Neeraj_s_notes_Step3.pdf

Neeraj’s Step-3 Notes 1. Case of back pain with normal thorough physical & Neurological examination excluding systemic and visceral disease Rx Supportive care and NSAID’s like Acetominophen 2. Rx Acute Prostatitis: Cotrim or Cipro(Fluoroquinolones) 3. Low grade squamos intraepithelial lesions (LGSIL) or CIN I lesions usually revert to normal except 10-15% which may progress. One may perform colposcopy immediately or after 4-5 months. 4. Livedo reticularis: Seen in cholesterol emboli syndromepurplish web of discoloration over skin 5. GERD  Rx first non-pharmacological measures like elevating head, avoid eating before bed/Caffeine/Chocolates Fails H2 blockers Severe Ds not responding Proton Pump inhibitors 6. New born with FH of CF might have meconium plug syndrome involving jejunum  Ba Enema has a therapeutic as well as diagnostic value  DDx Ileal atresia 7. OCP’s reduced GnRH  Reduced ovulation Reduced disruption of ovarian germinal capsule  Reduced risk of ovarian CA(Nulliparity,HRT and ovulation inducing drugs increase the risk) 8. Parapneumonic effusion  Rx antibiotics and tube thoracostomy Empyema? Decortication 9. Hot tap water burns: Usually first degree burns presenting as erythematous swollen skin  Run cold water over the area or hold a cool compress over it Apply aloe vera cream and use aspirin/Ibuprofen for pain  Adv for setting water temperature <120-130F 10. Olfactory dysfunction: Caused by Brain tumors,Sinusitis,Rhinitis,Nasal poly/Neoplasm,Hypothyroidsm and depression  PE  Neuro to assess odor perception with alcohol  R/o Neoplasm with CT 11. Acute renal failure due to Pre-Renal cause usually associated with hypovolemia  Is associated with Sodium avid state as Kidney tries to retain water. The urine Na+ will < 25mmol/L 12. H/o encephalopathy is contraindication to TIPS. 13. Pseudogout associated with calcium deposits in meniscus.It has close association withhemachromatosis, Hypothyroidism, Hyperparathyroidism, and Hypomagnesemia. Pseudogout + Pigmented skin + Raised liver enzymes/FH liver failure Hemochromatosis 14. DM + HTN  Drug of choice ACE inhibitors 15. Patient with known PID develops tenderness and guarding s/o peritonitis ?Ruptured TO abscess  Immediate Surgery 16. Hemodynamic subsets of Shock CO PAWP SVR Cardiogenic shock Low High High Hypovolemic Low low High Septic High-Normal-Low High low Extracardiac Low Normal or High High Obstructive Shock 17. Surgical resection of Choledochal cyst is essential to prevent frequent recurrent cholangitis and malignant degeneration.

Neeraj’s Step-3 Notes:Kaplan

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18. Suspected Insulinoma v/s Factitious disorder: Measure C-peptide  Low in Factitious disorder  If found high  Measure Sulfonylurea levels to r/o possibility of Factitious disorder before searching for insulinoma. 19. Pulmonary HTN  Gold standard is cardiac catheterization Significantly low DLCO + normal ventilatory pattern Rx O2 to prevent hypoxic vasoconstriction Diuresis to control Rt heart functionAnticoagulant to prevent thromboembolic events  INR 1.5-2.5  Add calcium channel blockers for vasodilatation 20. alpha 1 antitrypsin deficiency  Counsel about alcohol  Accelerated cirrhosis 21. Post fracture fat embolism is usually soon after injury or surgery.Alcohol withdrawal is mostly seen within 48hrs(max upto 10 days).DVT may occur even after 10days. 22. Cat scratch fever(Bartonella Henslae)PapuleAxillary lyphadenopathy Rx not required usually as it is self limiting except secondary infection with staph aureus or complication with encephalitis Needle Biopsy of lymph node is required to exclude lymphoma 23. Recent onset of atrial fibrillation without any obvious cardiac cause should raise the suspicion of hyperthyroidismit also stimulates bone resorption and increased calcium. 24. Wt gain  ?H/o smoking cessation, use of medicationBiochemical evaluation to r/o DM(Hyperglycemia) or Cushing syndrome(Hyperglycemia,Hypokalemia/Chloremia,Metabloc alkalosis and hypercholesterolemia)Apple shape body = Thick trunk/Thin limbs seen in crushing’s. (Pear shape body = Thin torso and thick hips). 25. Porphyria cutanea tarda  Screen for Hepatitis C and Iron overload Both may lead to PCT and are treatable. (Hepatitis B associated PAN  Cutaneous vasculitis) 26. Minor illnesses with or without fever is not a contraindication to routine immunization (both live and inactivated vaccines). 27. Symptoms of hypoglycemia: autonomic response(tremors,palpitation,sweating) and neuroglycopenic response(nervous system dysfunction like blurry vision,headache,confusion) usually manifest when <45 mg/dl Causes postparandial,fasting,insulinoma and factitious 28. Inspiratory chest pain + Leathery heart sounds on systole/diastole + Newly enlarged heart  In post viral bronchitis/Illness  Pericarditis Rx NSAID’s 29. Community acquired pneumonia due to pneumococci: Criteria to admit the patient: (1) >65yrs age (2) significant co-morbidities like DM(3) Staph, anaerobe or G-ive bacteria (4)Failure of OPD Tx(5) RR>30/HR >140/Hypotension/Po2<60(6) Poor social support  DOC is Penicillin in Pneumococci but Vancomycin may be given empirically till the sensitivity is available. 30. Recurrent flash (rapid onset) pulmonary edema:Often responds to Lasix DDx Transient MI,MR,AR and Renal artery stenosis(Patient of recent onset HTN and episodes of flash pulmonary edema  Evaluate for RAS) 31. Recurrent fungal and PCP infections  R/o HIV  Negative R/o T cell immunodeficiency Order hypersensitivity skin testing. 32. Want to conceive?  Start multivitamin + Folic acid at-least 1 month prior to conception(USPSTF) 33. Aura  Behavioral arrest /Motion less stare Automatism(picking movements with hands,Chewing,swallowing)  Post ictal confusion = Complex partial seizure. DDx Absence/Petit mal seizure(Automatism + LOC + Stare) = No postictal confusion! 34. Agitation in context of delirium DOC is haloperidol + Soft restrains/Dim light


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35. CDC recommendation for admission in PID patients: (1) noncompliant/Followup not possible (2) Pregnancy with PID (3) Severe nausea /Vomiting (4) TO abscess or peritonitis (5) Immuno-deficient (6) Failure to OPD Rx 36. Chronic plaque psoriasis = Silvery/Pink well defined plaques at Scalp,ear,elbow,knee,sacrum,ankle  Migratory glossitis(Moving locations)  Onycholysis  Confirm with biopsy from scalp or elbow 37. Typical trigeminal neuralgia is not a constant pain 38. Rapid onset of hypoxia?  Interstitial fibrosis : Idiopathic(Hammond Rich syndrome)  Rx O2 via nonbreathing mask 39. Tinea Corporis(Ring worm): Elevated border with central clearing. 40. Tinea Versicolor(Malassezia furfur):Macules of variegated colors(Even hypopigmented) growing radially KOH preparation shows numerous hyphae breaking into short rod shaped fragments with intermixed round spores(Spaghetti meat balls appearance).

Spaghetti meat balls

Malassazia Furfur

41. HTN = > 3 readings at separate occasions > 140/90mmHg 42. Supratherapeutic INR = increased possibility of bleeding 43. HIV patient with focal brain lesions = 70% Toxoplasmosis + 10-20% Lymphoma  Empiric Tx for toxoplasmosis for 3-4 wks Deteriorates clinically/Radiologically  Biopsy to R/o Lymphoma(CSF PCR for EBV is highly specific and sensitive for primary CNS lymhoma) 44. Post orthopedic operative procedure risk of DVT >> PE 45. Physiological vaginal discharge: Clear to off white(yellow when it air dries on undergarment),non-homogenous,cyclical,scanty-moderate,PH<4.5, MicroscopicEpithelial cells with lactobacilli 46. TUR Syndrome: During TURP irrigation fluid is absorbed thru venous channels and lead to hyponatremia due to hypervolemia  Neurological manifestation like color / visual changes. (A similar picture can be seen in hysteroscopic procedures). 47. Isolated low HDL: DOC is Niacin followed by Fibrates.A moderate cardiovascular exercise for 30mints x 5times/week also helpful. 48. Lack of endocervical cells on pap smear: Improper sampling Low risk(Monogamous relation,Normal early smears): Wait till next examination after 1 year High risk(Multiple partner,Abnormal paps): repeat the sample. 49. Post SAH vasospasm usually responds to Nimodipine –No other CCB has been proven to be helpful. 50. Controlled asthma: (1) <2 rescue treatment of albuterol/week (2) <2 times waking up in the night due to asthma/month (3) <2 canister/container of albuterol/month  If not fitting into criteria  Go for Steroid MDI 51. Patient on amitryptyline  Develops dilated pupil/non-reactive to light/redness of conjunctiva? Acute angle closure glaucoma


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52. CD4+ count <200 start prophylaxis TMP/SMX for PCP 53. High clinical suspicion of appendicitis  Go for exploratory laprotomy No need to perform CT/USG It is acceptable to have 15% negative exploration rate. 54. GPC (Giant papillary conjunctivitis): Cobble-stoning of palpebral conjunctiva Seen in contact lens wearer  Discontinue lenses in acute phase. 55. Stroke t-PA  Increased risk of intracranial hemorrhage Do not give Aspirin/Heparin for 24hrs and review Neuro status every 1 hr for 24 hrsKeep BP <180 56. Internationally adopted children: Do not rely on records even if it is available and immunize the child as per a schedule for an un-immunized child do not forget to screen for Hepatitis C/B, HIV, Syphillis, TB and stool for ova/parasites. 57. Acute arterial occlusion  Pulseless cold foot start IV heparin and prepare for surgical embolectomy 58. Osteoporotic compression fracture of vertebrae  Rx Calcitonin + HRT + Calcium + Ibuprofen for pain 59. It there is scale scrape it –Dermatological adage –a sound advice! 60. Prognosis of Squamous cell CA of face is better then Squamous cell CA of lip. 61. Suspected esophageal perforation  Normal contrast study with water soluble agent  Repeat with barium to ascertain result or R/o perforation 62. Chronic pancreatitis Splenic vein thrombosis selective splenic vein hypertension may ensue Gastric varices without esophageal varices  Rx Splenectomy 63. Common nose bleed  Dry mucosa or Nose picking Pinch the nose + Apply ice packs + Keep the area moist 64. Wernicke’s encephalopathy triad =Ataxia + Confusion + Oculomotor dysfunction(all component not always present) Require high clinical suspicion in diagnosis and history+Neuro exam is sufficient to diagnose the same Thiamine levels in body are not indicative of levels in brain hence not useful. 65. Psychomotor agitation + Delirium + Autonomic instability(raised BP/HR) + seizures = Delirium Tremens v/s Benzodiazepine withdrawl  Rx Supportive measures + Benzodiazepine/Cholrdiazepoxide 66. Tricyclic antidepressants do not have any withdrawal and can be stopped abruptly 67. Hepatopulmonary syndrome is a syndrome of shortness of breath and hypoxemia caused by vasodilation(due to increased hepatic production or decreased hepatic clearance of vasodilators, possibly involving nitric oxide) in the lungs of patients with liver disease. Dyspnea and hypoxemia are worse in the upright position. A useful diagnostic test is contrast echocardiography. IV microbubbles from agitated saline that are normally obstructed by pulmonary capillaries rapidly transit the lung and appear in the left atrium within 7 beats S/O Rt to Lt shunt.Other diagnostic options are pulmonary arteriography and Tc scanning.Tx: Liver transplant 68. Continue breast feeding even when on treatment for mastitis. 69. Majority of cirrhosis in the world due to schistosomiasis but in US it is due to alcohol & Hepatitis. 70. Dilated pupils (Raised ICT?) + Coagulopathy(raised PTT) + Hypogycemia = Fulminant Hepatic failure DDx  Acute viral hepatitis,HELLP syndrome,autoimmune or Medications like acetaminophen(Most common cause of drug ingested fulminant hepatic failure-Suspect when no previous medical history available). 71. ONLY contraindication to testosterone therapy is CA prostate. 72. Linezolid(Zyvox):New “oxazolidinone” antibioticused for multi-resistant bacteria including streptococcus and methicillin-resistant Staphylococcus aureus (MRSA)Inhibit protein synthesis by stopping the 30S and 50S subunits of the


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ribosome from binding together MC side effect is Thrombocytopenis especially when given >14days. 73. Diagnosed with DM-II Go for yearly ophthalmology check ups soon after diagnosis 74. Burn patient  Increased non-junctional acetyl choline receptors Avoid succinyl choline As it may lead to increased K+ causing cardiac arrest/death. 75.

Porphyria cutanea tarda Blistering of the skin in areas that receive higher levels of exposure to sunlight with scarring+ fragile skin + Milia(Tiny white papules) Drugs like Naproxen may also precipitate event=Pseudoporphyria or Drug Induced PCT 76. Angiodysplasia of colon is associated with VW disease and aortic stenosis(crescendo decrescendo murmur radiating to carotid) 77. Superior vena cava syndrome  Most feared complication is upper airway obstruction? Radiotherapy is Tx of choice 78. Acutely deteriorating renal functions  Immediately evaluate potentially Like K+,PO4important derangements secreted/excreted by kidneys Acidosis/Uremia(Irrespective of etiology) Electrolytes,Ca++,PO4-79. Renal failure patient with baseline anuric  About 3 times/week dialysis run. 80. Indirect hernias may manifest as a complication within 6 months of birth In case detected late Should be operated soon after diagnosis without delay Explore other side also and operate the occult hernia(Usually prresent) 81. Occupational Vitiligo  De-pigmentation patch of skin resembling autoimmune vitiligo Due to antioxidants often present in gloves or rubber industry Fluorescent white patch on wood’s lamp


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82. Hematospermia Often due to nonspecific infections of urethra/Prostate/SV Self limiting Reassurance 83. During an outbreak of influenza aspirin is contraindicated  Reye’s syndrome 84. Dermatomyositis  Myositis(Prograssive muscular weakness) Search for Internal neoplasm?

Gottron papule:edema associated with erythematous papules over the knuckles

Heliotrope erythema: erythema and scaling over her eyelids(Lavender shade) 85. Neutropenic enterocolitis Often localized to sigmoid colon Seen in patients on chemo  Tx : Antibiotics + Bowel rest + Platelets+ Granulocyte stimulating factor 86. CA prostate : Confined to gland/Early stage  Prostectomy 87. Metastatic CA prostate to spine  LHRH agonist (Leuprolide/Goserelin) or B/L orchidectomy 88. Post MI Indefinite Baby Aspirin 89. Postpartum 3-4 days  Anxiety,Irritability,Confusion Postpartum blues Resolve by 2 wks by itself. 90. EBV/Infectious Mononucleosis=Few wks sore throat Strepto: Few days 91. Kawasaki Ds: Fever>5dB/L conjunctival injectionstrawberry tongue + Edematous soles/palms+ Desquamatous rash + Cervical LN + Thrombocytosis  Tx


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Aspirin + IV gammaglobulin  Echocardiography to evaluate cardiac status  Most Important complication is aneurysm of coronary artery(Steroid not required!) Mortality is 0.05% only Long term aspirin?  Yearly influenza vaccine to avoid Reye’s syndrome 92. Cherry red lips ? CO poisoning  Methylene Chloride is a solvent used in paint remover readily absorbed thry skin Hepatic metabolite COMeasure carboxyHb  Use 100% supplemental O2  If carboxyHb levels > 25% use hyperbaric O2 chamber.(Remember Methylene blue is for MethHb not carboxyHb) 93. Hyperbaric O2 chambers for CO poisoning indications: (1) >25% carboxyHb (2) Mental state changes(3) EKG showing Ischemia/Angina pain (4) Ph <7.2 (5) Unconscious >20 mint(6)Preganancy with >15% carboxyHb Fetal Hb has more affinity 94. Post-infectious cerebellar ataxia : Unsteady broad base gait + Nystagmus seen in children 25% have h/o varicella infection within 1 month prior Resolution within weeks 95. Scleroderma  Anti-topo-isomerase I antibodies:highly specific for scleroderma(Association with interstitial lung ds)  Anti RNA polymerase I/II antibodies: Renal and skin involvement  Anti U3 RNP (Fibrillarin) antibodies: Pulmonary HTN  Remember anti PM scl antibodies seen in MYOSITIS not in scleroderma  CREST= Anti CENTRO mere 96. Alkalosis + Hypokalemia + HTN =? Conn’s Measure Renin and aldosterone levels 97. Biphasic basal body temperature(Rise on 14th day Stays for 13 days and drops after that and menses occur on next day) =Leutinization + Ovulation Sports women often have altered ovulation due to decreased GnRH 98. IHD = Leading cause of death in elderly >65 99. Baby born to mother having HepB Surface antigen positive  Give hep B vaccine + Immunoglobulins within 12 hrs at different sites  Repeat vaccine at 1 & 6 months 100. Patient allergic to penicillin may have allergy to cephalosporin in 7-8% cases Perform skin penicillin test Negative results exclude such possibility 101. Mind it-even an annual check up of an adolescent includes a private interview and nobody else can stay with her/him(including parents). 102. Funneling beer: A large funnel and a tube used to supply a large quantity of beer at fast speed into the mouth 103. Erythema multiforme (also called erythema multiforme minor to distinguish it from Stevens Johnson syndrome, which is sometimes known as erythema multiforme major)asymptomatic skin patches appear like a target, i.e. three rings of red, white and pink. Often the centre of the patch forms a fluid-filled blister that crusts over within a few daysOften, the rash is accompanied by sores and blisters on the lips HSV or medications may cause this  HSV related lesions are recurrent  Topical steroid + Antihistaminic Use acyclovir to prevent recurrence.


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Target Lesion: Red-white and pink rings/Bull’s eye 104. Predictor of Restrictive lung disease on PFT: Decresed FEV1 but FEV1/FVC is normal (>80%) and there is disproportionate decrease in DLco(Diffusion capacity of CO) as compared with TLC.(Proportional decrease s/o extra-throacic restrictions like Kyphoscoliosis) 105. Lyme’s ds transmission requires about 24-28hrs attachment of Tick to the body. 106. Discitis in Immunosuppressed might be due to many organism Start broad spectrum antibiotic first  Take tissue from disc under fluoro guidance to ascertain organism Blood culture though taken but has low yield 107. Eosinophilic pneumonia: Ac hypersensitivity reactionHypoxemic resp failure + Diffuse pulmonary opacities +>25% eosinophils on bronchoalveolar lavage + eosinophilic infiltrates on lung biopsy Tx Methyprednisolone 108. Threatened abortions  There is no proven role of bed rest in prognosis!  But do not forget to perform blood grouping in every case of any bleeding in pregnancy (RhoGam?) 109. Rheumatoid ds might be associated with anemia of chronic ds 110. Asthma Prolonged expiration and increased TLCVentilator setting will require sufficient time to exhale air and no overload over preexisting expanded lungs Choose low tidal volume +slow respiratory rate(to allow time to expire) + High flow rate on inspiration. 111. Tx Vitiligo: Topical steroid & Phototherapy 112. Milk line: along axilla and inguinal region Site for accessory nipple 113. Epidural catheter: To infuse drugs into epidural space for anesthesia + analgesiaPatient receiving narcotics thru epidural catheter should not have IV narcoticsIf “patient controlled analgesia” (via electronically controlled infusion pump activated by patientas per the need) with IV morphine is required first discontinue Hydromorphone in epidural mix.


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114. Benzatropine is often added with high potency antipsychotics like haloperidol with extrapyrimidal effects to avoid parkinson’s like symptoms. 115. First pregnancy earlier = Low risk of Breast CA 116. Platinum =ATN(Cisplatinum =Nephrotoxicity) 117. Screening for prostate CA in a patient with increased risk due to first degree relative DRE at 50 yo age(African American 40 yrs) PSA soon after DRE(It doesn’t elevate levels) 118. Suspected HPV infection in male(His partner detected with cervical dysplasia on pap smear)No visible lesion Apply vinegar over anogenital area Invisible lesions will turn white!(Hyperplasia =increased glycogen content + permeability) 119. Hydrocortisone=Glucocoticoid(regulated by pitutary) Mineralo = fludro (Regulated by renin) 120. Nicotine is addictive and it is common to have about 5-6 attempts before quitting it. At an average a significant wt gain of about 7-10 pounds is usual after quitting. 121. DIC = Low platelets + Elevated PT/PTT 122. How to verify normally placed endotracheal intubation With a commercially available, disposable, colorimetric “End Tidal co2 detector”  color changes using a numerical scale measuring % carbon dioxide in exhaled gases 123. MC cause of jaundice in pregnancy =Hepatitis 124. Symptomatic Gall stones in pregnancy should be operated in second trimester(Avoid first due to untoward effects to fetus) as most of tem may have second attack before delivery. 125. PCP  Hypoxemia + Elevated LDH = S/O lysis of fungi and inflammation leading to increased mortality and indication to use IV steroids/dexamethasone. 126. Sod Nitroprusside toxicity Cyanide + Sod Thiosulfate  Sod thiocyanide  excreted from kidneys. 127. Rocky Mountain spotted fever: DOC is Doxycycline Although tetracyclines should not be routinely prescribed to children younger than 8 years, the benefits far exceed the risks in treating Rocky Mountain spotted fever (RMSF)Chloramphenicol was previously recommended for use in children younger than 8 years (to avoid teeth staining), but it poses a risk of permanent aplastic anemia and should be avoided if at all possible Still used as DOC in pregnancy. 128. Accentuated fall in systolic BP with inspiration >10mm Hg Pulsus paradoxus Cradiac temponade or severe asthma 129. DKAInsulin drives K+ and PO4 into intracellular space Hypokalemia and hypophosphetemia the later may manifest as rhabdomyolysis +Hemolysis and weakness. 130. Aspiration pneumonitis clinically improves within 24-48hrs and radiological improvement seen after 7 days. 131. Referral to cardiac surgeon in a case of MR: <55% of LV ejection fraction or >55mm dimension of LV end systolic. 132. Tracheal stenosis after an intubation should be about 1-2mm to cause respiratory distress.Cricoid is at the level of C6 and we can not pass an endotracheal tube at this level. 133. Antenatal visit at 28wks1.GTT 2. Blood typing in Rh –ive to give RhoGam 134. Ca++ containing antacids may combine fatty acids and cause absorption difficult.(Steatorrhea) 135. Sick sinus syndromealternative tachy /bradycardiaasystoleTx Pacemaker


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136. Pelvic abscess in post operative phase manifest earliest as diarrhea after 7days with fever. 137. Nitric oxidevia inhalation acts thru cGMPselectively acts on pulmonary HTN sparing systemic system. 138. Before you start Ribavarin or interferon +Ribavarin in a patient of Hep C take a liver biopsy to ascertain prognosis. 139. Alk phos is useless test in pregnancy as it is secreted from placenta and always raised. 140. Osler Weber Rendu syndrome:Hemorrhagic Telengiectasia(autosomal dominant) around lips,oral/nasal mucosa and internal GI lining presenting as bleeding,epistaxis or melena Manifest around 20-30 yrs 141. Msl injuryRhabdomyolysis Raised SGOT/LDHRenal failure/Eleveted creatinine 142. Recurrent unilateral photophobia,pain and epithelial staining defectsHerpes?keratitis Slit lamp shows dendritic ulcersRefer to ophthalmologist Tx 143. Diverticulitis in elderly should be operated with sigmoid colon resection after >3 attacks/Fistula or abscess formationDiverticulitis in<50yrs/youngEven the first attack is very severe and has tendency of recurrenceOperate after first attack 144. URTIUnilateral conjunctivitis presenting with redness,gritty sensation,pain,crusting with periarticular nodes Viral etiology 145. PCOD DOC is OCP’sMetformin in patients want to conceive 146. Acneiform eruptionPapules & pustules resembling acne but not confined to areas of acne vulagris(Involving trunk) All lesions in same stageSudden in onset Many medications including steroids & cyclosporins are responsibleWhen seen after shoert term steroid course called as steroid acneTx Tretinoin cream 147. Pitreasis Rosea:

The herald patch of pityriasis rosea is then followed by the appearance of multiple smaller oval pink patches on the child's trunk, arms, and legs. These can be mildly itchy and can linger for several weeks or months, but the child will otherwise have no symptoms and pityriasis rosea is thought to be harmless. It is not known what causes pityriasis rosea, but it may be cause by a virus or a reaction to a previous viral infection. No treatment is usually required, except perhaps to control the itching if it is bothersome.


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Christmas Tree

appearance

148. Fruit juices which have sorbitol like pear/prune may relieve constipation. 149. Iron deficiency anemiaFeSo4 for 2-3 months +Iron rich diet with meat 150. Bloody diarrhea+Hypotension in an elderly?Ischemic colitisSigmoidoscopy shows green mucosa with isolated depigmented patches. 151. DKA on insulin+Fluid+K Suddenly develops headache?Edema cerebral Rx Mannintol 152. Type-I:Distal RTA (dRTA)failure of acid secretion by the alpha intercalated cells of the cortical collecting duct of the distal nephronfailure to acidify the urine to a pH of less than 5.3 even if the blood is too acidicclinical features of DrtaNormal anion gap metabolic acidosis/acidemia,Hypokalemia,Urinary stone formation,Nephrocalcinosis (deposition of calcium in the substance of the kidney),Bone demineralisation (causing rickets in children and osteomalacia in adults) . Type-II: Proximal RTA (pRTA) is caused by a failure of the proximal tubular cells to reabsorb filtered bicarbonate from the urine, leading to urinary bicarbonate wasting and subsequent acidemia. The distal intercalated cells function normally, so the acidemia is less severe than dRTA and the urine can acidify to a pH of less than 5.3. pRTA also has several causes, and may occasionally be present as a solitary defect, but is usually associated with a more generalised dysfunction of the proximal tubular cells called Fanconi's syndrome where there is also phosphaturia, glycosuria, aminoaciduria, uricosuria and tubular proteinuria. The principal feature of Fanconi's syndrome is bone demineralization (osteomalacia or rickets) due to phosphate wasting Rx NaHco3 153. MiliariaHeat rashes due to prolonged bed restTurn frequently+Cooler temperature 154. Low Cardiac outout(CO)+Normal pulmonary artery wedge pressure(PAWP)+High systemic vascular resistance(SVR) S/o extracardiac obstructive shockTemponade/Tension pneumo/Pulmonary TE


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155. 3-10% spina bifida patients have allergy to latex due to excessive exposure to surgical processes in early life. 156. Mallet finger: Extended finger focibly flexed leading to avulsion of proximal part of dorsal aspect of distal phalanxRequires extensor splinting 45wksComplication:Permanent swan neck deformity 157. Lithium level >4mEq/L requires emergent dialysis. 158. Aggressive diuresis in a case of ascites may cause renal failure and hyperkalemia 159. Anabolic hormones for longer duration may cause testicular atrophy. 160. Needle stick injury from a discrded needle in sandboxPostexposure prophylaxix of HIV is controvertial. 161. Simple(No loss of consciousness) partial(a part of brain involved)seizure:Jerky movements of limbs with aura(Often described as weired feeling)EEG to ascertain any further abnormality. 162. # radial head: (1) Non-displacedConservativeImmobilize for 1-2 weeks(Light posterior splint & Sling (2)Displaced or comminuted Surgical excision of radial head with 24-48 hours (Child: ReductionClosed/Open reduction and internal fixation Radial head is never excised in growing child as epiphysis removal results in unequal forearm growth 163. Meneier’s disease: Tx Low salt diet + HCTZ 164. HSV 2 infection:Subclinical Viral shedding is documented even when the lesions are not thereDuring lesions skin to skin transmission is well documented(Condoms to not prevent transmission)Acyclovir will reduce the duration of symptoms and viral excretion time. 165. Chancroid:H.Ducery

The lesion begins as a soft, red papule. Within 1 to 2 days, it becomes pustular, eroded, and ulcerated. The ulcer is usually 1 to 2 cm in diameter, painful, and covered by a yellowish or gray exudates; it bleeds easily when scraped. The edges of the ulcer are ragged and undermined. Chancroid does not have a vesicular stage. In males the ulcer is typically located on the distal penis, but may occasionally occur in the urethra and anal orifice. In females, the lesions tend to be localized to the vulva but can also occur in the vaginal, perianal area, and cervix. Painful inguinal lymphadenopathy and over-riding erythema is associated with chancroid in nearly half of all cases in males, less often in female cases. The lymph nodes become fluctuant, can spontaneously rupture, and drain pus.Tx Azithromycin single dose 166. Fracture in cervical spine involving transverse foraminaVertebral artery trauma? Dissection/ThrombosisAngiography /Yolk sac tumourHCG by both seminoma & 167. AFPEmbryonal nonseminomaRP nodes involvement s/o stage 2Supradiaphragmatic nodes s/o satge 3Stage 1 seminoma requires orchidectomy + RT 168. Roseola/Sixth Ds/Exanthema subitum:mild illness that mainly affects children that will go away on its own. Roseola is caused by viruses of the herpes type6 or


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7. Infected children have a few days of high fever followed by a rash as the fever goes down. The rash usually lasts 1–2 days, or it may go away more quickly. Child mostly appears well with some LN and rose pink macules involving trunk/neck.

169. A 12-lead electrocardiogram obtained at a body temperature of 32°C.(Hypothermia) Note J wave of Osborn, which have an extra deflection a the end of the QRS complex. 170. “Monitored bed units”:To regularly assess cardiac & respirstory systemsE.g Postop orthopedic patient with intathecal morphine still have pain and requires more IV morphineNeeds respiratory monitoring 171. Insulin like growth factor(IGF)-1 elevated at multiple occasionsconfirms diagnosis of acromegaly. 172. Insulin dependent DM scheduled for operative procedureReduce the insulin dose to 1/3-1/2 on the day of procedure as he/she is kept NPORegularly monitor glucose levels and adjust it with insulin/Dextrose.


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173. Vibrio vulnificus implicated in septicemia and does not cause diarrheaIII gen cephalosporin +Minocycline(Synergistic effect) 174. MC cause of neurological deficit in an elderly is metabolic or toxic cause especially glucose(improperly treated DM) or electrolyte imbalances. 175. Punctured wounds like bite should not be vigorously irrigated or debrided as it may dislodge the infection deeper.Mx Augmentin or Cotrim+ClindamycineReview it within 48hrs. 176. Patient in acute respiratory distress requires intubation but eaten food within 8hrs(In case of trauma within last 12hrs)Increased risk of aspirationPut pressure on cricoids while inserting tubeOnce inserted inflate balloon to prevent from aspirationCheck end tidal Co2 177. Scabies in one member of familyRx Permethrin to all irrespective of their status of infestation and wash cloths/beddings in HOT water and dry in HOT cycleTake scrapping after putting mineral oil to microscopically confirm mites. 178. Young nonsmoker patient developing recurrent DVT? Fcator V Leiden deficiency 179. Dysnea on exertion/Nocturnal paroxysmal dyspnea are symptoms of Lt heart failure while raised JVD/Edema/Hepatojuglar reflux are s/o Rt heart failure. 180. Resistant & recurrent candida vaginitis  Culture to R/o presence of C. Glabarta 181. Safest position for an infant in a car is middle of back seat which is rear facing till the age of 1year or 20ounds(Child upto 12 yrs back seat) 182. Propanolol may lead to depression. Severe respiratory distressEmergency 183. Epiglottitis intubationCricothyroidotomy 184. Co-oximeter measures levels % of carboxy/Meth/Oxy HbPulse oximeter saturation/Arterial o2 pressure & satuartion are normal in CO poisoning(CarboxyHb read by pulse oximeter as saturated) 185. OCP + Smoking = Stroke/MI 186. CA Cx stage IIB(Extension into parametrium) or more Tx RT External beam radiation/Brachytherapy 187. Dialysis dysequilibrium syndromeSeen as neurologic symptoms like confusion & headache soon after or during the first dialysisDue to cerebral edemaTx Mannintol 188. Dx of crohn’s ds is often made with Upper GI barium study 189. Blalock Taussing Shunt for TOFTo improve pulmonary Bd supply 190. Relapsing Polychondritis: All cartilage areas can be affected, though in many cases the disease will affect several areas where cartilage is found in the body, and leave others entirely alone. Parts of the body with cartilage, and therefore potentially affected by polychondritis, include the ears, nose, throat, heart valves and of course all areas where musculo-skeletal tissues are connected by cartilage. Specific resultant conditions may include Tracheomalacia and Vasculitis.Complication may include aortic aneurysm.Tracheal narrowing is typical finding on Xray.Rx Steroid 191. To detect small pneumothorax CxR in maximum expiration to reduce the lung volume. 192. Lithium may flare up psoriasis 193. AntiHCV antibody generally not detectable until 18wks after illness hence negative antibody doesn’t rule out HCV infection in post transfusion hepatitis state. 194. Papules with central umblication covered with hemorrhagic crust in an HIV patient ?Cutaneous cryptococcus


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195. Native valve endocarditis empiric therapyVancomycin + Gentamycin(Also for blodd culture negative endocarditis) 196. Predictor of poor outcome of Asthma: Earlier intubation or hospitaliztion and use of steroid. 197. Billiary colic v/s Calculus cholecystitisRaised leucocytes absent in former/Murphy’s sign –ive 198. APCKD DOC is ACE inhibitorSecond line Calcium Channel blockers(If creatinine levels rise after ACE inhibitors) 199. Acute angle closure glaucoma Rx Acetazolamide,Mannintol,Topical Timolol/Pilocarpine. 200. Scheuermann's disease:form of juvenile osteochondrosis of the spine. It is found mostly in teenagers and presents a significantly worse deformity than postural kyphosis. Patients suffering with Scheuermann’s kyphosis cannot consciously correct their posture. The apex of their curve, located in the thoracic vertebrae, is quite rigid. The sufferer may feel pain at this apex, which can be aggravated by physical activity and by long periods of standing or sitting; this can have a significantly detrimental effect to their lives as their level of activity is curbed by their condition and they may feel isolated or uneasy amongst their peers if they are children, depending on the level of deformity. Also, the decreased level of height will emphasize body fat around the intestines, making the person with Scheuermann's kyphosis seem more heavy-set than normal. This can make children even more uneasy, with a possibility of being harassed by peers, since they appear to be "fatter" than other children. Whereas in postural kyphosis the vertebrae and disks appear normal, in Scheuermann’s kyphosis they are irregular, often herniated, and wedge shaped over at least three adjacent levels.The seventh and tenth thoracic vertebrae are most commonly affected. It causes backache and spinal curvature. In very serious cases it may cause internal problems and spinal cord damage. The curvature of the back decreases height, thus putting pressure on internal organs, wearing them out quicker than the natural aging process


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201. Indications for tonsillectomy are recurrent tonsillitis(7 episode in one year or 5 each in two year or 3 each in three years), peritonsillar abscess and airway obstruction/Dysphagia,swollen anterior cervical nodes,pertonsillar exudates 202. Aspiration pneumonitis(chemical pneumonitis)generally responds to supportive careRequires antibiotic when progresses to pneumonia. 203. Severe pruritic rash not responding to steroids + low WBC’s?Idiopathic rash of HIVCD4 counts 204. Flu Shots: All>50yrs, Chronically ill,Prenatal,Health care worker and someone who asks for it! 205. Urethral discharge Mucoid:ChlamydiaPurulent:Gonococci 206. Villous adenomatous polyp has highest risk of CA while tubular has lowest. 207. Hamstring(Arising from inferior pubic rami) avulsion fracture(Seen as soft tissue infiltration and callus) is common in hurdlers. 208. Pulmonary alveolar proteinosis -(PAP) is a rare lung disease in which abnormal accumulation of surfactant occurs within the alveoli, interfering with gas exchange. PAP can occur in a primary form or secondarily in the settings of malignancy (especially in myeloid leukemia), pulmonary infection, or environmental exposure to dusts or chemicals. Rare familial forms have also been recognized, suggesting a genetic component in some cases.Bronchoalveolar lavage shows turbid material which is PAS +ive.Tx Whole lung lavage 209. Variant angina common in (young asymptomatic)east-asians and associated with migraines/Raynaud’s phenomenon.Tx CCB like Dilantin 210. Lumbar puncture headache: seen after LPPpt in sitting position and relieved in supine position. 211. External skin tag protruding from anal skin margin with linear ulcer in the posterior commisure in anal vergeFissure 212. Esophageal varicesBleed stopped(30-60% stop spontaneously)No active lesionBanding +IV Octeoride(Causes vasoconstriction). 213. Retropharyngeal abscessH/o sore throat and exudates+Air in superior mediastinum + Stridor 214. Pemphigus is an autoimmune disease of the skin and mucous membranes(oral) that causes vesicles (blisters), bullae and raw sores. It may be triggered by medications, such as penicillamine/Allopurinol.In pemphigus, autoantibodies form against desmoglein. Desmoglein forms the "glue" that attaches adjacent epidermal cells via attachment points called desmosomes. When autoantibodies attack desmogleins, the cells become separated from each other and the epidermis becomes "unglued", a phenomenon called acantholysis. This causes blisters that slough off and turn into sores. In some cases, these blisters can cover a significant area of the skin.Tx Steroids 215. SSRI cause headache and nausea initially and later may cause decreased sex drive and prolonged time of orgasm. 216. Grave’s Disease in pregnancy DOC propylthiouracil.(Methamizole crosses placenta/Radioactive iodine destroys fetal thyroid). 217. Patient using an alternative medication or an illegal drug Do not criticise provide him a better alternative. 218. Diabetic foot ulcer may lead to necrotizing infection and a X-ray is mandatory before debridment/incision or amputation is planned.(Simple incision or darinage is not useful) 219. Polymyalgia rheumatica is an inflammatory condition of the muscles, which causes pain or stiffness, usually in the neck, shoulders, and hips(Proximal muscles).Most PMR sufferers wake up in the morning with pain in their muscles.Anemia and an overall feeling of illness/slight fever are commonly seen.Studies have shown that about 15% of people who are diagnosed with


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polymyalgia rheumatica also have temporal arteritis, and about 50% of people with temporal arteritis have polymyalgia rheumatica.ESR >100,Tx Steroids & NSAIDS 220. Metformin causes weight loss or stablization. 221. Leading cause of deaths in males between 15-25yrs is motor vehicle accidents and 50% of which involves alcoholAvoid drinking and driving. 222. During long flight due to low oxygenation,altitude and humidification the gas containg viscera may expand.Any body with recent intestinal obstruction,Volvulus or abd surgeries should avoid long flights leading to a probable emergency. 223. Volvulus not treated for few hours +Leukocytosis + Fever IschemiaResection 224. ST elevation MI Cardiac catheterizationDecision of stenting/plasty as per the need. 225. Postop patient developed a new rash over dependent buttockSize matching with size of dressing(DuoDerm: maintains a moist wound environment for optimal healing.)Contact dermatitisTopical steroids 226. Baby born at >35 wks gestation in a Strep B + ive motherMother received <2 doses of antepartum ampicillinLimited evaluation observation for 48hrs + complete blood counts with diffrential required (>2doses= Only observation) 227. AIDS associated dementia =Rx HAART + Antidepressants 228. Varicella vaccine at 12months once 229. MC cause of erectile dysfunction is vascular disease in man >50yrs 230. Metabolic disorders are common in bulemic patients usually as Hypokalemia and hypomagnesemia. 231. AF >48hrs needs anticoagulats for 3wks before opting for elective cardioversion to avoid artrial thrombi. 232. Fisrt line Rx for migraineModerate to high dose NSAIDS + Environmental control(e.g. dark quite room) 233. Screening of colon CA: (1) Asymptomatic without any risk factor Annual DRE>40 yrs and annual FOBT + sigmoidoscopy every 3-5 yrs in >50 yrs age(2) Symptomatic or Risk factors/Family history  Annual Colonoscopy 234. Test PSA in high risk men >40 yrs >4ng/ml levels warrants biopsy 235. Sodium polystyrene sulfonate is the resin binding K+ 236. Pyogenic granuloma is a relatively common benign vascular lesion(granulation tissue) of the skin and mucosa whose exact cause is unknown. This misnamed entity is neither infectious nor granulomatous. The lesion occurs as a solitary glistening red papule or nodule that is prone to bleeding and ulceration.Pyogenic granuloma often arises in pregnancy (or rarely with oral contraceptive usage), particularly on the gingiva or elsewhere in the oral mucosa, and then is termed the "pregnancy tumor." Removal of the lesion is indicated to alleviate any bleeding, discomfort, cosmetic distress, and diagnostic uncertainty. A number of malignant tumors may clinically mimic pyogenic granuloma, making histopathologic confirmation important if the presentation is atypical. The precise mechanism for the development of pyogenic granuloma is unknown. Trauma, hormonal influences, viral oncogenes, underlying microscopic arteriovenous malformations, the production of angiogenic growth factors, and cytogenetic abnormalities have all been postulated to play a role.


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Pyogenic granuloma on the hand. Courtesy of Jeffrey P. Callen, MD 237. Headache during pregnancy or post C-section Think of venous sinus thrombosis 238. Gold standard to diagnose GB rupture is direct visualization with laproscopy. 239. Coagulopathy and decreased albumin =Synthetic liver ds?Cirrhosis 240. Only language development delay in a child? Hearing defect 241. Stool guaiac test:To detect the presence of fecal occult blood.It involves feces, a thick piece of paper attached to a thin film coated with guaiac (which comes from the Guaiacum tree), and hydrogen peroxide.When the hydrogen peroxide is dripped onto the guaiac, it oxidizes the guaiac causing a color change. This oxidation occurs very slowly. Heme, a component of hemoglobin found in blood, catalyzes this reaction, giving a result in about 2 seconds.It detects distal neoplasm best.Iron/Aspirin will not cause guaiac + test. 242. General anesthesia may ppt an episode of goutSuspect somebody with severe pain in great toe after operative procedure and not responding to morphine. 243. During mechanical ventilation limit tidal volume <6cc/kg/Peak inspiratory pressure(PIP)<35CM H2O in a critically ill patient.(Traditional Teaching TV >15 and PIP >45 leads to ventilator induced lung injury) 244. Temporal lobe epilepsy could be simple partial or complex partial. Simple Partial Seizures (SPS) involve small areas of the temporal lobe and do not affect consciousness. These are seizures which primarily cause sensations. These sensations may be mnestic such as déjà vu (a feeling of familiarity), jamais vu (a feeling of unfamiliarity), a specific single or set of memories, or amnesia. The sensations may be auditory such as a sound or tune, or gustatory such as a taste, or olfactory such as a smell that is not truly present. Sensations can also be visual or involve feelings on the skin or in the internal organs. The latter feelings may seem to move over the body. Dysphoric or euphoric feelings, fear, anger, and other sensations can also occur during SPS. Often, it is hard for persons with SPS of TLE to describe the feeling. SPS are often called "auras," and are sometimes thought to be preludes to more severe seizures. Complex Partial Seizures (CPS) by definition are seizures which impair consciousness to some extent. This is to say that they alter the person's ability to interact with others. They usually begin with an SPS, but then the seizure spreads to a large portion of the temporal lobe and impairs consciousness. Signs may include motionless staring, automatic movements of the hands or mouth, inability to respond to others, unusual speech, or unusual behaviors. Because judgement is impaired, persons experiencing CPS may not legally drive vehicles for periods of time which are set by local governments worldwide. Estrogen is known to exacerbate TLERefer to Neurologist 245. Hallmark of heatstroke is LOC with increased core body temperature.At first start cooling measure and then collect urine/perform CT to make DDx. 246. Asymptomatic bacteriuria doesn’t require any treatment. 247. Nephrotic syndrome may increase the susceptibility to bacterial infection.


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248. Pharmacotherapy should be offered to ALL smokers who want to quit-in the INITIAL discussion itself.They reduce withdrawl symptoms and craving. 249. Pruritic urticarial papules and plaques of pregnancy (PUPPP), known in United Kingdom as polymorphic eruption of pregnancy (PEP),[1] is a chronic hives-like rash that strikes some women during pregnancy. Although extremely annoying for its sufferers (because of the itch), it presents no long-term risk for either the mother or unborn child. PUPPP frequently begins on the stomach and spreads to the legs, feet, arms, chest, and neck. It spares umblicus.Treatment of mild cases during pregnancy consists mainly of the application of topical moisturising creams or aqueous/emmolient ointments. Class I or II corticosteroid creams and ointments are used in more aggressive cases.

DDx Gestational Pemphigoid or Pemphigoid Gestationis (PG) is a rare autoimmune blistering skin disease that occurs during pregnancy, typically in the second or third trimester, and/or immediately following pregnancy. It was originally called Herpes Gestationis because of the blistering appearance. Gestational Pemphigoid is not associated with the herpes virus.It involves umblicus. 250. Meningococci prophylaxis Rifampicin,Ceftriaxone and cipro all three are acceptable.However,children with splenia may require quadrivalent vaccine. 251. Fenfluramine is associated with valvular heart disaese and has been discontinued. 252. Dislocation of knee and anterior cruciate ligament injury may be associated with popliteal artery rupture. 253. Nov is a flu seasonFlu shots 254. Marcus Gunn pupil(afferent pupillary dfect):On swinging flash light the affected eyes sees less light and pupil dilatesOptic nerve defect like ischemia,neuritis or compression by a tumor. 255. Association of DM with skin diseases: (1)Scleroderma: A syndrome is recognized with late onset DM+ Chronic scleroderma+obesity +High CVS ds incidences(2)Candidiasis: along redundant skin folds(3)Necrobiosis Lipoidal diabeticurom:seems to be marker of DMcharacteristically anterior and latral legPlaques with irregular,flattened with eventually depressed atrophy.


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256. Fifth disease is one of several possible manifestations of infection by parvovirus B19. The disease is also referred to as erythema infectiosum (meaning infectious redness) and as slapped cheek syndrome, slapcheek, slap face or slapped face

The bright red cheeks are a defining symptom of the infection in children (hence the name "slapped cheek disease"). Occasionally the rash will extend over the bridge of the nose or around the mouth. In addition to the red cheeks, children often develop a red, lacy rash on the rest of the body, with the upper arms and legs being the most common locations. The rash can last a couple of days (some cases lasting for several weeks) and may itch. Patients are usually no longer infectious once the rash has appeared.Teenagers and adults may present with a self-limited arthritis. The disease is usually mild, but in certain risk groups it can have serious consequences:In pregnant women, infection in the first trimester has been linked to hydrops fetalis, causing spontaneous abortion In people with Sickle-cell disease or other forms of chronic hemolytic anemia, infection can precipitate an aplastic crisis 257. Rotavirus diarrhea are great problem in day care center.Child in whom the stools are not contained within diaper should be excluded from day care until diarrhea ceases.Washing hands is the most effective preventive measure. 258. Familial throid CAMedullary?


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259. NHL Mets to extraocular mslsIV steroids to relieve edema 260. Duodenal perforationHypoactive or absent bowel sounds on auscultation. 261. Myeloproliferative diseasePolycythemia,myelofibrosis,Chronic myelogenous leukemiaHyperviscosityRisk of Stroke 262. H.Pylori3x increase in gastric CA incidences. 263. Synchronized electrical cardioversion is the process by which an abnormally fast heart rate or cardiac arrhythmia is terminated by the delivery of a therapeutic dose of electrical current to the heart at a specific moment in the cardiac cycle. Synchronized electrical cardioversion is used to treat hemodynamically significant supraventricular (or narrow complex) tachycardias, including atrial fibrillation and atrial flutter. It is also used in the emergent treatment of wide complex tachycardias, including ventricular tachycardia, when a pulse is present. Pulseless ventricular tachycardia and ventricular fibrillation are treated with unsynchronized shocks referred to as defibrillation. 264. Chlodiazepoxide is usual drug of detoxification for alcoholic withdrawal and delirium in uncomplicated caseWhen LFT’s raised or COPD is present it may become even more long acting due to its metabolitesDOC in these complicated cases Lorazepam(Excreted by kidney/Short acting/No active metabolite/No respiratory depression). 265. African American with uncontrolled HTN has risk of aortic dissection. 266. Patient on long HRT still showing osteoporosisThink of Multiple Myeloma? 267. Suspected Thyroglossal cystpreoperative evaluationR/o Ectopic Thyroid with Ultrasound 268. ProteinuriaOvernight 24hrs protein collection shows <150mg ProteinOrthostatic proteinuria 269. Bacteremia <4wks Vaginal floraStrep B,Listeria & E.coliAmpicillin + Cefotaxim 270. Iron deficiency anemiaIron TxReticulocyte count rise within 3days and peaks within 10days. 271. Orbital floor # Most likely complication inferior rectus msl blue body pinkwhole 272. APGAR: Appearance(Blue/paleExt pink),Pulse(absent<100>100),Grimace(No of limbsActive responseGrimaceSneeze),Activity(NoFlexion motion),Respiratory effort(NoneSlow irregularGood crying). 273. Newborn of a Koch’s motherTuberculin +Chest X-ray –iveStart Isoniazid for 3 months and repeat Both tests againStill –iveDiscontinue INH otherwise continue for 9months i.e. 6 moth more 274. Nappy rash is a common problem for neonates within the first few months of life. Whilst the exact aetiology of nappy rash is not clear, it is felt to be due to moisture in the nappy environment and from irritation from urine and stool. Many infants will be affected by superinfection with Candida albicans. Typically in Candidal nappy rash, there is erythema in the perineal region, with satellite lesions which may coalesce. There is often an appearance of scale. In the images to the left from the same baby, satellite lesions are seen. Note that there are some lesions close to the umbilicus and extending around the flank. Swabs were positive for Candida(Pseudohyphae and spores).Treatment primarily involves the use of a topical agent such as nystatin or miconazole


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Irritant diaper dermatitis:Spares intertrigoExpose to air Rx ZnO2Due to soaps/Detergent. 275. Molar pregnancy after D&CFollow-up for 1 year with b-hcg to r/o chorioCAShe should not be pregnantRx OCP’s 276. HIV ChildMMR at 12months and repeat after 4wksAll other household children should also receive MMR irrespective of age. 277. Post-thyroidectomy bleeding and hematoma along capsule may lead to stridor and cyanosis. 278. To assess fidelity of both nerve and msls(Neuromsl integrity)an electromyogram is used. 279. Ectopic B-hcg at day 4 and day 7fall of 15% on day 7successful treatmentWeekly follow up 280. Establishing and quantifying amount of reflux24hrs PH monitoring 281. In Suspected Methanol poisoning measure serum osmolarityosmolar gap >10mOsm 282. Multiparous woman may have both pelvic floor dysynergia and anorectal reduced sphincter tone leading to constipation and fecal incontinence respectivelyAnorectal manometery(In case of dysnergia it is increased and biofeedback training may help) 283. Post-therapeutic NeuralgiaIn post Shingles dermatome nonpainful stimulus cause pain which is refered in surroundingUse Tricyclic antidepressants. 284. MMR vaccine should be given in children with egg allergiesThough they are developed from chick embryo fibroblast but they have very less egg cross reacting proteins. 285. Topical intranasal steroids are DOC for allergic rhinitis. 286. MVP is not a high risk valvular defect for procedures unless have MR Or thickened flap(confirmed with Echo)In that case give antibiotic prophylaxis. 287. Age 33-44 have 3x increased incidences of ectopic when compared with 1524yrs. 288. Brachial aretry is an end artery with collateral distal to antecubital fossa.Its thrombosis with indwelling catheter makes it a high risk artery. 289. Decompression sickness (DCS), the diver’s disease, the bends, or caisson diseasefollowing a rapid ascentType 1 DCS can occur when bubbles affect the tissues around skeletal joints.Decompression sickness might also present as a skin (cutaneous) disorder. Nitrogen bubbles can cause mottling, lumps or a rash. "Skin bends", as they are colloquially termed, are more common during


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hyperbaric chamber 'dives' and when diving using a dry suit. Type 2 decompression sickness reflects involvement of the Central Nervous System (CNS) and / or the cardio-respiratory system. 290. Before a thorough pelvic examination a pap smear should be taken(if indicated)to avoid contamination.First ect and then endocervix. 291. Post MI one can resume sexual activity after 2-4 wks of discharge. 292. Transferrin saturation is the aerliest test to become abnormal in hemochromatosis. 293. Primary pulmonary HTN Test for vasodialtor response testing to ascertain response to medication. 294. Neonatal jaundice 5mg/dl at 24hrs anf 15mg/dl at 3day is normal Phototherapy when >15mg/dlExchange transfusion when >20 mg and/or not responded to phototherapy. 295. Most of Vesicoureteric reflux grade 1 or 2 usually resolve spontaneously Prophylactic Antibiotics only 296. Aspergilosis in neutropenic AMB IV 297. Pulmonary function tests showing increased diffusion capacity for CO s/o blood in alveoli/hemorrhage. 298. Fat embolism O2 therapy/endotracheal tube. 299. Seborrheic keratosis consists of benign, verrucous (wart-like), often pigmented, greasy lesions consisting of proliferating epidermal cells which usually occur after the third decade.A common occurrence among black people is the appearance of many small lesions on the face, known as dermatosis papulosa nigra.Leser-Trelat sign, the explosive onset of multiple pruritic seborrheic keratoses, often with an inflammatory base, can be an ominous sign of internal malignancy, especially stomach/colon carcinoma. 300. Post chemotherapy persistent fever?Fungal(Multiple B/L lung nodules with surrounding hemorrhage) or resistant G+ive organism 301. Hypervolemic hyponatremia Restrict Salt + Diuretics. 302. Interstitial Fibrosis: Mildly progressive SOB with non-productive cough + Late crackels with inspiration + No sign of CHF/Reactive airway ds like wheeze. 303. Side effects of testosterone therapy Exacerbation of sleep apnea , Erythrocytosis,and BPH/CA prostate exacerbation. 304. IgA nephropathy/Berger DsRecurrent Hematuria within few months Picture of Nephrotic syndrome(Hyperlipidemia,Hypoalbuminia,Proteinuria)Mostly benign course but 50% may develop renal failure by 20yrs. 305. Moraxella CatarrhalisG-ive dipplococci normal inhabitant of upper respiratory tract. 306. Rapid lowering of serum glucose in DKA may lead to cerebral edema. 307. Contraception in postpartum periodProgestin only pill 308. During insertion of central line the dislodged wire may commonly lodge in distal pulmonary artery/tip in Rt ventriclecardiac arrhythmia 309. Visit in woody area +Dry cough +Erythema nodusum Histoplasmosis 310. Highly suspected meningitisEmpiric antibiotic before neuroimaging. 311. Methotrexate is preferred DMARD over penicillamine due to more toxic side effects of later one. 312. Hematemesis following prolonged use of NSAID’sIV access/Fluid and cross matchgastric lavage to remove bloodContinued bleeding UGI endoscopy 313. C-ANCA + in 65-90% of Wegener’s Granulomatosis 314. Baby born to HBS Ag mother should receive Ig +Vaccine as soon as possible after birth but breast feeding should be initiated irrespective of immunization.(It doesn’t increase risk).


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315. Hypernatremia due to dehydration and water deficitTreat with oral water onlyHalf of the deficit within 12hrs and rest half in next 24hrsSerum Sodium fall <12mEq/day 316. Advanced RA B/L lung nodules(Caplan syndrome)+Neutropenia+Spleenomegaly Felt’y syndromeFailure of routine therapyStart with azothioprine/Cyclophosphamide HyperthyroidismThyroid 317. B/L proptosis +Anxiety +Low TSH msls may compress and lead to optic OphthalmopathyEdematous neuropathyVision loss 318. Monoarticular arthritis in an adult should always be taken as septic unless proven otherwise. 319. Nasal septal hematoma is a rare but potentially serious complication of nasal trauma. Because the septal cartilage has no blood supply of itself and receives all of its nutrients and oxygen from the perichondrium, untreated septal hematoma may lead to destroyal of the septum. Immediate drainage is necessary. Septal hematomas can cause a saddle nose deformity. 320. Rabdomyolysis Raised CPK and K+EKG changes peaked T wave Stablize membrane wit Ca++ 321. Conjunctivitis? R/o photophobia/decreased visual acuity or globe pain to exclude keratitis/Iritis etc(Vision threatening conditions) 322. Nickel induced allergic contact dermatitisAreas around metals like button alon pants(Periumblical),underneath watches/rings etc 323. Acute III N.plasy Dilated pupil +Extraocular msl abnormalities + PtosisDeviated to down and outCompression? Aneurysm of PCA/PCOM or supr cerebellarMRA/MR 324. Alendronate Esopahgeal irritation/UlcerationRemain upright for 30mint after intakeTake empty stomach to avoid interactions 325. All patients abusing IV drugs are often constipated. 326. Cirrhotic not taking medication and confused ?Encephalopathy 327. Athlete's foot, also called Tinea Pedis, is a parasitic fungal infection of the epidermis of the human footdermatophytesestimated to be the second most common skin disease in the United States, after acne. Transmission from person to personcommunicable diseasetransmitted in moist environments where people walk barefoot, such as showers, bath houses, and locker rooms.It can also be transmitted by sharing footwear with an infected person, or less commonly, by sharing towels with an infected person.Transmission to other parts of the body skin infections on other areas of the body, most often under toenails (Onychomycosis) or on the groin (tinea cruris). 328. Isolated Bell’s plasy?Herpes Tx with Acyclovir 329. Stable CHFB-blockers and ACE inhibitors are known to decrease mortality. 330. Patient of >65yrs + AF Increased risk of Stroke x17 increase with Coexisting RHD 331. Abd wound dehiscence Due to poor facial healing Causes bronchitis/Smoking,DM and poor wound closure techniqueusually seen after 7-10 days post-op as serous discharge 332. Concussion, ("to shake violently") is the most common and least serious type of traumatic brain injurytemporarily interfere with the way brain worksdon't always involve a loss of consciousness Usually mild and people usually recover fullyTwo most common concussion symptoms are confusion and amnesia(may or may not be preceded by a loss of consciousness)Late symptoms seen up-to 6 months like memory disturbance, personality changes, poor concentration and irritabilityShould not return to sport for a week even if asymptomatic.


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333. Child bumped his head  Thorough PE to R/o significant injury to head like ecchymoses behind ear/blood from ear/depressed # Everything fine?  Keep him under observation/Monitoring. 334. Cigarette smoking is associated with increased severity of Thyroid ophthalmopathy Unilateral exophthalmos is possible in Grave’s ds 335. Risk factors for osteoporosis: Caucasian, advanced age, decreased gonadal function, steroids, low calcium/Physical activity, LOW weight(Not obesity),first degree relative. 336. Neutropenia(<500 counts)+Fever(single oral reading >101.3F)Rx Antipseudomnal antibiotic(3rd Gen cephalosporin like ceftazidime)Piperacillin has developed wide resistance hence not used. 337. Zollinger Ellison? R/o co-existing MEN-I( Pitutary, Pancreas and parathyroid) 338. In neuroleptic malignant syndrome anticholinergics like benzatropine are contraindicated due to heat retention. 339. Lynch syndrome (hereditary nonpolyposis colorectal cancer :HNPCC) AD  risk of proximal colon cancer + breast/ovarian/Endometrial CA. Biannual colonoscopy >25yrspelvic examination/Endometrial Bx every 3years and Mammography at early age. 340. In suspected sarcoidosis the skin and trans-bronchial lung biopsies have supplemented mediastinal LN biopsies because of high yield/specificity and low morbidity. 341. Respiratory distress in a new born Absent Lt lung sounds with “Gurgling” + Displaced heart towards Rt  Diaphragmatic hernia? 342. Nursemaid elbow (Sub-luxation of radial head)Rx Supination with elbow flexed. 343. Recurrent aspiration pneumonia: prevention Place NG tube, elevate head to limit passive reflux, monitoring during all oral intake, choice of appropriate food (thick liquids). 344. Schizoaffective disorder symptoms of a mood disorder(manic and/or mixed and/or depressive episodes) + symptoms of schizophrenia(hallucinations, paranoid or bizarre delusions or disorganized speech and thinking)  2 types: the bipolar type and the depressive type. (Later has worse prognosis which can result in a residual defect). 345. Fluoxetine once started continue indefinitely when patient had 2 or more episodesafter single episode continue for about 6-9months after initial remission. 346. Amblyopia poor or indistinct vision in an eye that is otherwise physically normal The problem is caused by either no transmission or poor transmission of the visual image to the brain for a sustained period of dysfunction or during early childhoodTwo imp causes (1)Strabismus(eyes are misaligned) and (2)Refractive amblyopia (due to a difference in the refraction between the two eyes) Treatment of strabismic or anisometropic amblyopia consists of correcting the optical deficit and forcing use of the amblyopic eye, either by patching the good eye, or by instilling topical atropine in the eye with better visionbest outcome is achieved if treatment is started before age 5 (research has shown that children older than age 10 and some adults can show improvement in the affected eye). 347. Feeding mother given with MetronidazoleIt is secreted in breast milk but effect is not known on newbornSuggested to pump the milk for 24hrs and discard itResume breast feeding after 24hrs. 348. Bilateral mandibular subcondylar fractures : "flail mandible" concomitant loss of support of tongue muscles is thought to result in obstruction of the upper airway


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349. Best noninvasive test to confirm suspected pulmonary HTN Echocardiography Measures ventricular function and pulmonary artery pressure >25mmHg at rest/>30mmHg at exercise 350. MC peri-operative complication of major vascular surgery like aortic aneurysm repair is: MI 351. After 24-72hrs of SAH 25% of CT will be normalCSF Xanthochromia 352. Subclavian line could be associated with pneumothorax in 1-3% cases and requires follow up with Chest X-ray. 353. Stanford Type-A dissection of aorta (Involving any part of ascending aorta) requires urgent surgical interventionType-B Only B-blockers 354. Most significant factor determining risk of stroke is HTN-Treat it first. 355. External hemorrhoids (Symptomatic-Nonthrombosed):Sitz bath/Local steroid and High fiber diet. 356. External hemorrhoids (Symptomatic and Thrombosed):Incise and evacuate thrombus and compression to control bleed. 357. Hep-B core Ag is not a part of Hep vaccine and IgG against it represents a remote infection. 358. OCP’s increased cervical mucosaPreventing spread of Gonococci into endometrium and tubesReduced PID! 359. Viral meningitis is self limited and supportive care + Analgesics are sufficient. 360. Person with diastolic dysfunction  CHF+ Ejection Fraction >70% (!! More than expected )These patients are prone to develop increased pulmonary pressure in response of tachycardia of any cause Keep them B-blocked ! 361. Erythema nodosum may present as nodules on tibia Over the period of time lesion flattened leaving a hue like bruise(Purple/Blue)Search for Infectious causeOCP’s may also cause EN! 362. Nail injury traversing through “Sneaker”(Casual athletic shoe) Risk of Pseudomonas infection. 363. Multiple GI bleed/Bleeding diathesis DVT?  Do not give anticoagulants/put Greenfield filter. 364. Indications for synchronized cardioversion in Tachycardias: Hypotension,CVS instability, Pulmonary edema,ischemia/MI,Altered mental status. 365. Febrile seizure: (1) Simple: The setting is fever in a child aged 6 months to 5 years. The single seizure is generalized and lasts less than 15 minutes. The child is otherwise neurologically healthy and without neurological abnormality by examination or by developmental history. Fever (and seizure) is not caused by meningitis, encephalitis, or other illness affecting the brain (2)Complex: Age, neurological status before the illness, and fever are the same as for simple febrile seizure. This seizure is either focal or prolonged (ie, >15 min), or multiple seizures occur in close succession. 366. CF?  Need to eat in excess to gain weight Many women are infertile due to tubal defects. 367. Taking cocaine in postpartum state Avoid breast feeding  otherwise baby will have Growth retardation and neurologic damage. 368. Mantaux test : Interpretation of the Mantoux / PPD tuberculosis skin test depends on the following: Mantoux / PPD tuberculosis skin test results showing a raised bump measuring 5 mm or greater is interpreted as a positive result in the following: 1. persons with weakened immune systems, such as those with HIV/AIDS 2. persons who have been exposed to persons with active TB/Healthcare staff 3. persons with fibrotic changes on chest x-rays/scans that are consistent with an old TB infection


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4.

persons with organ transplants and other immunosuppressed patients (receiving the equivalent of > 15 mg/day of prednisone for > 1 month)

Mantoux / PPD tuberculosis skin test results showing a raised bump measuring 10 mm or greater is interpreted as a positive result in the following: 1. persons recently (<5 years) arriving to the U.S. from a foreign country 2. persons who use injectable drugs but HIV -ive 3. persons who live or work in high-risk environments, such as cities and crowded areas 4. persons who work in laboratories, especially Mycobacteriology 5. Children under the age of 4 6. Children and adolescents exposed to adults in high-risk environments All other persons with test sites showing a raised bump of 15 mm or greater are considered to have a positive test result.

Most important risk factor contributing in Prinzmetal angina(pain at rest not responding to sublingual NG)Tobacco 369.


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Few more small tips: 1. Hypertrophied heart with speckled pattern Amyloidosis 2. Tricyclic overdose Anticholinergic effects and respiratory depression Leading to hypoventilationAim to treat is PH>7.45 by infusing Sod. BicarbonateHyperventilation after intubation 3. Acute variceal bleedingOcteoride Nodalol has role in primary and sec prevention of variceal bleed but not in acute episode. 4. Actinic keratosis (also called solar keratosis, or AK) is a premalignant condition of thick, scaly, or crusty patches of skin. It is most common in fairskinned people who are frequently exposed to the sun, because their pigment isn't very protective. It usually is accompanied by solar damage. Since some of these pre-cancers progress to squamous cell carcinoma, they should be treated.

5. 6. 7. 8. 9.

Patient surviving acute spontaneous bacterial peritonitisRisk of recurrent infection for 1 year Prophylaxis Rx Levofloxacin Rib fracture Insufficient chest expansion due to painShallow breathing Retention of secretion Predisposed to infectionPneumonia Colovesicle fistula is the commonest fistula formed due to divertculitisPresents as pneumaturia Bleeding esophageal varices 80% chances of rebleeding within 1 year Medical Tx like B-blockers,Sclerotherapy and banding Surgical TIPS Asthma flareDyspnea Hyperventilate to relieve asthmaPH >7.45 and low PCo2


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10. Urgent need to reduce ICT (E.g Tonsillar herniation due to SDH)Most rapid method is hyperventilation with mechanical ventilator and intubation. 11. Patient on chronic steroid Adrenal insufficiency May not cop-up with acute stress like pyelonephritis or infections Orthostatic hypotension/Eosinophilia/Low glucose. 12. Ribavarin Most common side effect  “Hemolysis” Raised bilirubinAbsolute CI for ribavarin Tx is CAD(Can be life threatening). 13. Tetanus immunization for adults:  All people every 10 years  Hx unknownGive vaccine in all wounds  Patient received <3 doses in past 5yrs Give for all wounds  3 shots in last 5 yrsNothing in any wound  >5 years have been passed since last dosegive booster for all wounds except clean/Minor wound  Ig + Vaccine in all patient with major non-clean wounds with unknown Hx or incomplete vaccination 14. DEXA: T score – to -2.5 is osteopenia and <-2.5 is osteoporosis. 15. Patient with cirrhotic ascites developed acute fever,Mental state changes,abd pain or nonspecific complaints ?Spontaneous bacterial peritonitisParacentesis  >500wbc/250PMN or Gram –ive bacteria or+ culture confirms DxIII Gen cephalosporin 16. Hyperglycemia may cause interference with FDG uptake and may lead to false negative results on PET studies. 17. Menieres dsDiuretics and H1 agonist. 18. Breast engorgementTender rock hard breat + Fever Frequent feeding + Pumping 19. Early catatractLens appears yellow brownLate :whiteIf patient is comfortable with visionUse specksotherwise surgery 20. Effective contraception should be used one month before and after the use of isotretinoin. 21. Polycystic kidneys: 50% will result in end stage kidneys by the age of 70 yrs 20% will have berry aneurysm  Associated diverticular ds also possible. 22. Gastric Ulcer treated with triple regimen No dyspepsia Repeat endoscopy to confirm healing as GASTRIC Ulcers have great tendency to develop malignancy. 23. While operating testicular tumor don’t violate scrotal skinIt may disrupt normal lymphatic pathway to RP nodes and may lead to metastasis of tumor to Inguinal nodes (Drainage of scrotal skin) Orchidectomy from inguinal approach! 24. Contrast induced ATN (Tubular cast in urine without RBC-often seen in diabetics with baseline renal functions) can be prevented by giving acetylcysteine prior to IV contrast. 25. Primary pulmonary HTN  Decreased levels of Nitric Oxide 26. Suspicious of bacterial meningitis?  Immediately give IV ceftriaxone CSF will be taken later (Do not delay treatment for CSF collection). 27. A diabetic suddenly developed dyspnea without chest pain still it can be MI Diabetics may have MI without pain due to neuropathy. 28. Most common cause of nephritic proteinuria(Urinary proteins >3.5gms/1.73 m2) in adults is diabetic nephropathy(Most common non-diabetic cause if Membranous glomerulonephropathy) Irrespective of magnitude ACE inhibitors decrease protein excretion and prolong survival. 29. Methylphenidate Side effects: Appetite and wt loss, Insomnia


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30. Any sexually active female or >18yrs should be essentially screened for Chlamydia (Not Gonococcus!). 31. Down’s syndrome: Ligament laxity, Atlantoaxial subluxation,patellar dislocation and hip instabilityScoliosis is not a contraindication to sports participation ! 32. Refeeding syndrome is a syndrome consisting of metabolic disturbances that occur as a result of reinstitution of nutrition to patients who are starved or severely malnourished. Patients can develop fluid and electrolyte disorders, especially hypophosphatemia, along with neurologic, pulmonary, cardiac, neuromuscular, and hematologic complications. Most effects result from a sudden shift from fat to carbohydrate metabolism and a sudden increase in insulin levels after refeeding which leads to increased cellular uptake of phosphate. 33. COPDWhen to start home O2?  PaO2<55mmHg or O2 saturation <89% at room O2 or ambulation (Value higher than this with polycythemia or corpulmonale). 34. Brachial v/s Ankle BP is the preferred first noninvasive evaluation for the case of intermitten claudication. 35. Acute coronary syndrome= ST elevation MI, Non-ST elevation MI ,USA(Unstable angina) EKG + Fractional cardiac enzyme type of MI/USA Rx Non ST elevation MI Aspirin,B-blocker,Heparin 36. Scleroderma patient presented with dyspnea  ILD V/s Pulmonary HTN  PFT  Decreased DLCO + Restrictive pattern =ILD  Decreased DLCO + No restrictive pattern = pulmonary HTN  assess Lt ventricular function/Pulmonary systolic arterial pressure Contrast Echocardiography Rx Options Nifidipine/CCB, Anticoagulant, Misoprostol/Epoprostenol, Bosentan(Endothelial receptor antagonist) Put Rt cardiac catheter before initiating any therapy to monitor response and consider another therapyBosentan is CI in pregnancy(B-Hcg before initiating it). 37. Interval from the time of operation –return of flatus and bowel movement =Ileus May be prolonged due to narcotic analgesic use like PCA(Pt controlled analgesic) pumps  Tx NPO + NG tube 38. Gasgangrene(Feathery lucencies on X-ray) + Myonecrosis Cl. Perfringes Rx Hyperbaric O2 + Antibiotic (Penicillin + Clindamycin)+Fluid replacement + Surgical debridment 39. HIV patient developed respiratory distress Respiratory isolation in separate rooms. 40. How to exclude cervical injury after trauma?  Cx spine x-ray + Assessment of pain by asking pt If the patient is intoxicated=do not remove cervical collar as assessment is not possiblewait till he is able to communicate. 41. Neomycin is very common allergen (5% population) causing allergic dermatitis. 42. Pulmonary TE  Begin LMW heparin + Warfarin Discontinue Heparin AFTER 2 DAYS of therapeutic INR is achieved. 43. Gout With liver & kidney disease  Avoid colchicine /NSAID’s Intrarticular Steroid 44. In acute pancreatitis ideal nutritional approach is delivery of high protein/low fat food directly to jejunum(Placing jejunal feeding tube). 45. Asymptomatic bactriuria generally doesn’t require treatment except in three conditions: (1) Pregnant female (2) Renal transplant patient (3) Expected GU procedure. 46. Recurrent chest infections in CF patients Antibiotic + Chest physiotherapy to expel mucus plugs.


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47. Child attending day care develop recurrent otitis media ! 48. Acute suppurative parotitis a severe –life threatening condition might be seen in debilitating patient remained dehydrated  due to stasis and infection of StaphStart rehydration + Antibiotic against staph Surgical drainage if no response within 12 hrs. 49. Normocytic anemia ?Reticulocyte counts  Raised =Bd lossLow =Marrow failure. 50. Patient with indwelling catheter develops high fever Empirically cover coagulase -ive and coagulase positive bacteria  Vanco + Genta 51. Household contacts of a patient (child putting fingers in mouth-fecoral transmission) with Hepatitis A should receive Ig within 2 days of last exposureChildren can return to day care after 7 days of onset of symptoms. 52. Ascetic patient on diuretics and compliant with medications still observing increasing abdominal girth ? Probably not limiting salt intake. 53. “Heaped-up” appearance of flesh colored lesions on penis/Scrotum HPV lesions/Genital warts.

54. Neurologic deficit in elderly R/o Metabolic or toxic causes first 55. HTN + Hypernatremia + Hypokalemia Conn’s? 56. Aortic valve area <0.7 cm2 is considered critical 57. How to confirm suspicion of Myasthenia Gravis  (1)Decremented response on EMG on repetitive stimulation or (2)Antibody to Ach receptor 58. Spontaneous intracranial hypotension (SIH):Headache due to SIH is similar to headache occurring after lumbar punctureCardinal featurespostural headache and a low CSF pressuresubdural fluid collections on MRIRx Bed rest and hydration 59. Acute febrile hemolytic reaction:Due to ABO mismatchManifest as Fever + Chest pain + erythema at IV site + Hemoglobinuria 60. LAST TIP : PRAY TO GOD!

Good luck!


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Neeraj_s_notes_Step3.pdf

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