentifies pt as high risk.

Angina, Unstable - 2
Ishcemic chest pain only partially releived by Nitroglycerin, T wave inversion, and negative cardiac enzymes. Tx for unstable angina and NON-Q wave infarction is with IV heparin, aspirin, B-blobker and nitroglycerin is indicated. Thrombolytic tx is asso with mortality in these pts. Thrombolytic therpay is indicated in MI with ST elevation after sublingual Nitro rules out coronary vasospasm. Another indication for Thrombolytics is LBBB. ****Give CLOPIDOGREL not Ticlopidine for platelet de aggregtion.

Angiodysplasia or Vascular Ectasia

The two mc causes for pianles GI bleeding are diverticulosis and Angiodysplasia. DDX is that Angiodysplasia is asso w Aortic Stenosis. Other asso is renal failure. Also Sigmoidoscopy reveal Diverticulosis and not Angiodysplasia. MERK:Angiodysplasia is an acquired submucosal AVM, which may cause lower GI bleeding in elderly patients. When the bleeding is massive, it is usually from either angiodysplasia or diverticulosis. Typical angiodysplastic lesions are 0.5 to 1.0 cm, bright red, flat or slightly raised, and covered by very thin epithelium (see Plate 22-3). Treatment is indicated for angiodysplasia that has bled because of its tendency to cause chronic recurrent hemorrhage. Active, severe bleeding may be controlled quickly by intra arterial or IV administration of vasopressin when the patient is stabilized, but results are variable. The lesions then may be treated more definitively by endoscopic coagulation or surgery. The most difficult aspect of treatment is to eliminate other potential causes for the GI bleeding and to locate all of the angiodysplastic lesions. If the lesions are not large or numerous, endoscopic coagulation with hot biopsy forceps or laser photocoagulation is preferred. The usual surgical treatment is a right hemicolectomy because of the propensity for angiodysplasia to involve the right colon.

Angioedema - 2
ACE inhibitors are notorius for producing Angioedema in ER. Pt presents with non-inflamatory edema and laryngeal edema that could be life threatening. Angioedema occurs due to proinflamatory action of substance.P which is stimulated by Bradykinin. Bradykinin can be broken down by angiotensinogen converting enzyme. When an ACE inhibitor blocks this enzyme, the levels of brady kinin increases leading to angioedema. Tx is Anti histamine.

Angiofibroma - 3
A benign vascular tumor found in adulescent male. Present with frequent epistaxis(Epistaxis is the major symptom), nasal obstruction, HA & conductive hearing loss. In PE hay greyish-red mass in the posterior nasopharynx. CT is Dx, TX is medical and surgery, depending on stage. ****Any adulescent boy with epistaxis and has localized mass with bony erosions on the back of the nose has an Angiofibroma unless proven otherwise.

Anion Gap Metabolic Acidosis 3
T9Q3. First see pH<7.4, then see HCO3<24 then we know its MA. To calculate compensation use Winter's Formaula PaCO2= 1.5 (HCO3) + 8, this is what CO2 would be after compensation. Normal AG is b/w 6-12. MERCK: When metabolic acidosis results from inorganic acids (ie, hyperchloremic or normal anion gap acidosis), HCO3 is required to treat the acid-base disturbance. However, when acidosis results from organic acid accumulation (ie, increased anion gap acidosis), as in lactic acidosis, ketoacidosis, most experts still recommend judicious use of IV sodium bicarbonate in the treatment of severe metabolic acidosis (pH < 7.20)******AG formula is (Na)-(Cl+HCO3), normal is 6-12.

Ankylosing Spondolytis - 3
Asso with IBD.****regular exercise is the only tx that halts progression of the disease. Pt is young, presents with insidious onset of back pain for more than 3 months, positive family hx, reduced back motion and chest expantion, also HLA-B27. Xray shows scoliosis. NSAID is for pain control. Sulfasalazine is for peripheral joint involvment. Surgey is recommended when dis is sever and refractory to medical tx. ****Dx cant be made unless there is evisence of sacrolitis. So when pt has symptoms of AS, the next step is to do Xray of the sacro iliac joint. If Xray is inconclusive then MRI is done.

Anorexa Nervosa - 2
Elevated carotene gives the skin a yellow color. Carotene is also elevated in DM and Hypothyroidism. Pregnant women with current or previous AN are at risk for Miscarriage, intrauterine growth retardation, hyperemeis gravidarum, premature birth, cesarean delivery, & post-partum depression. Osteoporosis is a common finding in women pregnant or not. Also elevated cholesterol and carotene levels, euthyroid sick syndrome, cardiac arrythmias (prolonged QT). The FIRST step of MGMT is Hospitalization. ****There Ammenorrhea and body weight is below normal. In bulemia weight is normal.****Once the dx is made the first step in managementis hospitalization.

Anserine Bursitis
Pain over medial tibial plateu, hx is asso with trauma and cxr is normal.

Anterior Cord Synd
Usually occurs due to motor vehicle accident injury. There is Paralysis and analgesia below the level of injury and preservation of posterior column function like position,touch and vibratory. Pts trearted with High-dose Methyl prednisone w.I 8 hrs of injury have significant neuorologiccal improvement. All trauma pt do 2 things, 1-Immobalize, 2-ABC.*****Asso with burst fracture of the vertebra, characgterized by total loss of motor function (Paraplegia) below the lesion, with loss of pain and temperature on both sides below the lesion. MRI is the best initial Dx procedure.

Anti Psychotc drugs
Work by blocking Dopaminergic receptors. Typical ones are Haloperidol, Chlorpromazine, Fluphenazine. Atypical ones , add Serotonin blocks as well, so block EPS SE. Atypical is Clozapine, Risperidone. ****Dystonia, an extrapyramidal SE of Haloperidol is treated with Benztropine or Diphenhydramine.

Anti-D Ig
After events that are asso with maternal-feto hemorrhage (placenta abruption) the failure to correct the dose of Anti D can result in maternal Alloimmunization (T22Q39).

Anti-depressants - 2
Are SSRI, MAO inhbx,TCA. SSRI causes sexual dysfunction. If it does, discontinue and give Bupriopoin (inhibit Nepi, and dopamine reuptake) it doesn’t cause impotence. TCA also causes sex dysfunction. Trazodone is good for antidepressant in those with Insomnia, but it too causes sex dysfunction. *****In pts with terminal dis, when severly depressd with active suicidal thoughts antidepressnt should be given immediately, not lectures about accepting the fact and the feeling being normal and .blahblahlah...

Antiphospholipid Antibody Synd
Recurrent arerial or venous thrombosis or recurent fetal loses in the presnece of Antiphopholipid antibodies. There are 3 types of APLA, first one is responsible for false VDRL, Second is LUPUS and falsly elevates APTT, the Third is Anticardiolipin. The tx is Heparin+Aspirin.

Antisocal Personality
Is dx in those older than 18 yo who engage in illegal activites and abuse others. They show CONDUCT disorder when they are minors.

Aortic Aneurysm
MCC is ascending aorta and cuase is cystic medial necrosis. Descending aorta is asso with atherosclerosis.

Aortic Aneurysm, Abdominal -3
After AAA repair (surgery) , diarrhea and blood in stool should raise the question of Ischemic Colitis. . If CT is inclusive, a sigmoidoscopy/Colonoscopy is recommended. DDX is Pseudomembraneous Colitis due to antibiotics will present with same symptoms but not the ischemic changes in the colon. CT shows ruptured aorta and blood around aorta, tx is exploring the abdomen.***The study choice of Dx and folow up is abdominal USG. ****When pt presents with pulsatile mass and hypotension , a presunptive dx must be entertianed. and pt should be taken directly ro surgery, NO USG OR CT.*****spinal cord ischemia with lower spastic paraplegia is a rare complication of AAA. Its due to loss of blood during the operation.*****When there is ruptured AA confirmed with CT, then the next step is Explore abdomen not Laparoscopy (not used in acute conditions).

Aortic dissection - 6
Htn and BP difference in two arms. First thing to do is admit to ICU, IV Nitropruside(reduce BP), Beta blocker(Esmolol,reduce heart rate). Any delay maybe fatal, don’t even give pain killer first, just do the above. So first tx is antihypertensive agent, before CT,MRI,TEE or Cxr. Intense retrosternal pain that radiated to subscapular area, also check for Aortic regurgitation (decresendo diastolic murmur in the left sternal border, also Hypertension. Dx w TEE. ******The mCC of AD is HT, if given no info pick this as the cause.****Acute AD is a risk factor in Marfan pts. Tearing pain and raddiation to the back and a difference BP of 30mmhg b/w two arms are impotant clinical clues. TEE or CT ar the dx studies of choice.

Aortic Regurgitation
Presents with Water hammer or collapsing heart and pistol shot femoral pulses. These occur due to hyperdynamic circulation and early diastolic runn off of aortic insufficincy.****Tx is Diuretics+ACE inhibitors+Digoxin, are given first to releive congestive sysmtoms for LV dysfuntion and then we need to change valve is indicated. Pt must undergo Echo for diagnosis.

Aortic Anreurysm Rupture
Aortic rupture should be rulled out in ALL trauma pts with Severe chest trauma, pulsatile mass and hypotention. Its best done with Cxr. The signs are:1-widening of mediastinum>8cm, 2-Depresion of L main bronchus >140degrees, 3-Deviation of nasotracheal tube, 4-Fracture of 1st&2ns rib,sternum,scapula, 5-L apical hematoma. Immediate surgery is very important but do confirmatory CT or angiogram. BUT REMEMBER if question gives you option b/w Surgery and CT go with surgery.

Aortic Coarcation:
The tx for RECURRENT AC is Baloon Angiography.

Aortic Stenosis - 4
Age dependant idiopathic sclero-calcific changes are the mfc of isolated AS in elderly. Pt presents with exersional syncope. PE shows increased intensity of point of maximal impulse. Auscultation reveals ejction-type systolic murmur. With radiation to carotid arteries. NOTE:Bacterial endocarditis may lead to Aortic insufficiency not aortic stenosis. ****Pt presents with Anginal chest pain, dyspnea or syncope (The classic triad of symptoms is syncope, angina, and dyspnea on exertion.). Pain is ischemic in origin and occurs due to increased O2 demand 2ary to LV hypertrophy. ECHO is the study of choice to Dx AS. Its also used in follow ups****Key to Dx is Harsh systolic murmur over the right sternal edge, know that only left sided murmurs increase on exspiration. S4 results from forceful atrial contraction against the thick non-compliant ventricle. The classic indication for surgery in pt with AS is SAD (Syncope, Angina, Dyspnea). Dyspnea results from CHF. Presentation of either indicates valve replacment surgery. The indications for Aortic valve replacment are:1-All Symptomatic pts, 2-Pt with severe AS undergoing CABG. 3-Asymptomatic pt with severe AS either poor LV systolic function , LV hypertrophy > 15mm.****In ALL AS pt who are SYMPTOMATIC, IE prophylaxis and repeated regular follow ups are recommended.

Aplastic Anemia, Acquried
Injury to the bone marrow by drugs, radiation, toxins or insecticide. Pedaitrics disese. Pallor,fatigue, loss of appetite, easy bruising, petechia, mucosal hemorrhage and fever. Lab shows, anemia, leukopenia, thrombocytopenia. BM biopsy is essential for Dx and shows hypocellular BM and fatty infiltration. MERCK:Tx: Equine antithymocyte globulin (ATG) has become the treatment of choice for older patients or those without a compatible donor. Combined ATG and cyclosporine is also effective.. Bone marrow transplantation from an identical twin or an HLA-compatible sibling is a proven treatment for severe aplastic anemia, particularly in patients aged < 30.. DDX:Fanconi syndrome, familial, pancytpenia, brown pigmentation, cafe au lait, short stature, upper limb abnormality, skeletal abnormality, it starts w thrombocytopenia then neutropenia and then anemia. DDX2 Diamond-Blackfan Anemia, or congenital RBC aplasia presents in the first three months of life w pallor and poor feeding. WBC and platelet counts are normal.

Appendicitis:
If a 62 yo on WARFARIN comes in with appendicits and requires emergent surgery, first step is to reverse the effect of Warfarin not by Vitamin K infusion (takes 1-2 days for effect), but with infusion of FFP. Then proceed with the surgery. ****Acute Appendicits may be complicated by pelvic abscess that presents with lower abdominal pain, malaise, low grade fever, and tender pelvic mass on rectal exam. Most of pelvic abscesses are due to perforation of appendix. Pt could have had appendicits that resolved with rupture and abscess formation. The diarrhea is reactive due to irritation. Drainage of the abscess is the tx in these cases. ****Experiecne has shown that right hemicolectomy with ileotransverse anastomosis has best postoperative results, when resection of part of ascending colon is required, when hay appendicits with cecum inflammation and pus.******Complicated appendicitis is when the pain is ignored for days and pt presents with high fever and localized pain to RLQ. Tx is with IV hydration, Antibiotics and bed rest. Non-operative management is curative, CT may reveal abscess that can be drained percutaneously Antibiotics should cover Gram negative and Anaerobics, Cipro+Vancomycin.

ARDS - 4
Could happen secondary to Acute pancreatitis. Dx:PaO2/FiO2 must be <200 (PaO2=55, Receiving O2 by mask
is 60%) in the setting of absence elevation of left atrial pressure (PCWP<19mmhg). Sepsis is the mcc of ARDS. Other causes are Herion, acute pancreatitis, severe burn and near drawning.****Goal of mechanical ventilation is to improve oxygenation and is best doen with increased PEEP. PEEP keeps the alveoli at end expiration and keeps them open for a longer duration to inprove oxygenation. PEEP is the major factor in improving oxygenation in ARDS.***In a postoperative pt who prsents with dyspnea and tachypnea one must exclude MI,PE,Pneumonia and ARDS. If pt presents with Bilateral fluffy infiltrates on a chest xray and hypoxia with diffuculty with oxygenation Its most probabely ARDS. Its not Atelectasis so there is NO FEVER.

Arm Fractures
1-Colles, outstreched hands in elderly. 2-Smith, my injury, 3-Bartion, intraarticular fraction of distal radius. 4-Chauffer's, fracture of radial styloid process in drivers. 5-Galazzi, isolated fracture anywherea long radius with asso injury to the distal radial joint.


Arrest Disorder - 2
Midpelvic contraction which is indicated by prominent ischial spines is an important cause of Arrest disorder or dialation. DDX:Inlet Dystocia, Descent of the presenting part at +1 indicates that fetus is engaged, so ID is unlikely.****Arrest in dilation more than 2 hours, and arrest in descent more than 1hour is the definition. Can be caused by hypotonic contraction, anesthesia, cephalopelvic malproportion or malpresentation. If arrest is in midpelvic contraction, indicated by prominent ishcial spines, then the next step is to do a C-section. Forcetps cant be used until cervix is fully dialated (10cm). Oxytocin might cause uterine rupture due to pelvic prevention of birth. Now in case of Shoulder Dystonia, a last resort tx is 'Zavanelli' maneuver (pushing back the fetus in uterus & doing a C-section.

Arthritis, Reactive
It’s a form of seronegative spondyloarthropahty. Enthesopathy(A disease process occurring at the site of insertion of muscle tendons and ligaments into bones or joint capsules ) causes heel pain and sausage digits. Enthesopathy is quite specific to spondyloarthropathy. Tx of choice for Reactive Arthritis and Reiter's is NSAIDS. Tetracycline is added if UTI with Chlamydia is suspected and IM Ceftriaxone if Gonoccocal is suspected (but NIsseria does not cause RA).

Asbestosis
The hx of shipyard worker with cxr with pleural plaques is dx. DDX1:Sillicosis, hx of glass and pottery making. DDX2:Berylliosis, hx of high tech industries.

Ascending Cholangitis
Characterized by Triad of RUQ pain, Fever and Jaundice (charcot triad). Its an infection of the CBD, generaly 2ndary to obstruction of CBD with a stone leading to dilatation of CBD. Broad spectrum antibiotics should be started immediately, however, its very important to decompress the billiary duct and provide their drainage. ERCP (Endoscopic Retrograde CholangioPancreatography) is the method of choice. ERCP can be used to do a sphingtrectomy with the stone removal and drain the bile via the sphingter or by placement of a stent. Early drainge can significantly reduce mortality and morbidity.

Ascites - 3
Management starts wirh sodium, water and protein restriction, spironolactone, furesamide. If given a choice for only one drug tx b/w spironolactone and Furesamide, pick spironolactone. If that didn’t help then slow tapping of up to 2L of ascites fluid a day balanced with infusion of 10gr albumin per liter tapped. If that didn’t work then do surgery. The vascular shunts are indicated after first bleeding. Distal spleno-renal shunt will not improve and it might worsen it. Side to side porto-caval shunt might improve the ascites but worsen encephalopathy. Peritoneum-Jugular shunt is designed for tx of Ascites only. *If pt 's ascites is so much that is compromising other systems, the next step is Paracentesis which is both therapeutic and diagnostic. ****Spironolactone is the DOC in tx of Cirrhotic Ascites. Tx of ascites in Cirrhotic pts should be as followes: 1-All the pt shold have Dx paracentesis done. 2-Salt Restrcited Diet is the coner stone of the therapy, in 10-20% of pt thats all you need to do. 3-Pts not controlled with SRD, Spironolactone is next. Its an Aldosterone antagonist, and it works because Ascites is only due to 2ary Hyperaldosteronism. 4-Recalcitrant (difficult to manage) ascites should be tx with TIPS. 5-Very severe ascites should be tx with paracentesis initially.

Aspergilosis - 3
An opportunistic infection in South East USA. A mobile cavitary mass in the lung, which prestns with occasional hemoptysis. DDX1:Lung abcess, due to anerobic organism, with an AIR FLUID level on Cxr. Medical mgmnt is antibiotics, postural drainage and bronchoscopy. DDX2:PE, from lower legs, presents with Dyspnea,Tachpnea, Chest pain and collapse. ECG may demonstrate RV Hypertrophy, RBBB, Right Axis and T inversionin antreior leads. Cxy may show decreased pulmonary vascular markings. DDX3:Histoplasmosis:The mc fungal infection in US. Acquired by inhalatin. "Calcified Nodes" in lung , mediastenum or spleen. Cxr shows central or target calcification. Ocasionaly causes mediastinal lymph node enlargment.***Allergic Broncho Pulmonary Aspergillosis (ABPA), finding of central bronchiectasis on the cxr and elevated AgE and Eosinophilia is characteristic. Next do a skin test for Aspergilosis antibody and you ahve your Dx. Tx is Prednisone oral. Itraconazole may reduce the need for steriod but its not the main therapy.****It occurs in immunocompromised pt (those taking cyclosporine, chemotherapy). Pt prestns with fever, cough, hemoptosis, and dyspnea. Cxr may show cavity lesion. CT shows pulmonary nodule with a 'halo' sign. ****Aspergiloma is the “fungus ball” in preexisting cavities, mc presentation is hemoptysis, TX is Lobectomy.****4 types of infection: 1-ABPA (tx is Prednisone), 2-Aspergious Colonization, 3-Aspergiloma (surgery), 4-Invasive Aspergilosis (tx ix IV Amphotericine)

Aspirin intoxication - 3
!-ADULTS: Initially increased respiration leads to respiratory alkolosis and then uncouples oxidative phosphorylation and leads to met acidosis. So they have mixed metabolic acidosis and respiratory alkalosis. 2-CHILDREN: Initially causes Metabolic Acidosis and then compensatory Respiratory Alkolosis. Aspirin can cause acute erosive gastritis and upper GI bleeding. , alcohol can aggrevate this effect.

Aspirin Sensitivity Synd
Pathogenesis is 'Pseudo-allergic reaction'. Accumulation of leukotriens and changed leukotrien/progtaglandin balance triggers bronchoconstriction, nasal polyps in suseptible individuals. Tx are Leukotrien receptor inhibitors(DOC), topical steriods and aspirin desensitization therapy.

Asthma - 9
before and after administration of a bronchodialator (Beta-2 agonist). Significant improvement in FEV1 after bronchodialator indicates reversibility of destruction, which is more consistant with Asthma. ****Mast cell stabalizers (Sodium Cromolyn) are doc for pts who have other allergic disorders, so give this to a boy who started to have night time cough and wheeze with hx of allergic rhinitis.**** Exercise induces Asthma (not to be confused with post excercise asthma) presnts with chest discomfort, wheezing cough, breathlessness, fatigue and abdominal discomfort. Beta Agonist and Mast cell stabalizers (Sodium Cromolyn) are the best tx for these pts. **** When an asthmatic pt presents with Subcutaneous Emphysema, which is face becomes all swollen and palpation reveals crepitans all over face and neck, then the first thing to do is to do Cxr to rule out Penumothorax. Once that is rules out just observe the pt, it needs no tx.****Inhaled corticosteriods are indicartd in pt with persistant asthma symptoms. The agents are beclomethasone. In adults SE of low-dose drug are limited to are Dysphonia and Thrush. In high-dose systemic toxicity may occur. ****Its a common illness in childhood. 10% of children come ro ED with un-remitting asthma (continues wheezing despite tx with neubelizers and een steriods). This is called Acute Status Asthmaticus. Of these pts 10% require MECHANICAL VENTILATION, however hospitalization is mandatory. If on auscultation there is no air entry bilateraly, the child has 'silent chest' or absent air entry and continues to desaturate despite Prednisone therapy, therefor the best option is mechanical ventilation and hospitalization.*****For pt who have asthma accompanied with other allergic disorders, mast cell stabilizers like Sodium Cromolyn are the agent of choice. *****1st neubelizers, 2nd IV steroids, 3rd mech ventilax.Normal PCO2 is one of the indicators of a severe attack. During an attack, pt is tachpneac so he hyperventilates which should cause decrease in PCO2. So if PCO2 seems to be normal that means the obstruction is getting worst or respiratory muscel are getting too tired. Other signs of severity are broken speech, diaphoresis, cyanosis, altered sensorium and "silent lung". Inhaled corticosteriods improve long term quality of life in Asthmatics. Initial hypertensive therapy for pt with asthma is Hydrochlorothiazide.***To differentiate b/w Asthma and COPD (Emphysema) the best test is a bronchodialator response test. , its conducted by measuring FEV1

Astrocytoma
Occurs in Parietal lobe, supratentorial. It’s the mc tumor in both infra and supra tentorial. Medulablastomais the 2nd mc tumor in posterior fossa, 90% occur in vermis. Craniopharyngioma arise in sella torsica, visual field defect, Its characterized with cystic structure with calcification.

Asymptomatic actriuria of pregnancy:
When everything is normal but a routin clean catch urine culture grows 100000 colonies of E choli. Untreated pt have increased risk for cystitis and acute pyelonephritis. So they should be treated with 100mg Nitrofurantoin or Ampicillin for 7-10 days.

Atelectasis
its common after surgery in smokers. Bronchoscopy needs to be done to remove mucus Plug.Pt prestns with tachycardia, tachypnea, low grade fever. Once Bronchopscopy is done, cxr is repeatd and coughing is encouraged.

AtheroEmbolic Disease
It immitates Gout, but does not say red toe but its Blue toe. DON’T FALL FOR GOUT TRICK. Pt has cyanosis and circulation problems like pain in calf, pulses are fine.

Athlete foot
Pt presents with sever itching, fissure, thickness of the nail in a swimmer. Best tx is antigungal medicine, Tolnaftate.

Atpoic Dermatitis:
Edema and erythema of the skin. Skin is Itchy. Tx is Pimecrolimus, like Tacrolimus, its MOA is through inhibition of T cell activation.

Atracurium:
Is the neuromuscular blocking agent of choice for pt with renal and hepatic problems, because its metabolized in plasma.

Atrial Fibrillation - 4
Control rate and rhythm.**** AF along with WPW tx of choice is Procainamide or Disopyramide. Drugs that slow AV conduction (Dixogin, Verapamil) are CI in these pts, they may lead to malignant arrythmais. Lidocaine might als worsen the situation. Cardioversion is used in pts that are HemoDynamicalt unstable (very rapid vent rates with hypotension).*****When AF (absent P waves and irregular heart rate) is asso with HemoDynamic compromise, tx is only Cardioversion. If AF is not asso with hemodynamic compromise, Amiodarone is used. Amiodarone causes hypotension so its CI with HD compromise (hypotention already in pt), but once cardioversion stabalizes pt then Amiodarone is an excellent choice to maintain the pt. Calcium channel blockers are also ONLY excellent choices for AF when there is no HD compromise.

Atrial Flutter
shows with saw tooth EKG. Unstable AF is best tx with cardioversion. ACUte AF with stable hemodynamics is tx with cardioversion or rate control. Chronic stable AF is best tx with rate control with Ca Chanel blocker(VerapamiL) or Betablocker.

Aut Dom Polycystic Kidney Dis
5-7% asso w. Berry aneurysm. Routine screening is not recommended.

Autism - 3
Mainstay of tx is special education and behavioral modification techiques. *Have special interests.Usuallt starts before age 3. DDX:Childhood Disintegrative Disorder, is a rare pervasive developmental disorder, mc in males. Chracterized by a period of NORAML development for atleast 2 yrs, followed by a lost of already acquired skills. They have autism symptoms. Prognosis is poor and they are disabled for life.****Rett Synd: characterized by an initial period normal development until 6mo, followed by loss of hand coordination and sterotype hand movments. Almost exclusively in Females.

Autoimmune Hemoytic Anemia
SEE Spherocytosis

Avascular Necrosis of femur
The well known causes of non-traumatic avascular (aseptic) necrosis are chronic corticosteriod therapy, alcoholism. Pt presents with progressive hip pain w/o restriction of motion and normal Xray. MRI is the gold standard.

Avoidant personality:
Shyness and feeling of inferiority, and desire to make friends.

B12 Deficincy, Hem&Onco, 6/2
DDx b/w Anemia and vegeterian diet is the duration. We store 3-4 years of B12 in the body, so if you’re a vegeterian <3 years and you get B12 def, its due to Pernicious Anemia not vegy diet. If >4 years then we do Abody test for intrinsic factor.****DDX b/w Folate and B12 is increase in Methylmalonic level. Folate will cure anemia but neurological problems will progress.

Bacillary Angiomatosis:
Is caused by Bartonella species, gram negative bacilli. Cutaneous lesions are round papules or nodules, vascular and asso with fever malaise and headache. It occurs in HIV pts.


Bacterial Meningitis
CSF : elevated protein, decreased glucose, and elevated WBC. Plus skin lesions of Purpura and petechia.****Acute Bacterial Meningitis:the 3 mf causes in communit acquired ABM are S. Pneumonia, H. Inf and Meningococcus. Pneumococci have become resistant to penicillin and cephalos, so empirical therapy in adults and children include Vancomycin in addition to Ceftriaxone. Listeria Monocytogenes is a fc in pt older than 55, so we add Ampiccilin for these pts. Other pts at risk for LM are immunocompromised and lymphoma pts. In children >3 yo, LM is a risk so empiric regimen inclused Ampicillin in addition to Cerotaxime. Now S. Aureus and pseudomona are agents in meningitis in hospitalized pts, so empiric therapy is with Vancomysin (for aureus) and Ceftazidime (pseudomona).

Bartter Synd - 2
The DDX of normotensive pt with hypokelemia and metabolic alkolosis include: 1-Diuretic abuse, 2-Surrepticous vomitting, 3-Bartter synd, 4-Gitelman synd. Classis Barter usualy presnts early in life, as polyuria,polydupsia,growth and mental retardation. However this can occur later. The underlying pathology is defective sodium and chloride reabsorption. in the ascendign loop, thereby resulting hypovolemia and consequent activation of renin-angiotensinogen aldosteron system. This then causes increase in K & H ion secretionleagin to hypokalemia and alkolosis. DDX:Primary hyperaldosteronism and Renin secreting tumors are charcterized by HT, Met Alk and Hypokalemia. Measurment of Plasma renin activity and aldosterone is used for DDX b/w the two. in Primary hypoer Aldosteronism, PRA is suppresed and aldosteron is elevated, but in renin tumors, both PRA and Aldosterone are elevated. Now remember the mcc of Hypokalemia in clinical practice is Diuretics, which is hard to ddx with Barter.

Basal Cell Carcinoma - 2
Is the mc malignant tumor of the eyelid. Lesions are slow growing, pearly and indurated. Invasive clusters of spindle cells surrounded by palisaded basal cells. It rarely might appear on upper lip but NEVER on the lower lip. The mc location is the lower eyelid. They rarely metastasize. Squamous CC is much less commn and faster growing, It presents as plaque nodule or inverted wart, its ddx is Actinic Keratosis.****sun is Bad for Basal cell carcinoma. Five warning signs are 1-Open sore tht bleeds, oozes and remain open for >3weeks. 2-Redish patch,3-Shiny bump, scar like area, 5-Pink growth with rolled border. BCC is the mcc of skin in US. Never metastasis. Its removed using by 1-Cauterization(burning), 2-Surgical (excision with 1-2mm margin). 3-Cryosurgery(freez) and 5-radiation.

Basilar skull fracture
Signs are rhinorrhea, raccoon eyes (black eye), ecchymosis behined the ear. A way to see if hay CSF mixed w blood is to drop a drop on a cleansing tissue, if hay csf there would be a yellowish spreading on the paper. In this pt head fracture has to be ruled out w CT of head and spine. Expectant therapy for all uncomplicated cases. Anterior packing is not necessary to control CFS loss. If CSF leak continues for >4 days, spinal drainage and acetazolamide is used to reduce CSF production and reduce ICP.

Bechet - 2
Is a rare multisystem disorder that affects males <20yo, in mediteranean area and east asia. An AUTOIMMUNE mechanism is suspected. It manifest with Ulcers in mouth and genital area and asso with Uveitis. Oral lesions are Aphtha like but genital lesions are more destructive leading to fenesterated vulva. No specific tx yet. ***Its a Multisystemic Inflammatory condition with recurrent oral and genital ulcers, skin lesions, mc in Turkey, Asian and middle east.Corticosteriods offer releif but dont prevent progression to Dementia and Blindness.

Beckwith-Wiedemann synd
Infant with macrosomia, macroglossia, visceromegally, omphalocele, hypoglycemia & hyperinsulinemia. iT might be asso with duplication of CH 11p, this region has the gene for IGF-2, which may explain macrosomia. DDX1:congenital hypothyroidism has umbilical hernia instead of omphalocele, and there is no hypoglycemia and hyperinsulinemia. DDX2:Macrosommia due to maternal diabetes, however these infants dont have the dysmorphic features of omphalocele, prominant occiput and macroglossia. The common congenital problems in these infants are Caudal progression synd, Transposition of great vessles, Duodenal atresia and small left colon, Anencephay and neural tube defects. DDX3:WAGR synd, Wilms tumor, Aniridia, Genitourinary anomaly, and mental Retardation. Its related to deletion of CH11involving the gene WT1.

Bells palsy
Is the PERIPHERAL seventh nerve palsy, Its dx with absence of forehead furrows and thus ruling out the CENTRAL Facial Paresis. Pts with Central lesion still have furrows because contralateral motor inervation of forehead rremians intact.

Benign Intrahepatic Cholestasis
It can develop after a major surgery in which hypotension, extensive blood loss in tissues, and massive blood replacement are noted. Jundice develop due to pigment load from transfusion. Jaundice becomes evident 2nd day post operative. Alkaline phosphatase is markedly elevated but ALT & AST are only mildly elevated. DDX1:Acute hepatic failure, has increased PT, low albumin and neurologic signs due to hepatoencephalopathy. DDX2:Hepatitis, presents with marked elevation of ALT & AST. DDX3:Halothane Hepatotoxicity, type-1 has mild elevation of liver enzymes and NO jaundice, type-2 is characterized by Acute Liver failure.

Bernard_SoulierSynd
The hallmark is GIANT platelets.Its auto recessive. There is mild thrombocytopenia but the major defect is of membrane glycoprotein Ib. This defective membrane lacks the receptor for VW atachment so platelet cant adhear to endohtelium. Plateles don’t aggregate in presence of normal VWF and Ristocetin. Vigniet prsents a 16 yo girl who's periods last 6-10 days and her brother also had bleeding problems.

Beta blocker Toxicity
Overdose causes hypotension and bradycardia. Sever overdose may result in cardiogenic shock. If bradycardia or AV abnormallity is found Atropine is indicated to oppose unopposed vagal tone. Isoproterenol is given if Atropine fails and if both of them fails then Glucagon is the DOC. If medication fails then a temp pacemaker is indicated.

BIASES: SEE STEP UP book
1-Selection: loss of people to follow up in prospective studies.
2-Observers and Ascertainment: result in misclassification of the outcome due to flaw of the design of the study.
3-Recall: Misclassification of the exposure status, its potential problem for case-control.
4-Confounding:
5-Generalizability: when th epopulation you study does not include all the population where the topic of the research is covering. Like studying just men when ALL people are targeted.
6-Reliability:
7-Validity.
8-Leadtime: Its prolongation of apparent survival in pts whom this test was applied, w/o changing the prognosis.

Bicuspid Aortic Valve
Is the mcc of aortic stenosis in middle age adult. Both AS and HCM produce a midsystolic (Ejection systolic murmur) murmur, however murmur of HCM is best heard at left lower sternal border and it doesn’t radiate to carotids. Valsalva Attenuates AS murmur but Accenuates HCM murmur. Murmur of AS is best heard right second intercostal space and radiates to the carotids. Slow rising puls is seen in HCM.

Billiay Cholic:
Is symptomatic for CheledoCholelithiasis. If there are no signs of acute cholecystitis (Murphy sing, elevated WBC and fever) then there is no need for hydration, antibiotics or emergent chlecystectomy. There could be Emphesematous cholecystitis that presents with gas in gall bladder. DM pts are at increased risk. For an uncomplicated billiary cholic just do spasmolytic and analgesic therapy and elective surgery is done at a later time.

BioPhysical Profile
BPPis a scoring system to evaluate baby's well being. Its indicated when there is Decreased movement or a non-reactive NST. It includes NST in addition to 4 things, 1-Fetal tone, 2-Movment, 3-Breathing(30/10min), 4-Amniotic fluid inxed(5-20). Each has a score of 2, when present and 0 when absent. 8-10 is normal, and should be repeated once or twice weekly, until term.In presence of OlygoHydramnions (AFI<5) delivery is considerd. If score is 6 w/o OH, Contraction stress test is ordered. If it gives non-reassuring results then Deliver, if it gives suspicious results then repeat the next day. If its 4 w/o OH and fetal lung are mature, Delivery is considered. If lungs are not mature, steriods is gven and BPP accessed w/i 24 hrs. If score is <4, deliver now.

Black widow spider:
Presents with Acute abdomen and best treated with calcium Gluconate and muscle relaxant. Brown Recluse spider causes skin necrosis localized, resembles pyoderma gangreosum. Deep skin ulcer develops. Local excision is tx of choice for the ulcer. Dapsone is used for pts with G6PD def.

Bladder cancer - 2
Up to 80% of pts who go through a urinary diversion procedure, specially an ileal conduit, can develop hyperchloremic metabolic acidosis due to exchange of Cl for HCO3 in the intestinal mucosa, leading to loss of HCO3 and increase Chloride

Bladder Rupture - 2
Hematuria, suprapubic tenderness, non palbable bladder and lower abdominal and perineal edema. The best Dx method is retrograde cystogram with voiding films. Remember for Urethral injury we do Retrograde urethrogram. ****Intraperitoneal rupture is more common in pts in trauma accidents.

Blastomycosis - 2
Anyone in Wisconsin, Ohio, Mississippi with chronic respiratory problem is suspected. Another dx triad is Skin,Lung Cavity and Bone Lytic lesions.

Blood Transfussion
Femur fracture can acct for 1L blood loss, if Pelvic is also fractured the blood loss could be several liters. General guidelines are start iv crystalloids initially, 2L in 10 min, if pt continues sign of hypovolumia then Blood transfusion is started. So the best indicator for transfussion is blood loss of >1500ml.****Washing of RBC washes off antigens asso with transfusion. Its used for IgA def pts. Leukoreduced RBC reduces the risk of allosensitization

Blunt Chest Trauma:
When it happens with wide mediastinumon CXR, aortic injury must be suspected. Either a CT scan or Echo is Dx.

Body Dysmorphic Disorder
Woman thinks her nose is 'enormous'.

Boerhaave's Syndrome
Complete tear of distal esophagus that leads to pneumomediastinum, vs incomplete tear in Malory Weiss and no Pneumomediastinum. Xray shows subcutaneous emphysema. Dx w barium swallow. Tx give antibiotics and thoracotomy and repair of esophagus immediately.

Borderline Personality
Spliting characteristic. You are the best and the other doctor was terrible.

Bordetella Pertusis:
For preventin, all close contacts (houshold and daycare) get 14 day Erythromycin, regardless of age, immunization or symptoms.

Botulism - 2
we have two types: 1-Infantile type, organism gains entry through the food and prduces toxin in the intestinal tract. It’s a protease that blocks Ach release. 2-Adult type the toxin is ingested pesay, produces the effect.****Infntile botulism, tx is supportive only. BUT if Children get it then administer equine derived botulism anti toxin right away.

Bowel Ischemia
Always consider it as an early complication of operation on the abdominal aorta . Pt presents with bloody diarrhea and abdominal pain. Its due to infarction of Inferior Mesenteric artery, 1-2 daya post surgery. DDX:Pseudomembraneous colitis, takes 2-3 weeks after drug therapy. ****** Unrecognized bowel ischemia is one of the mc causes of lactic acidosis with severe atherosclerotic disease. Pt complains of abdominal pain after meals.

Bowel Obstruction
If a pt comes with constipation and no flatulus, even then, unless strangulation or perforation is suspected, bowel obstruction is treated conservatively. So dotn do surgery first. 1st thing to do afyer IV is nasogastric suction and barium enema.

Bowel resection:
In pt who goes under bowel resection the mc type of kidney stone is Oxalatedue to excessive absorption of Oxalate from GI tract. Increased intestinal fat binds calcium which is then unavailable bind oxalate. Therefore increased absorption of oxalate occurs in GI and precipitates in kidney.

BP criteria
BP should be kept below 140/90. But BP in DM and chronic renal pts should be kept under 130/80 to prevent end-organ damage.

BPH - 7
Starts in the center of the prostate. Cancer starts in periphery. The mcc of overflow incontinence in elderly male. Finasteride acts on epihtelium and alpha-1blocker acts on smooth muscles of prostate. Alpha blockers (Doxazocin) are prefered in pt with BPH and dyslipidemia and glucose-intolerance. If Creatinine is elevated do US of kidney, bladder and ureter to check for damages. ***** Tamsulosin, an Alpha-1 receptor blocker has the least SE of all alpha one blockers used for Tx of BPH.****The two initial tests that are recommended in ALL possible bph pts are serum creatinin and urine analysis. Urine analysis rules out infection and creatinin rules out kidney problems.*****US of the kidney, ureter and bladder should be done in pts whose creatinin level is elevated.

Brain Abscess
A pt with acute onset of HA and focal neurological symptoms (cant walk right) after an episode of acute otitis media or sinusitis most likely has brain abscess. CT and MRI show ring enhaning lesion. Fever pesents with only 50% of cases so its not a reliable sign.

Braindeath
is defined as irreversible cessation of brain activities. It’s a clinical dx. The characteristic findings are absent cortical and brain stem functions. The spinal cord may still be functioning, therefore DEEP TENDON REFLEX are intact. EEG can confirm but is not necessary. In brain dead people, pupilary reaction & oculovestibular reaction are absent, Atrpine doesnt accelerate heart since vagal is gone, and there is no spontaneous respiration.

Brainstem Infarction
1-Medial Medulary Syndrome:Occlusion of vertebral A. Contralateral paralysis of limbs, contralateral loss of tactile, vabratory and position. Tongue deviated to affected side. 2-Lateral mid-pontine synd:A lesion in Lateral Pons. Impaired sensory and motor function of CN V (trogeminal) and limb ataxia. 3-Medial midpontine Synd:A lesion in Medial Pons. ipsilateral limb ataxia, and contralateral eye deviation and paralysis of the face,arm and leg. 4-Wallenberg synd: A lesion of laterla Medula. ipsilateral horner synd, loss od pain and temperature of the face, weakness of the palate, pharynx and vocal cords, and cerebellar ataxia. Also loss of pain and temperaturein cotralateral side of the body.

Breaking Bad News Protocol
1-Comfortable environment, 2-Ask pt how much he knows about his symptoms, 3- Ask pt how much he wants to know, 4- Give him a warning shot ( ie its worst that we thought, do you want someone with you), 5-Break the news if he wants that. 6- Tell him of prognosis but also of the option to make hi slife as comfy as possible, 7- Try to explain everything clearly and simple as possible.

Breast Carcinoma - 4
Inflamatory beast cancer: Erythema and edema of non lactating breast could be due to locally advanced cancer, biopsy should be done first to rule out that dx. Tx is 2-3 weeks of combination chemotherapy to shrink the tumor allowing sybsequent extended resection. ****Metastatic Breast Cancer has a poor prognosis. with little chance of cure. Its importnat to choose Local (Surgery) vs Systemic (Systemic Chemotherapy) tx in pt with metastatic breast cancer. ****Tumor burden, based on TNM staging, is considered the single most important prognostic consideration in treating pts with breast cancer. ER+ and PR+ are good prognostic factors. Over expression of Her2/Neu oncogene is worst progosis. ****Breast cancer is the leading cause of metastatic skin disease in women. These lesions are erythematous that present as erosions covered by necrotic skin. Tx is palliative radiation therapy with aggressive wound care. *****Two proibitions when hay breast cancer in pregos: No chemo in 1st trimester, and no Radiotherapy anytime in pregnancy. Also Lumpectomy is not a good choice for 1st trimester cuase it needs Radiation afterwards. So the only Tx for 1st trimester is Modified Radical Mastectomy.

Breech presentation - 2, 6/24/06

If prior to 37 must be left alone. After that External cephalic version may be attempted PRIOR TO onset of labor, given no CI (Hypertension).

Bronchiectasis - 2
An irrevesible widening of medium size airways in the lung. Characterized by destruction of bronchial walls and chronic bacterial infection. They migh thave life threating Hemoptysis. Bronchiectasis is due to formation of large collateral vessels, which have a very fragile wall. Hemoptysis could be very extensive and ALL pt should be admited. ****Any pt with fever, night weats, copious foul smelling sputum has one of the following: 1-Bronchiectasis, 2-Lung Abscess, 3-Anerobic Pneumonia. "Copious foul smelling" sputum is the KEY word. Cxr shows characteristic "Tram Track Appearance" (increased vascular markings) ring shadows, peribeonchial thickening. CT is the confirmatory investigation, it has REPLACED Bronchography. After that Sputum for AFB is done.

Bronchiolitis:
Is defined as the first episode of wheezing asso with an URT infection. The infection is usually caused by CMV and is common in winter. In affects 50% of children in the first two years of life especially those prone to airway reactivity, and there is an increased inidence for Asthma later in life. WBC in nl and Cxr shows air trapping or atelectais. Tx is supportive care and humidified oxygen and bronchodilators.

Bronchogenic Carcinoma. Pulm. 6/3
BGC is the mc lung cancer asso with asbestos exposure, while Malignant Mesothelioma is almost exclusively asso with asbestos exposure but its not the mc malignancy after asbestos exposure. Pleural involvment is HALLMARK of asbestos exposure. Cigarete smoking acts synergicaly with asbestos exposure in increasing risk factor for BGC.

Brown Sequard synd
Asso with damage to lateral spinohtalamic tract, causing contralateral loss of pain and temperature beginning TWO LEVELS BELOW the lesion. Therefore, a lesion of right sided Laterla SPT at T10 will result in left sided loss of pain and temperature at beginng at T12.

Bruton's Agamaglubinemia
T9Q14. X-linked. MERCK: Panhypogammaglobulinemia of male infants characterized by levels of IgG < 100 mg/dL and other Ig levels low or absent, low or absent B cells. onset of infections sometime after age 6 mo. These infants have recurrent pyogenic infections of the lungs, sinuses, and bones with such organisms as pneumococcus, haemophilus, and streptococcus. A defect of the Btk (Bruton's tyrosine kinase) gene at Xq22 prevents differentiation of pre-B cells to B cells. Lifelong IG given IM or IV in the lowest dose that prevents recurrent infection is essential.

Bud Chiari Syndrome

Buergers disease
Triad of occlusive dis of arteries, migratory superficial thrombophlebitis[Thrombi+Phlebe(vein)+Itis(inflamation)], and Reynaud phenomenon in a smoke male. DDX w atherosclerotic disease is that in those Pulses are normal.

Bulimia Nervosa - 2
Outpatient tx include: SSRI antidepressant, cognitive therapy, interpersonal pshychotherapy, family and group therapy. If pt failed this and/or has metabolic problems or is suicidal then Hospitalize. *Pt bing eat and then feel guilty. They might even feel sad about their situation. But they maintian their BMI and are NOT Amenorrheic. They bing eat at least TWICE per WEEK. If they dont do that, they are dx as "Eating disorder, not otherwise specified".

Bullous Pemphigoid- Dermo, 6/3
Is characterized by tense blisters in the flexural areas. Commonly in elderly (>60). The precipitating factors are ultra violet rays, NSAIDS, antibiotics. Autoantibodies are formed against basement membrane. Immunofloresence microscopy reveals diagnostic findings of IgG & C3 at the epidermal-dermal junction and Prednisones are tx of choice. In Pemphigus vulgaris IgG deposits are intercellulary in the dermis. In Herpes there is C3 at the basement membrane zone.

Bupropion - 2
Its used for Major depression, ADHD, cigaret craving. It ma be used in conjunction with Nicotin patches, but such combination requires frequent BP monitering. It reduces weigh gain that comes with cigarett smoking. Although it might cause seizure, you dont stop the drug due to this rare SE, unless pt has a Hx of seizures. ***Pt has hx of epilespy and wants Bupropion, Dont give him Bupropion its CI for his Hx of epilepsy, give SSRI

Burns
Tx of superficial and deep burns. * For inhalation injury which may take a few days to manifest, Dx is best done with bronchoscopy. *****For calculations only consider 2nd and 3rd degree burns. Kids: head=18, lower ext 27. *****when circumferencial full thickness burns involving extremities or chest is present, Escharectomy maybe the best option.*****Parkland formula for ressecitation is 4ml/kg/ % of body burned, half in 8hrs and rest in 16hrs. ****Early excision therapy is indicated for extensive partial thickness and full thickness burns.*****mcc of death in burn pts in hospital is infection.*****Inhalation injury is commonin burn pts and may take several days to manifest. Dx is best done with a bronchoscopy. Beta agonists along with steroids, endotrachial intubation and antibiotics have all been used in pt with inhalation injury.*****1st degree: confined to epidermis, erythomatous skin. Heals w/o scarring. Example is sun burn. 2nd degree:Involves entire epidermis, red and blisters. Its partial thickness burn. 3rd degree: is full thick ness burn, epidermis and ermis completey destroyed. Not painful. Debridment and grafting is required.

Calcanium Fracture: Surgery 6/2
If due to fall, evaluate for other injury, plain film of head, neck, abdominal, lumbar & pelvic. Its asso with compression fracture of thoracic spine.

Cancer Drugs
1-Anorexia: doc for anorexia asso w cancer is Megesterol Acetate. 2-Nausea&Vomit: Metoclopropamide and ondansentron

Carcinoid syndrome –3, 6/3
Triad of flushing, diarrhea and valvular heart disease. Its asso with carcinoid tumors and hepatic metastasis. Isolated tumors w/o metastasis do not produce carcinoid syndrome. These tumors produce serotonin. Elevated serotonin and its metabolite (5HIAA) are in plasma and urine. Tryptophan is the precursor of Serotonin . Tryptophan is the aa used in synthesis of Niacin. Pts of Carcinoid synd are at risk of Niacin deficiency due to increased formation of serotonin from tryptophan. As a result supply of tryptophan is decreased and 3 Ds of Niacin def (Diarhhea, dementia, dermatitis) of Pellagra develops. ****Carcinoid tumor when symptomatic is in Small bowel, when asymptomatic its in Appendice.***Triad of flushing,diarrhea and wheezing.

Cardiac Contusion
Is asso with arrythmias, so the first thing to do if you suspect it, is Continues ECG NOT Echo.

Cardiac Temponade - 2
Characterized by 1-hypotension, 2-Sinus tachycardia. 3-Pulsus paradoxus. 4-Prominent JVD with 'Y' descent. US shows blood in pericardial sac. DDX is Medicastinal hemorrhage, which is the same as CT except that US shows no blood in pericardium and the blood is in mediastinum. It could happen in pts who are taking warfarin and cause coagulation abnormality.

Cardiomyopathy, Dialated - 3
Characterized by 1-Impaired systolic function of left and right ventricle leading to progressive cardiac enlargement. 2-Cxr shows marked or moderate enlagemnt of cardiac silouette. 3-Echo shows systolic dysfunction and left ventricle dilatation with Normal wall thickness. Pt should refrain from drinking alcohol. Viral infection is the mcc of myocarditis that results in DCM, and the mc virus is Coxsackie virus. .****DCM is the end result of myocardial damage produced by toxic, infectious, or metabolic agents. Viral or idiopathic cause is mc by Coxsackie virus. The dx is by Echo, shows dilated ventrilces with diffuse hypokinesia resulting in low EF (systolic dysfunction and CHF). Concentric Hypertrophy is seen in Aortic stenosis. Eccentric in Valvular regurgitation. Hypokinesia is due to MI inferior wall. MS has Left atrial hypertrophy. HCM shows Asymetric vent septum hypertrophy.

Cardiomyopathy, Hyper - 5
Characterized by 1-Asymetric left ventricular hypertrophy. 2-Harsh systolic Diamond shape murmur best heard at the left sternal border. 3-Cxr shows mild enlargement of cardiac silouette. 4-Echo shows vigorous systolic function, Asymetric septal hypertrophy and Systlic anterior motion of the mitral valve. 5-Due to hypertrophy of left ventricul there is Diastolic dysfunction. * Beta blockers are the tx of choice for isolated ventricular diastolic dysfunction. MERCK:Systolic murmurs are usually present, but patients with apical and symmetric hypertrophic cardiomyopathy may have no murmur. Most common is a crescendo-diminuendo ejection-type murmur that does not radiate to the neck; it is best heard at the left sternal edge in the 3rd or 4th intercostal space. This murmur is caused by obstruction of left ventricular ejection (produced in systole when the hypertrophied interventricular septum and the anterior leaflet of the mitral valve approach each other). A mitral regurgitation murmur due to distortion of the mitral apparatus is heard in some patients. It has a characteristic blowing quality and is best heard at the apex, radiating toward the left axilla. Rarely, early or midsystolic clicks are heard. In some patients with right ventricular outflow tract narrowing, a systolic ejection murmur is heard in the second interspace at the left sternal border. An S4, almost always present, indicates a forceful atrial contraction against a poorly compliant left ventricle in late diastole. Mitral regurgitation is as a result of anterior motion of the mitral valve leaflet. Mitral regurgitation in "Infective endocarditis" or "trauma" is caused by rupture of chordae tendinae. Mitral degeneration in "elderly women" can be caused by mitral annulus calcification. Mitral valve prolapse is the mcc for "isolated mitral trgurgitaion" in north america. * Echo is dx of choice, shows asymetrical ventricle septal hypertrophy. *in 25% of HCM pt there is obstruction of LV ourflow tract (echo shows anterior motion of mitral valve) , becauseof this filling preffure is furthur elevated and out is compromised. This outflow gradient is incresed by manuvers that reduce cavity size of left ventricle. Valsava and standing after squatting, decrease LV Vol thus increasing the gradient and intensify the murmur. But Handgrip, increases systemic arterial resistence and so decreases gradient and the murmur. Leg elevation also decreases the murmur.because it increases LV vol. *****To screen young athlets for HCM Echo is non sensitive. Do detailed personal,family Hx and PE.****Tx for HCM is Beta blockers.***HCM is Auto DOMINANT. Pt is young, dyspnea on exertion, harsh diamond shape systolic murmur at the left lower sternal border.Echo shows Asymetrical septal hypertrophy.

Cardiomyopathy, Restrictive - 4
Characterized by 1-Severe Diastolic dysfunction due to a stiff ventricular wall. 2-Echo shows symetrical thickening of the ventricular wall. 3-Kussmal sign. 4-Apical impluse palpable. DDX: Constrictive pericarditis no no 4, cxr shows calcification, and normal thickness of ventricular wall. ****Tx of most causes of RCM is useless except Hemochromatosis, Phlebotomy and Iron chelation with subcunatous defroxamine may result in substantial improvement.*****Since heart cant relax filling is compromised so both Liver and Lung are congested.****Xray shows mild cardiac slouette. Echo shows symetricly thickened vent wall and near normal systolic function. "Speckled Pattern" is specific for Amyliodosis .

Caroli Syndrome
Is a rare congetnital disorder characterized by intrahepatic dialatation of billiary tree, asso wi APKD.

Carotid Artery Stenosis & Endarterectomy
Asymp pt with 66-99% are considered for surgery, 100% is CI for surgery.

Carpal tunnel syndrome - 2
most likely location of pathologic process is the wrist. Pt presents with pain and burning sensation of the first three fingres and atrophy of thenar eminence, poor 2-point discrimination over the thumb, and they keep dropping things. Its seen in asso with RA, Myxedema, Sarcoidosis, amyloidosis and Leukemia. Most specific test is Nerve conduction study. Tinel test (tapping on Median nerve) Phalen test (90 degree flextion of both wrist and pushing them together dorsally), Carpel compression test (applying pressure over carpal tunnel) are not specific.

Cat Bite - 2
Should be tx prophylacticaly with Amoxicillin/Calvulanate for 5 days, due to fear from Pasturela Multicoida.****1-Pasturella Multicoida, occurs after cat or dog bite, and there is an intense inflamatory reaction w/I 24 hrs of the bite. Pain, swelling, purulent discharge are features. 2-Bartonella Hensalae, occurs after cat scratch or bites. Clinical features occur after 3-10 DAYS. . They include papular or vesicular lesion, at the site of injury and proximal Lymphadenpathy.

Cat Scratch Disease
By Bartenella Hensalea. It most commonly presents with localized cutanous and lymph node disorder near the site of inioculation. A local skin lesion evolves through vesicular erythematous and papular phases, but can be postular or papular. Dx is by clinically and antibody to B. Hensale or a positive Warthin-Stary stain on the tissue specimen.Most people resolve gradualy w/o therapy. However, tender lymphadenopathy and systemic symptoms require five days of Azithromycin.

Cataract congenital -2
Its due to progresively thickening of the lens. In "Congenital cataract" the retina CAN’T be visulized properly, exam reveals bilateral white reflex, the mcc of white reflex in the pediatric population is Congenital Cataract. Tx is extraction of the lens.

Caustic Poisoing - 2
Upper GI Endoscopy is the dx study of choice when a person comes in with ingestion of Alkali (oven cleaner) in the first 24 hr to assess the damage.

Cavernous sinus thrombosis
Presents with severe headache, followed by fever and periorbital edema. Also CN involvements in the form of opthalmoplegia, lateral gaze palsy, ptosis and dilated pupils. Nasal discharge and blood should be cultured. CT scans of the cavernous and air sinuses, orbit, and brain should be performed. Treatment with high-dose IV antibiotics, nafcillin or cefuroxime should be started, pending culture results. Surgical drainage of the infected air sinus may be indicated, especially if there is no response to the antibiotics in 24 h. The prognosis is grave; the mortality rate remains about 30%, despite antibiotic therapy. DDX:Orbital Cellulitis:Its unilateral, and more common in children. Presents w abrupt onset of fever, proptosis, restriction of extraocular movements and swollen red eyelids. there is NO CN dysfunction or visual disturbances in the early stages unless it spreads to cavernous sinus.Treatment with antibiotics, cephalexin should be started, pending culture results. Incision and drainage are indicated if suppuration is suspected or if the infection does not respond to antibiotics