Uworld Step 3 Synopsis

PREPARED BY SANTOSH DHUNGANAUWORLD SYNOPSIS FIRST: step 3 usmleworld.com Cardiology 1. Decreasing LDL is more imp to prevent CAD than stopping smoking, DM control, HTN control or exercise. DM is the second most important. 2. Pt with CHF on amiodarone comes with desaturation and basal cracklesprobably chronic interstitial pneumonitis, or organizing pneumonia due to amiodarone. It’s a cumulative dose effect, and not dependent on blood levels. Other adrs are liver, lungs, thyroid, BM toxicity and skin changes including Photosensitivity. Steroids can be used for severe pul disease. 3. Young patient with sec HTN, most common finding is abdominal bruit( 50%). Tachycardia if pheochromocytoma, but is less common. 4. In a patient with HTN, in absence of any known CAD, baby aspirin is useless. 5. All pts with stable angina should undergo stress EKG for risk stratification. High risk patients, ie those with failure to inc BP with exercise, inability to complete stage I of Bruce protocol,, or appearance of downsloping or horizontal ST segment during exercise >1mm, should undergo cor angiography, and thallium scan to see viable salvageable myocardium before PTCA or CABG. 6. Pt on warfarin is started on amiodarone- dec the warfarin dose by 25% 7. In a pt with h/o angioedema with ACEI, ARB are not the choice drugs- B blockers are, because ARB still have low risk of causing angioedema. Especially if the pt has no compelling indication to use ACEI, like Diabetic Nephropathy. 8. Stress Echo is always more sensitive than stress ECG, and can show wall motion abnormalities, but stress ECG is still the first choice for risk stratification in pts with stable angina. In patients who cannot exercise, eg due to OA, use dopamine stress EKG or Echo. Probably can use adenosine and dipyridamole stress EKG/Echo too. 9. Adenosine thallium/sestamibi scan, Dipyridamole thallium perfusion/viability scan both are c/I if the pt has COPD or asthma. These are used to see hypoperfused myocardium during stress. 10. Pharmacological stress testing (and probably radionuclide scan) are done in those who cant exercise eg due to OA or MI or unstable angina, and in those with abnormal baseline ECGs like LBBB, LVH, baseline ST changes, WPW, externally paced heart, etc. 11. Aortic sclerosis and ESM are normal finding in old patients. 12. Pt with CHF is given ACEI even in asymptomatic stage, ie if Echo shows low EF; B blockers and diuretics are added only if symptomatic. Isosorbide Dinitrate if evidence of pul edema. Low sodium diet and diuretics if pt has some fluid retention. 13. Orthostatic hypotension means fall of 20 mm in systolic and 10 mm in diastolic 14. Verapamil, quinidine, amiodarone and spironolactone can cause digoxin toxicity, so for eg a pt on digoxin comes with nausea, vomiting, confusion after starting verapamil. 15. In a pt with high LDL and TG, the first step is always targeting LDL with statin, then add fibrates if statin doesn’t decrease the TG. Cholestyramine can increase TG so is contraindicated. 16. Post CABG angina, with permanent ECG changes- do radionuclide perfusion imaging and not stress EKG or even stress Echo, as we cant interpret the Echo with previous wall motion abnormality due to previous MI or ischemic cardiomyopathy. 17. Inc fibrinogen >2.7 7 puts patient at high risk of MI; and lovastatin and atorva both increase fibrinogen. So if the patient has elevated levels of fibrinogen, change to either prava or simvastatin, as they have no effect on fibrinogen. 18. Wt loss is the single most imp measure to dec BP, more than stopping smoking, or dec salt or alcohol consumption or exercise 19. Preop cardiovascular risk assessment; age above 70 yrs 5 points, MI<6 mo ago 10 points, MI>6 mo 5 points; angina on walking 1-2 blocks 10 points, angina at rest 20 points, and critical aortic stenosis 20 points 20. Drug lupus with hydralazine, mdopa, CPZ, IFN a, diltiazem, minocycline, penicillamine, procainamide, INH- starts with flu like symptoms, fever, malaise, arthralgia and facial rash. 21. Asymptomatic hypoNa in CHF patients- water restriction is the TOC, even if NA <115; hypertonic saline only for symptomatic pts. Isotonic saline and oral salt tablets are contraindicated as they will increase the fluid overload. 22. Pt with unstable angina 2 weeks back- sent home from Er- do straightaway cor angio and then intervention. No need for stress testing. 23. If stress testing shows no change in EKG and we still suspect CAD, do stress perfusion scan. 24. MRI is the inv of choice for coarctation, not TTE. TEE is inferior to TTE for aorta. Coarctation is usually associated with bicuspid aortic valve and ESM murmur. 25. Lone AF, without any cause found, aspirin is the treatment. Warfarin if prosthetic or rheumatic AF, ticlopidine, dipyridamole and clopid if allergic or intolerant to aspirin. Ticlopidine causes neutropenia. 26. Monomorphic nonsustained VT- usually either MVPS/DCM/LVH or CAD; do Echo and Stress test. 27. Long QT syndrome, hypomag, hypokal, they cause polymorphic VT. 28. Pt on warfarin with increased INR upto 5- withhold warfarin; if between 5 and 9- give a small dose of vit k oral, if more than 20 only then give iv vit k or FFP. 29. External pacemaker means temporary one. Mobitz II needs permanent transvenous pacemaker insertion. 30. Multifocal atrial tachycardia in COPD, dec K or Mg, aminophylline or isoproterenol- P wave of 3 or more morphology with narrow complexes, variable PR and RR- always check pulse oximetry first too rule out hypoxia; correct underlying cause, then if it doesn’t subside give metoprolol. In COPD pts, give verapamil instead of metoprolol 31. HTN crisis can present with flash pulmonary edema. Administer morphine, oxygen and lasix, then start iv nitroglycerine or nitroprusside for the HTN. Since many heart diseases like acute MR or AR can present with flash PE, echo should be performed. If recurrent episodes of flash PE and HTN, then do renal duplex scan, esp in young patients. 32. A case of postop inferior MI with significant bradycardia (ie symptomatic, for eg causing pul edema)- start atropine first, and if it is recurrent do transvenous pacing. Don’t do pacing initially as the brady is usually transient. Don’t use dopamine or norepi as they increase cardiac oxygen demand. Thrombolysis or heparin cannot be given upto 2 weeks postop. DONNO ABOUT PTCA. 33. AF with hemodynamic instability- synchronized cardioversion. Also for VT. Asynchronised for VF and Torsades. In chronic AF or stable AF, rate control with metoprolol or diltiazem is preferred. Using iv load of digoxin then regular digoxin was the idea of the past. Stable AF can also be cardioverted either with defibrillation or chemically with class III drugs. Prior anticoagulation needed for cardioversion of chronic AF. Diltiazem is preferred as it has fast OOA and low DOA, except if CHF or heart block, where digoxin is needed. The problem with even iv digoxin in acute cases of AF is that it takes hours to act. 34. ACEI is the DOC in CCF, even more so in elderly with dementia, in whom digoxin and spironolactone etc can cause delirium. 35. Elderly with multiple risk factors coming with an episode of syncope should be admitted for continous ECG monitoring, to assess for possible ICD placement to prevent SCD, as arrhythmia is usually the cause. Also do cardiac enzymes to rule out CAD, Echo to see left ventricular function. 36. Young patient with acute MR and flash pul edema, is either due to IE or trauma or idiopathic rupture of chordate tendinae, the last being the most common re, esp if he has features of EDS like pes planus, hernias, cigarette paper scars on the skin due to easy bruisability, and rubber man syndrome with skin and joint hyperflexibility. Marfan usually causes chronic progressive MR and not acute one. 37. Diffuse ST elevation and PR depression are the hallmark of acute pericarditis postMI. Dressler syndrome is autoimmune pericarditis and pleuritis after weeks of MI or cardiac surgery. NSAID in former, steroid in latter, tho steroid has been shown to increase LV aneurysm formation. 38. CABG TOC for multivessel disease or lt main disease, esp if DM coz in them the chance of restenosis with PTCA is very high. 39. Thrombolysis- within 12 hrs of symptoms if ECG shows ST elevation >1mm in 2 contiguous leads, after nitroglycerine is given to rule out coronary spasm. Also in pts with new LBBB. No benefit in NSTEMI. C/I with BP>180, recent surgery or ischemic stroke. ST depression occurs with ischemia, strain, digitalis, hypokalemia and hypomagnesemia, so is not an indication, unless it is due to posterior MI. 40. Poor R wave progression- if the R remains same through V1 to V4. Seen in COPD, RVH, LVH, ant infarction, blocks and cardiomyopathy. 41. Prolonged QT means more than half of RR, seen in antiarrythmic ECHO shows diastolic collapse of both rt atrium and ventricle. Severe symptomatic AS (area <1cm2) is treated with valve replacement. 44. CCF or arythmia. and if embolism occurs even on warfarin. 52. That is because we cannot measure ionized Mg.ie if he recovers without any post MI chest pain. Aspirin should be stopped 7 d before most procedures. as balloon valvulotomy is associated with transient efficacy and high procedural morbidity. sepsis and alcoholics. cotrim. but less accurate and operator dependent.5. Radionuclide ventriculography (RVG) or Angiography (RNA) or MUGA (multigated cardiac blood pool imaging) is done before and after chemo with anthracycline to detect early cardiotoxicity. muffled sounds and elevated JVP. Transvenous pacing if refractory to Mg. 54. INR in mechanical aortic and mitral valves should be in 2. astemizole. 47. CCf.drugs. first thing to do is . 43. QRS>0. so use dobutamine. Lidocaine is the DOC for any vent arythmia that occurs. Adenosine perfusion imaging with thalium or adenosine Echo or ECG is always the choice in patients with CAD who cannot exercise. Lidocaine and isoproterenol are second line drugs if pacing is unavailable. seizure and stroke. aka electrical alterans.first thing to do is iv heparin. TCA overdose is treated with sod bicarb. renal failure. directly go for coronary angio. macrolides. hypokalemia.12. but needn’t be stopped for coronary angio or cath. which can lead to VT. TCA.12. TCA.5. Dipyridamole can be used. hence increase TCA toxicity re.5. Metformin should be stopped before coronary angio or other dye related procedures that can harm kidney and cause lactic acidosis. 46. CCB have no use. WPW: PR<0. Pt can resume sexual activity 6 weeks after uncomplicated MI. dec Mg or K. 48. postMI angina refractory to b blockers or nitrates. disopyramide and quinidine are membrane stabilizer. Acute arterial embolism suspect. In unstable angina. cardiac catheterization shows equalization of pressure in all chambers. Elderly patient comes with DCM and CCF. and infact are harmful in patients with acute MI. But in patients with COPD or asthma. however.only indication is when there is intolerance of b blockers. 45. both cant be used. Verapamil and b blockers are contraindicated as they will slow down the AV nodal conduction. Also ppnl is contraindicated. then followed by MgSO4 whether or not the Mg level is low. 53. If superadded AF more than 3. sotalol. 2D echo in children instead to prevent nuclear exposure. 42. 50.5 TO 3. 55. 51. Also in renal or hepatic failure. TOC is asynchronised defib. pentamidine. Cardiac tamponade: Beck’s triad of hypotension. Torsades: prolonged QT caused by liver. thus causing increased conduction in accessory pathway. and ECG shows low voltage with alternating sizes of QRS. as it dec conduction and inc arythmogenic potential of TCA re. before and after cardiac transplant and in severe CCF. then add aspirin and increase INR above 3. as the patients are almost always unstable. terfenadine. antipsychotics. 49. Procainamide. DKA management. Only symptomatic subclinical hyperthyroidism needs treatment. Asymptomatic subclinical hypothyroidism on the other hand doesn’t require treatment. so otherwise it might precipitate DKA again if we don’t overlap the insulin. and low PTH in turn suppresses D3 levels. Insulin requirement will drop following delivery of the placenta.continue NS and insulin till blood glucose is 250. an asymptomatic pt needs only follow up with TFT. 9. then change to DNS with KCL. instead of ketone level and urinalysis. 4. Switch to oral feed and sc insulin only after the anion gap has corrected. esp in adolescent and those with paget’s disease. For every 1 g/dl decrease below 4 of serum albumin. 2. 5. or if menstrual irregularity or TSH>10.8 mg to the total calcium level. and decrease the insulin infusion dose. Subsequent hypercalcemia will suppress PTH. as it is the most common cause. Paraproteinemia can increase the bound calcium. ENDOCRINE 1. but not indefinitely.implies its probably lactic acidosis and not DKA. hence the total calcium in the serum. Preop patient for emergency surgery like CABG for unstable angina is found to have hypothyroidism. 3.don’t stop regular dose of insulin night before. and there is no leukocytosis or hyperamylasemia. Also checking for sulfonylurea level in urine and plasma can be helpful. add 0. Immobility is a common cause of hypercalcemia. To differentiate. Diabetic for planned CS section. Only after the surgery. Treatment is warranted if antibodies are present. History and context is imp. tho there is higher risk of ileus.1/2NS and KCL. Start KCL regardless of serum level. ie more resorption and less formation. Do antibody profile first. as sc insulin needs time to act. ACEI has shown survival benefit when given for several weeks following MI. to prevent ketoacidosis. measure serum proinsulin levels. 10. Else. Dextrose infusion is very imp to decrease ketone levels. or . Then start insulin infusion during the surgery. Pt with hyperthyroidism with chief complaints of palpitationtreatment is ppnl and not PTU 11. 56. DM pt on metformin develops anion gap acidosis. 7.its not a contraindication for surgery. start with low dose T4 as the patient has CAD. or those with AF or low bone densities or MNG who have subclinical hyperthyroidism. even if she is npo. Hypoglycemia with high C peptide can be both due to insulinoma and sulfonylurea overdose. But always start sc insulin 1 hr before discontinuing iv insulin. who have high bone turnover.so do ABG and blood lactate level. hyponatremia and oversedation with narcotic. 6. or release excess insulin into circulation 8. Switch to scheduled sc dosage as soon as the patient starts tolerating food. usu 6 wks.Cardiac stress test to rule out IHD. Autoimmune hypoglycemia due to insulin antibodies which bind to insulin receptors. with D5. HCO3>10m and precipitating factor like infection is corrected. 12. Biphosphonates can be used in these patients to prevent this. if lipid profile is abnormal. due to uncoupling of bone turnover. Treatment is RT. as it can falsely increase the level of the CA. A pt on prednisone for RA develops infection and then hypotension. Mineralocorticoids aren’t used. and also to differentiate benign from malignant ones. because. Pt with Hashimoto develops rapidly enlarging thyroid and SVCO. Amiodarone. only then start beta blockade. Alpha blockade should be started only after the test. or one test shows pheo but the other doesn’t. MIBG scan can be used if either of the above three tests are equivocal and we still suspect pheo.acute adrenal insufficiency. as amiodarone prevents peripheral conversion of T4 into T3. which is treated with PTU or methimazole. Glucagon is also not recommended as it is short acting.instead of starting DKA treatment.use normal saline bolus and infusion.monitor patient’s TFT 6mthly.1-0. But check TSH first. or subsequent episode should get warfarin for 6 months. Long acting phenoxybenzamine is used before surgery. Administer fluid and dexamet. or it is due to induction of destructive thryoiditis. no need to stop amiodarone. DVT without precipitating cause. neither does tamoxifen help with postmenopausal symptoms.they take a longer time then just simply infusing saline. Increasing anticoagulation for continuing HRT is not justified. to undetectable levels.treat with D50 bolus. tho that increases the risk of AF and bone loss.always do TFT for diagnosing apathetic hyperthyroidism. it can be either due to induction of Graves disease.should stop HRT. 16. Then do cosyntropin test. Both have equal sensitivity. in which case the treatment is steroids. two. as it is long acting and doesn’t interfere with measurement of serum cortisols. 19. Only after biochemical confirmation we do CT/MRI to confirm location. Somatostatin is iv and is short lived so not used. Dopamine doesn’t help as the alpha blockade will blunt the response to vasoconstrictors. If hyperthyroid. Treatment is with alpha blockade. If distant mets. Giving D10 or D50 infusion for long time is not recommended as they can cause thrombophlebitis. In patients with thyroid cancer in remission. then give warfarin for 3 mo as this DVT has a precipitating cause and is the first episode. Long acting sulfonylurea induced hypoglycemia. along with liberal salt and fluid intake to increase the intravascular volume. Glucagon is hence only used in acute mgmt of hypo with mental . 15. then D5 infusion is required to prevent rebound hypo due to the D50 induced insulin release.they are not deficient. Mental state change in elderly. 20. plus increases insulin release causing reboud hypo.3). If refractory to this treatment. 18. start octreotide sc. T4 supplementation should be used to suppress TSH below normal range (ie between 0. Female on HRT for hot flashes develops DVT. Just give larger dose of T4. The common complication after surgery is hypotension.probably thyroid lymphoma. even lower. Hormone supplement should be taken on empty stomach. but MRI is useful for extraadrenal foci. Urinary metanephrines and catecholamines are better test then VMA for pheochromocytoma. 14. 13. 17. T3 is only used short term and never used for long term management of hypothyroidism. one. if it causes hypothyroid. obtundation, and the patient is given readily absorbed carbo after gaining consciousness. 21. Pt on amiodarone can have inc T4 and low T3 due to decrease in conversion from T4 to T3. Ppnl also does that, but not atenolol. Aspirin displaces T4 from albumin, so don’t use it as an antipyretic in the treatment of thryotoxic storm. 22. AF due to Grave disease is treated like any other AF- with b blockers and anticoagulation. So antithyroid drug or RI ablation is not the answer. 23. Effect of tight glycemic control on microvascular complications is proved, but not macrovascular. It reduces the incidence of neuropathy, but there are conflicting evidence for reversing previous neuropathy. 24. Fahr syndrome: pseudohypoparathyroidism, with Albright hereditary osteodystrophy (short stature, round facies, short metacarpals and short neck); they have hypocalcemia with hyperphosphatemia, latter causing basal ganglia calcification and cataract. Their PTH is also elevated. Patients with hypopara will have low ca, high phosphorus and also low PTH. Vit D deficiency causes low ca and phosphorus both, and inc PTH. Acute hyperphosphatemia like with rhabdomyolysis, seizures, ARF can cause decrease in calcium, but no basal ganglia calcification and cataract like in chronic hyperphosphatemia. 25. Hypercalcemia due to sarcoidosis- , due to 1a hydroxylase enzyme, vit D increases, PTH is suppressed, hence urinary calcium is increased. Treatment is glucocorticoid and not pamidronate. 26. Exercise increases non insulin mediated glucose uptake by muscles, so can cause hypoglycemia in a patient on insulin. Avoid insulin injection to the exercising limb, and lower the dose of insulin. 27. Medullary Ca thyroid, post surgery rise in calcitonin level indicates residual metastatic disease- first step is HRCT of neck and chest with HRUSG of neck, with surgical resection if possible. If these don’t show any lesion, HRCT abdomen and bone scan, or iodine 111-octreotide scan and PET may be required. Total body iodine scan is for follicular and not medullary cancer, as the parafollicular cells don’t take iodine. Thallium scintiscan is also nonspecific. 28. Don’t take thyroxin with calcium or iron over the counter supplements. 29. Pt with amenorrhea, low FSH and LH with high alpha subunit, high prolactin and a pituitary mass- probably has gonadotroph adenoma, with lack of functioning beta subunit. Increase in prolactin is probably due to compression effect. Treatment is surgery as bromocriptine works only with GH or prolactin secreting tumor. RT is never the first choice due to delayed risk of hypopituitarism. Octreotide is also not much effective. 30. Pituitary incidentaloma with no symptoms shouldn’t be treated, only followed up with regular MRI. 31. To diagnose spurious hyperthryroidism due to external intake and to differentiate it from primary thyrotoxicosis, do the thyroglobulin level. It is decreased in external thyrotoxicosis. RAIU study doesn’t help, as the intake is decreased also in different thyroiditis, iodine or amiodarone induced thyrotoxicosis. 32. Subclinical hypothyroidism- treat if TPO AB present, as they have high rate of conversion to overt hypothyroidism. Also treat if symptomatic subclinical (ie inc TSH but normal T4). 33. HTN with hypokalemia- do aldosterone to renin ratio to differentiate hypo and hyperreninemic hyperaldosteronism. In Conn’s syndrome, the ratio is >30, with high aldosterone level also needed for diagnosis, as essential HTN can also suppress renin. Patients present with polyuria and polydipsia due to hypokalemia induced DI. If hyperreninemic, then do MR angio of renal arteries, with fibromuscular dysplasia giving a beaded appearance, and is the most common cause of RAS in young patients. Suppression of both renin and aldosterone in a pt with hypokal and HTN is probably due to apparent mineralocorticoid excess (AME), so obtain a serum cortisol level. 34. Pt with DM, NASH due to hyperTG, and obesity- TOC is metformin, as it causes wt loss,, and helpful in hyper TG and NASH. Glitazones are contraindicated as they cause wt gain, partly due to fluid retention, as well as they are hepatotoxic. 35. Subacute thyroiditis- thyrotoxicosis with painful thyroid enlargement. Tt is NSAID and beta blocker, and steroid rarely if severe. Since preformed thyroid hormones are the cause of the problem, antithyroid drugs and RI are not effective. Its not difficult to differentiate from bacterial suppurative thryoiditis, as in the latter case, people aren’t usually thyrotoxic as it involves the center of the gland, as well as USG will show multiple abscesses. 36. Hyperthyroidism in pregnancy- PTU is the TOC, as methimazole is teratogenic. If PTU doesn’t work, or cause neutropenia, surgery is indicated, else she can have thyroid storm during the stress of childbirth. 37. Asymptomatic thyroid nodules: first step is to, do TSH- if normal, and if <1cm need f/u with yrly USG, >1cm need FNAC. If TSH is decreased, then RAIU study- if hot nodule, only observation. If symptomatic, then antithyroid drugs….. RAIU is seldom used in management of thyroid nodule, as most of cold nodules are benign, though most of malignant nodules are also cold. Since most of the nodules are benign, all nodules don’t need surgery, only FNAC is enough. Still, if we have done RAIU, then all cold nodules must be biopsied. IF the nodule is toxic or if there is carcinoma on FNAC, then the patient needs surgery. 38. CT of neck is less sensitive than USG for nodular thyroid diseases. 39. If pt has papillary cancer on FNAC, then he needs NTT- near total thyroidectomy, and then RI ablation therapy for residual tissue and mets, then RAIU study to see for remaining mets, then lifelong Thyroxine to suppress TSH. Also thyroglobulin can be followed up as a tumor marker. TSH should be suppressed below the normal range, tho this can risk AF and bone loss. Doing only subtotal thyroidectomy is ineffective, as it is difficult to ablate the remaining gland with RI, and we cant also use thyroglobulin as a marker when lot of thyroid tissue is still left in the body. 40. If medullary cancer, first test for RET to see for MENII syndrome, or do urine metanephrine/CA or abdominal CT to diagnose any concomitant pheochromo. Then start the pt on alpha blockade for a few weeks before surgery then beta blockade only after alpha blockade (else there will be vasomotor crisis), then do surgery- total thyroidectomy with central neck dissection. 41. DM with autonomic dysfunction, gastroparesis- its difficult to adjust insulin because due to delayed gastric emptying, pt will be hypoglycemic just after meal. Plus problems of postprandial bloating and constipation. Treatment is metoclopramide, or cisapride or erythromycin, and small frequent, low fat meals. Cisapride is especially shown to be beneficial, tho it is not freely available due to incidence of QT prolongation and Torsades. Last resort is feeding jejunostomy. Metoclopramide cant be used for long due to side effects and tachyphylaxis, so cisapride is the TOC re. High fiber diet will increase the constipation. 42. Octreotide can be given in intractable diarrhea in DM gastroparesis patient. 43. DM neuropathy- amitryptiline is the DOC, but since most patients have heart disease also, beware- use gabapentin instead. 44. Erectile dysfunction with normal morning erection- its psychological impotence. Erectile dysfunction is never a normal part of aging, so don’t tick that. 45. Pt of hypoparathyroidism- Tt is high dose of vit D( calciferol) and calcium; high dose because conversion to calcipotriol is defective. We don’t use calcipotriol as it is expensive. Calcipotriol has a rapid OOA, and can be used in hypercalcemic crisis, or if pt is refractory to calciferol. Pts thus treated with vit D and Ca for hypoPTH usually develop high urinary excretion of Ca, due to lack of PTH, which can lead to nephrocalcinosis. So adding THIAZIDE not only helps reduce urinary calcium, but also increases the serum calcium effectively. 46. Hypercalcemia with high PTH- can be either primary hyperPTH, lithium toxicity or familial hypocalciuric hypocalcemia. If hyperPTH, surgery is indicated if Bone mineral density is less than 2.5 SD (ie T score below -2.5), overt bone disease or fracture, kidney stone, reduced creatinine clearance, Ca level more than normal by 1, urinary calcium >400 mg/d, or if young than 50 years. For eg a postmenopausal woman with T score of -3 comes with hypercalcemia and high PTH, then she probably needs surgery. Alendronate is not as effective as surgery in preserving the BMD. 47. Those with hyperPTH who don’t need surgery are managed with periodic msmt of ca, Cr, and BMD. Pt can continue their vit D and Ca supplement, as research hasn’t shown any aggravation on calcium level with those. 48. Acromegaly: COD is cardiac- LV dysfunction, asymmetric septal hypertrophy, CAD, HTN and myocardial fibrosis; these changes may be reversible with treatment. Also increased risk of colon cancer. 49. Offspring of mother with DM I has 3% risk, if father then 6% risk of having In a pt with osteoporosis. TSH. with normal T4 but dec T3. Pt who doesn’t respond with biphosphonates.5 as osteopenia. Stroke. in addition to vit D and Ca. Medical therapy is the TOC in prolactinoma even if large and has effect on vision. Pt with Addison’s disease develops diabetes I. 53. 52. T score in DEXA is calculated in comparison to healthy adult of age 25. . do CBC/Ca and PO4 levels for secondary causes. 50. SPEP. with low wt. increasing dose of vit D and Ca isnot as much helpful.its autoimmune polyglandular failure type II (Schmidt’s syndrome). N telopeptide for bone resorption and AlP for bone formation. and below that as osteoporosis. has constitutional symptoms and pallor should be strongly suspected to have myeloma. and no investigations for antibodies too. A patient with unknown goiter undergoes cardiac cath. as the iodine uptake is reduced in the gland. Pamidronate iv is used if pt cannot tolerate oral alendronate due to esophagitis. No treatment needed. but RAIU doesn’t help. Etidronate is old and not used. Calcitonin is not very effective. 54. Pts with T score< -2. its EUTHYROID SICK SYNDROME (low T3 syndrome). Myeloma cells release OAF( osteoclast activating factor). 56. PTH. which also has Graves. Treatment is b blocker. need antiresorptive therapy with alendronate or risedronate. 51. its not subclinical hypothyroidism. 55. Just followup with TFT in a few weeks. HRT has fallen out of favor since 2002 due to report of inc MI. and breast cancer. Postpartum patient on heparin for DVT comes with osteoporosis – discontinuing breastfeeding can help re. DVT. smoking patient. pernicious anemia.DM I. while Z score is calculated in comparison with similar aged adults. or with fragility factures irrespective of T score. premature ovarian failure. pneumonia. Pt with inc TSH following say. WHO classifies T between -1 to -2. teriparatide (PTH) is very effective but needs daily injection and is expensive.its iodine induced thyrotoxicosis. or Antithyroid drugs or KCLO4. vitiligo and celiac disease. can do urinary calcium. then develops thyrotoxicosis. Calcitonin and steroids are not useful. 3. Only use in life threatening emergencies as intracerebral and massive GI hemorrhage. do bone scan. LMWH are not the treatment of HIT. lingual edema. persistent cough. Patient comes with metastatic ER/PR + cancer with occult primary in breast. Pt with AML gets multiple platelet transfusion. and can also help in CT guided biopsy. chest and neck pain.) IFNa will lead to cytogenetic and not molecular remission. can lead to limb gangrene. If saddle anesthesia or bowel bladder involvement.type I is less severe and occurs early. Prostate cancer post treatment. hoarseness. due to alloimmunisation (formation of anti-platelet antibodies). 4. mesenteric ischemia.XR shows thick outer cortex with sclerosis. dysphagia. hypercalcemia. as they can also rarely cross react with the antibodies and increase the problem. HIT usually presents as thrombosis.its called platelet refractoriness. then BMT is the TOC for CML. cerebral sinus thrombosis. and Tm scan shows increased uptake.000. Prevention of HIT is by using LMWH or danaparoid. cyanosis. If initial increase in platelet and then decrease within 24 hrs. still the platelet count doesn’t increase. or using heparin for less than 5 days. 10. immediate decompressive surgery. Biphosphonates are indicated if intolerable pain. PET/ bone scan can be used too. 8. CPS is used to prepare for BMT to prevent GVHD. Trastuzumab (HERceptin) in Her + ones. 7. so not recommended. Plt transfusion are useless in ITP. collateral veins in thorax.Old male comes with hip pain. 9. Pt with lung tumor with FEV1 and contribution of each lung giventhe best next thing to do is still to do CT staging.f/u with PSA. due to heparin-platelet factor 4 complex antibody. 2.no need for multiple core biopsy of breast or RM. If only back pain due to vertebral mets. HAEM/ONC 1. Steroid are the TOC in most cases. 5. ocular proptosis. Pt of NHL comes with epidural spinal cord compression( radicular pain). as they will also be rapidly destroyed. with fulvestrant in those not responding to tamoxifen. or CCF. with IVIG in . CT is best as it gives mediastinal and chest wall invasion.very tricky.only do chemo and hormonal therapy. If rising PSA or if skeletal complaints. type II more severe and occurs after 4-10 days. syncope. If imatinib is not in the choices. while treatment is using DTI like lepirudin or argatroban. Tamoxifen is preferred. MRI only if dye cant be used. 6. TVS has a lot of false +ve leading to unnecessary endom biopsy. mets to adrenal and liver. then start RT. only RT.give high dose steroid. obtain an MRI to confirm diagnosis. decreases platelet upto 30.best thing is CT with contrast. think DIC or sepsis or active bleeding or antiplatelet drugs. SVCO: dyspnea. aka HCT( hematopoietic cell transplantation. involve wt bearing bones. Pts on tamoxifen should be screened for endometrial hyperplasia with annual Pap and detailed history.its Paget’s disease. even if Klatskin. Also those with life threatening VTE like massive PE. then RT alone.LHRH analogue with flutamide to counter the initial flare. PE and stroke.if with mets. or unusual site like mesenteric or cerebral venous thrombosis should also be on lifelong warfarin. CholangioCa. Primary vs secondary polycythemia. 11. 15. or brachial plexus involvement. NSAID and hormone replacement are protective. 19. 17. 21. do BM biopsy to differentiate ACD and IDA. and 5FU is the third line treatment. so beware if the pt is smoking currently. Of all the features of Pancoast syndrome.severe cases ( IVIG is not the first answer). In these patients. then EBRT followed by chemotherapy. but if there is evidence of distant mets. 18. causing acute transfusion reaction. don’t tick antiphospholipid syndrome. Kelly and other antigens. Pts requiring frequent transfusion might develop antibodies to RH. SCC skin. as it signifies phrenic nv involvement with possible iv foramina invasion and imminent cord compression. The most important prognostic factor is the increase in CD4 count. 12. so the . Cryoppt can be used but associated with infections. Alcohol probably causes the risk by interfering with folate absorption. If secondary cause is suspected. 16. Pt of CRF comes with esophagitis and massive bleedingDesmopressin is the TOC as it releases VIII/VWF from the endothelium. 14. eg in a pt with COPD. after that dialysis. they don’t increase life expectancy. Any patient with inherited thrombophilia and spontaneous thrombosis should be on lifelong warfarin. first test is pulse oximetry after minimal exertion. 20. tho RT and corticosteroid help. if back pain is unresponsive to this. Estrogen can be used too. chest movement asymmetry with asymmetric lower leg DTR is the most dangerous. transferring and TIBC are low (can be due to both IDA and ACD). Among inherited thrombophilia. Rx is hydration. and sleep study to determine nocturnal desaturation. Dopamine and osmotic diuresis can be used. or positive bone scan. Pt with RA has pneumonia and found to have anemia. RT if pt refuses surgery. that is not inherited. Alcohol and colon cancer are strongly linked than remote smoking history. factor V leiden is the most common. 13. Methyl tetrahydrofolate reductase gene mutation is related to homocystinemia.TOC is hormonal therapy.surgery first line. AIDS with PCNSL.best therapy is HAART itself. Plasmapheresis is for HUS and TTP. but increases MI. and is another risk factor.ferritin is high ( can be due to both infection or due to ACD). 22. Radionuclide bone scan is the most effective diagnostic modality.WBC and platelet count will also increase in the former. is inoperable. DES reduces LHRH release from the hypothalamus too. Pancoast: RT with surgical resection is the TOC. Pt with prostate cancer comes with back pain due to mets. stopping transfusion. 29. If at all. Chemo don’t penetrate. So CBC should be monitored in these pts. 23. annual mammogram and tamoxifen which has shown dec risk of progression to overt carcinoma. next thing to do is colonoscopy to see for synchronous lesions and remove them. Morphine or iv ketorolac for pain. CXR. 30. if it is low. eosinophilia and peptic ulcer. and shows normal or increased iron in macrophages. 26. steroid help. systemic inflammation and Al toxicity. Pt with ESRD and ACD. and prophylactic anticonvulsant are not indicated. Lobular CIS of breast. 27. PTC only if ERCP fails. Double contrast enema is inferior.first thing to do is retic count. Avoid contact sports. GASTRO 1. . has to be bilateral prophylactic mastectomy. Sickling crisis with splenomegaly.during mens. 33. doesn’t respond to EPO.stereotactic surgery if single. If EPO is already high. EPO is the treatment. desipramine is the DOC.treatment is plasmapheresis and immunosuppressive therapy. blood and urine culture are followed by iv antibiotics esp if the pt wasn’t on prophylactic penicillin. Pt with ACD.if high. if low its hypoproliferative Electrophoresis and Coombs for earlier. Avoid BT in them. Pt comes with diarrhea. its hemolysis. so the best treatment is close observation. second line being valproate or gabapentin. plus doesn’t allow intervention also. Pt treated for SCLC comes with features of acoustic neuroma. BM is diagnostic. Contrast MRI showing the multiple well circumscribed mass with local edema is the investigation of choice. Not narcotics.mainstay of treatment is hydration.first thing is to do iron study to rule out iron deficiency. Ursodeoxycholic acid doesn’t help as it doesn’t relieve the obstruction. Electrophysiological studies confirm incremental response with repetitive stimulation. sclerotic bone lesions.treatment is ERCP and stenting for the pruritus and jaundice. Surgery. If polyps are found in sigmoidoscopy.Systemic mastocytosis. For dull pain. as that can risk causing allogenic graft rejection after kidney transplant. Do EPO level. A pt with normocytic anemia. alcohol. DTR are lost unlike in myasthenia gravis or polymyositis re. Sickling crisis. Local excision is useless. high ferritin. then periodic blood transfusion is the treatment. Breast cancer metastasis to brain. 24. BM for the latter. and decreased no of sideroblasts.low iron. Advanced gallbladder Ca with neuropathic pain in right thigh. 28. 25. 31.for sharp pain. Myaesthenic syndrome means Lambert Eaton.beware of splenic sequestrationdramatic fall in hemoglobin causing hypovolemic shock.it is multicentric and bilateral. Then see for folate deficiency. nocturnal hypoxemia. 32. EBRT if multiple. DOC is carbamazepine. its probably not neuroma but mets. normal or low transferring and transferrin saturation. Plus treatment of the underlying disease with close f/u might be the right answer. 8. but will have esophageal varices also. while enzyme supplement is inferior. massive splenomegaly and hypersplenism. 4. Octreotide works only in variceal bleeding.90% if perinatal. ng aspiration to prevent further pancreatic stimulation. but in malnourished or critically ill patients. a CT guided aspiration of the tissue for C/s is done.d. then do Tm tagged RBC scan. but only after localization of the site of bleeding. then take blood culture and start imipenem. This is similar to Budd Chiari. Mesentric angina.kg. Portal vein thrombosis is similar. Hypoechoic mass in pancreas doesn’t mean abscess unless there are systemic signs. lack of response to therapy or complications. Mallory Weiss tear that has stopped bleeding needs no intervention. Surgical debridement if severe necrosis. 3. Urgent colectomy might be needed. if PT remains normal during the acute infection. jaundice and ascites. Angiography is the gold standard.2. biliary pancreatitis. Mild pancreatitis. as it has a high negative predictive value. 10. 11. Only chronic active hepatitis needs lamivudine and adefovir. Hiatal hernia is a very frequent predisposing factor for the tear. IF pt fails to improve after 1 week of antibiotic therapy. Chronic pancreatitis: low fat diet is the most effective method to stop steatorrhea. LGIB: urgent colonoscopy is the procedure of choice due to diagnostic and therapeutic advantage. inc TNF. or necrotizing pancreatitis or large peripancreatic fluid collection.duplex USG is the screening test done first. but in . Imipenem or cefuroxime penetrate pancreas well. 6. 20-50% if below 5 and <5% if adult. and it can cause ischemic damage to organs and arythmia. 9. If the patient with pancreatitis develops fever. Antibiotics have been shown to be useful prophylactically only in severe pancreatitis (Ranson criteria).manage with pain control and iv fluid. as most resolve on their own. which is better than angio to localize the site. npo. IF there is poor visualization due to bleeding. TPN: average need is 30Kcal/d and protein 1g. Overfeeding leads to hyperglycemia. Conversion to chronic stage depends on age. PEG (percut gastrostomy) should be considered if pts need TPN for a long time. Vasopressin is inferior as bleeding recurs after stopping. piperacillin. quinolones. then the infection will likely resolve with no sequelae. its 35-40 and 1. but is done only after duplex. and can occur during blunt abd trauma. ERCP if concurrent dilatation of biliary system or elevated LFT.5 respectively. Isolated gastric varices without esophageal varices in a pt with chronic pancreatitis is due to splenic venous thrombosis. Hepatic venocclusive disease is due to occlusion of terminal hepatic venules and causes postsinusoidal portal HTN. Acute HepB needs only supportive treatment. 5. with hypatomegaly. 7. No indication of daily CT scan or CT aspiration unless features suggestive of infected necrosis. Interestingly. It may also present with noncirrhotic portal HTN. hyperinsulinemia. CPR and endoscopy too. ascites. bulk laxative like psyllium. but with cellfree margins. parasites. Screening colonoscopy every three years is safe in those with previous polyp. Achalasia: dec peristalsis but inc tone. again metro. showing villus blunting and increased lymphocytic infiltrate in the mucosa. Complete resection of a <2cm polyp which proved to be dysplastic. 19. Duodenal endoscopic biopsy is needed for diagnosing celiac disease. 13. Docusate is a softner but not used long term. no vascular or lymphatic involvement. ALS pts need PEG gastrostomy. methylcellulose and dietary fiber is the mainstay of treatment. Ginseng can cause SJ syndrome and psychosis. 22. leading to perforation peritonitis. Best way to see eradication is urea breath test or fecal antigen test 4-6 wks after therapy. as it is already produced by duodenal mucosa. Early testing might produce false negative. and preferring packed RBC to whole blood. and hypertrophied muscle in HPE. but prognosis is poor. fat.atrophy of muscle layer with fibrosis on HPE. wt loss. IF relapse. Fecal antigen test is best. 18. folate and calcium. Gingko can cause platelet dysfunction. dec peristalsis wave and dec LES tone. Triple therapy for H pylori failed. as it is . 12. Pain. blood. with malabsorption and anemia. 23. IF >2cm sessile. 17. rye and barley. 16. 21. Endoscopic biopsy is not warranted to document care. Pseudomembranous enterocolitis suspect: rapid immunoassay for C difficile toxin is very popular. Avoid wheat. and not TPN. Kava can cause hepatitis and cirrhosis. It can be nodular or ulcerative. 20. coz relapse is due to inadequate treatment more than resistance. Plus might need to supplement iron. Culture is useless also because many nontoxigenic strains of C Difficile exist. Magnesia is c/I in CRF. diarrhea are typical. or if poorly differentiated. Can take soyabean. 14. osmotic gap. repeat it if the pretest probability of infection is high. First test in chronic diarrhea is stool examination for leucocytes. rice and corn and potatoes. but its sensitivity is low. Pt of celiac disease not improving with gluten free diet must be suspected to have intestinal T cell lymphoma. not even low fat diet. Stool cytotoxin test and stool culture are outdated. f/u colonoscopy in 4-6 mon. Post chole: no change in diet is needed. Tt is metro. as Helicobacter can transform into urease negative coccoid form. using leukocyte depletion filter. Vanco if more than one relapse. Tt is surgery and chemo. Chronic constipation.we don’t have to do anything. 15.give quadruple therapy. Diffuse spasm: inc peristalsis and inc tone. Scleroderma. ph. Febrile transfusion reaction can be prevented by washing the cells.the latter there is thrombosis of major hepatic veins. Serology is uselss coz it doesn’t differentiate past and present infection. so that if one is negative. castor oil and bisacodyl are laxatives and cause electrolyte imbalance. Giving CCK is useless. None mild and moderate iv. fever.diagnosis criteria: PCWP <18. then extubate. 7. hypercalcemia or decreased pulmonary function to prevent fibrosis. and it doesn’t cause sinusitis. CXR is done first also because VQ cannot be interpreted if there are any previous lung pathology like COPD.5. Delayed PT. Asymptomatic sarcoidosis needs no treatment. Ascites. Thrombolytics if hymodynamically unstable. Treatment is mechanical ventilation with high flow oxygen. 25. 4. Bilirubin.treatment is water restriction. c/I to anticoagulation.cavitary mass inside bronchus 2. ie class B or C in child pugh classification. none. 5. 24. Postop pt on heparin develops dyspnea. 2-3 and >3 iii. PaO2:FiO2 <200. 2 or 3 accordingly ii. NO and prostacyclins are not much helpful. with clear lung fields on exam re. including erythema nodosum or hilar adenopathy.<15 sec. Steroid are not effective in acute phase. Decrease FiO2 gradually to keep SaO2 at 90 and PaO2 above 60. Child Pugh criteria: i. Large cell ca of lung.5 and >3. or stage 3-4 Liver transplant if score is >7. and a slightly acidic pH (ie permissive hypercapnia) confirmed by ABG. Heparin followed by warfarin. XR shows multiple round lesions in both lung fields. 6. ARDS.<2.5-3. Diuretics can be used but watch for hyponatremia.peripheral mass. and bilateral infiltrates. . stage 1-2. low tidal volume <6ml/kg and low plateau pressure<30 with PEEP of 5-10 (5 is physiologic peep. Should be weaned as soon as possible to prevent oxygen toxicity and atelectasis. irreversible. Albumin. so should be more than 5 here).i. If these fail. Encephalopathy. 15-17 and >17 sec v. chronic PE with PHTN. Mgmt is blood culture and antibiotic. 3. Class A is <7 RESPIRATORY 1. Protease inhibitors can be used to prevent ERCP induced pancreatitis. It is better than NGT as it doesn’t interfere with breathing and speech. Indications for IVC Greenfield filter.recurrent VTE. SIADH. IVDU can present with septic pulmonary embolism from either septic thrombophlebitis or tricuspid endocarditis. tho it is nephrotoxic. Steriods are used if other skin lesions. which is preferred to lithium due to less side effect. When FiO2 reaches 30% and patient’s neurologic status is improved.5. 2. SCC. but useful in reducing fibroproliferative phase of ARDS. with or without salt administration. Low tidal volume limits the barotraumas.score 1.<2. then demeclocycline. to prevent skin necrosis if only warfarin is given. tho risk of aspiration is the same with both.should usually be given only with hypertonic saline or salt tablets.ECG and CXR should be done before going for VQ or CT angiogram. pulsus paradoxus. MRI and nasopharyngoscopy before uvulopalatoplasty. then refer for sleep study (polysomnography). HRCT has to be done. 15. 16. OSAS: first rule out hypothyroidism. sputum. Cough. irregular or speculated border. Magsol is no more recommended for asthma.. or with inc WBC with bandemia. like OCP or immobilization. FNAC is less sensitive. lung infiltrate and central bronchiectasis. diffuse homogenous or popcorn calcification of pul hamartoma). anything in between is malignancy. VQ is the first investigation in suspected PE. but not done usually. 6 mo atleast if idiopathic. reticulate. OCP. fever. 14. 18. Sputum cytology is very insensitive. then VATS and excisional biopsy is the TOC for peripheral nodule. inc IgE and eosinophil in blood. concentric. Asthma patient develops fatigue. unless very toxic. while PET scan has high sensitivity but low specificity. alveolar proteinosis. Pts with PE can have fever and needn’t be treated. ABPA criteria: underlying asthma. so checking for previous XR is always the first step. PaCO2>40. then do lower limb Duplex to calculate the pretest probability of PE before jumping to CT angiogram. indefinitely if recurrent or continuing risk factor like antithrombin deficiency. laminated. Wedge shaped infarcts seen in subsegmental PE are seen as Hampton’s hump in XR. cancer patients. skin test reactivity. and can cause nephrocalcinosis and CRF 12. Pul angiogram is the gold standard. 11. D dimer has high negative predictive value. Sarcoidosis. confusion. diaphoresis. . and current XR is inconclusive. Other causes of nonresolving pneumonia are CEP( chronic eosinophilic pneumonia). If high suspicion for malignancy after this. If no earlier XR available. bronchiolitis obliterans organizing pneumonia (BOOP). wheezing are typical symptoms. 10. serum antibodies to Aspergillus. or more than 450 days. which can show the morphology and the mediastinal node involvement. esp if pretest probability is high like in immobilized. 17. so some say it should be done first of all. punctate or eccentric calcification (vs regular.risk of malignancy is high if >3 cm.hypergammaglobulinemia. atleast 12 mo ifmalignancy or anticardiolipin syndrome. Peripheral lung nodule. and cutaneous anergy is common. Think carcinoid if nonsmoking patient comes with recurrent postobstructive pneumonia. central. 13. BAL however shows high CD4. Hypercalciuria is much more frequent sign then hypercalcemia. Doubling time of benign lesion is either less than 20 days in acute conditions. etc. Warfarin is given for 3-6 mo for PE that occurred in the setting of reversible risk factors. esp if there are suggestive symptoms in a patient.8. Fiberoptic endoscopy with lavage and /or biopsy is the next best step. depressed CD4: CD8 ratio ie depressed cell mediated immunity and activated humoral immunity. PEFR <25% of personal best: indications for intubation and ventilation. marked tachy. use of accessory muscles with sterna retractions. 9. if it is negative and suspicion is high. First thinkg to do is skin prick test as it has high NPV. If it is positive. INFECTIOUS DISEASES . Silicosis. Cough induced by forced expiration is very suggestive of asthma. as silicosis is highly associated with TB. Also vasodilators like CCB are used. due to slow pul blood flow and dilated rt heart. because using dilators who are not reactive to NO or CCB show acute cardiopulmonary decompensation if oral vasodilators are used. plus peripheral neuropathy in most of the patients. So before deciding for LTOT. if inconclusive. 23. ANCA is negative. Recurrent pneumonia. so monitor LFT. Churg Strauss syndrome is similar. Loeffler syndrome presents with migrating pulmonary infiltrates. ABPA and Churg strauss. Steroid is the TOC to prevent bronchiectasis and lung fibrosis. Stable COPD need only hx and ex preoperatively. and don’t need PFT. They also cause BM suppression and idiosyncratic hepatitis. 26. 27. as PaCo2 has prognostic value also. as it is an invasive procedure. 25.glasswares or pottery. then do HRCT. Admit if PEFR is 40-50% lower. Asthma with PEFR 25% lower than the patient’s baseline: after beta inhaler. Pt comes with symptoms of asthma. 24. but before that should do vasoreactivity test. 20.biopsy of parotid or superficial LN should be preferred to hilar LN biopsy. and can have allergic rhinitis. Lymphangioleiomyomatosis is a rare condition in women. ABG should be done. ie bronchial hyperreactivity. small nodules in upper lung. The commonest complication of PPHTN is cor pulmonale. chest pain and reticulonodular infiltrates on XR. but antibodies to aspergillus may be positive (doesn’t mean its ABPA). 19. oral steroids are the next step. or SaO2<88. Glucocorticoids are the treatment in all three conditions. ABG or spirometry.Xr shows peripheral infiltrate that are the photographic negative of pulmonary edema is very characterstic. all pts need anticoagulation because of increased risk of pul thromboembolism. RHF or HCT>55. Intubate if danger signs or PEFR <25% of normal. Primary PHTN.first do CXR to rule out a mass. or if c/e shows airflow limitation or suggests that the patients are not at their baseline lung functions. and involvement of other organs like kidney. 29. 28. Or if PaO2<60 but with cor pulmonale. 21. HRCT is last to detect bronchiectasis. with asthma and rhinitis. LT antagonist like zafirlukast are associated with Churg Strauss. ie CEP. with eggshell calcification in hilar LN. then only bronchoscopy. These are needed if lung resection is planned. BAL shows eosinophils. 22. Diagnosis of sarcoidosis. Annual PPD testing and INH prophylaxis in the condition of seroconversion is important. plus effusion and pneumothorax might be there. measure total IgE and antibodies to Aspergillus. CEP (Chronic Eosinophilic Pneumonia). presenting with dyspnea. LTOT: PaO2<55 on room air. peptostreptococcus. Meningoencephalitis. 5. preexisting CNS disease. Type II is associated with laceration. E coli. esp if pt is on anticoagulant. 12. but these days penicillin resistant strep and staph are increasing. old aged or immunocompromised. Pt on antiepileptic. Eikenella corrodens( main one. Erysipelas as a consequence of sinusitis. Saw palmetto acts like finasteride in BPH. GAS. and XR shows right lower lobe fluffy infiltrate. to prevent hypoxic resp failure. with later bulla formation and systemic toxicity. HRCT and DLCO measurement are highly useful for pneumocystis. but still bronchoscopy and BAL is the diagnosis of choice. but not urine. 2. Treatment for type II NF is iv clindamycin. 7. Admit if danger signs. its probably aspiration pneumonia.treatment is heavy fluid loading. and iv cotrim if moderate to severe. TSS. 10. monobactam.Strep. It is universally fatal once patients are symptomatic. GNB). Presents like culture negative endocarditis. Staph. 13. cephalo and quinolones as they can cause seizures. Type I necrotizing fasciitis is polymicrobial. Gingko biloba. 3. Prevotella. Garlic for lipid disorder.and can cause platelet dysfunction like Gingko. sweat. Human bite. Treatment with doxycycline. and typically caused by GAS (pyogenes). esp if vet. hemophilus. HIV prophylaxis indicated for exposure to genital fluids and blood. Treatment is ampicillin-sulbactam after cleaning thoroughly. penicillin. Chinese wt loss herbals have artistolochic acid which is nephrotoxic.avoid imipenem. renal insufficiency. Treatment is oral cotrim if mild. St John’s wort for depression. blunt trauma or surgery. poultry or bird breeders. with or without transbronchial biopsy to increase the yield. so the TOC is shifting from iv penicillin to anti-staph penicillin. Esp if pt has old age. irritability but more importantly bleeding. 6. Steroids indicated if A-a gradient>35 or if PaO2<70. with steroids. splenomegaly. dry mouth. seizures. seen in DM and PVD patients. pneumonia triad in immunocompetent host is Chlamydia psittaci UPO. Elderly in nursing home presents with pneumonia. Its bcoz it inhibits PAF. confirmed by serology. with clindamycin with or without nafcillin to prevent recurrence of TSS 4.1. 11. Kava is used for anxiety and insomnia. ST John wort can cause GI distress. bacteroides. . Giving only antiretroviral can worsen the resp failure due to immune reconstitution phenomenon. with surgical debridement. etc. and each has been proved to be effective than placebo.used in intermittent claudication. and is sedative and hepatotoxic. Pasteurella multocida in cats and dogs bites. 9. sputum. Staph alone is not associated with NF. Rabies can be transmitted by aerosols from bats in caves. actinomyces and fusobacterium. 8. and microbes include Staph. can cause diarrhea. tears or saliva.beta hemo strep. Severe pain in the absence of significant skin change is the initial presentation. Bacteroides. ARMD and Alzheimer’s. hypoxia. anorgasmia. IVDU. if CXR negative. like if children have CF. Begin at 45 if high risk. chronic diseases like COPD. C/I if egg allergy. however. CRF. so use ator even if TG is much higher than LDL. don’t need it. 2. Total cholesterol >200. 6-23 mo child. for eg woman working in a nursery. however. Fasting glucose to screen for DM is advised in everyone after 45 yrs. healthcare worker. 6. 10. nursing home residents. wt loss. alcohol. the first step is stopping the HRT. or older if on long term aspirin treatment. then add fibrates. metabolic syndrome. exercise. African or Hispanic or PCOD is present.should counsel about safe sex. Screening for prostate cancer with DRE and PSA should be done in males 50-70 yrs of age. or yrly if risk factors like f/h. asthma. Wellness examinations. Close contact of meningococcal patients should receive rifampin to eradicate pharyngeal carriage. HRT is not preferred these days due to risk of breast and endo cancer and cardiovascular diseases. Smoking cessation has far better effect on preventing osteoporosis than exercise or dec alcohol. A decrease of BP by 5 mm decreases the risk of stoke by 40%. smoking and drugs. and then bupropion if needed.14.3 mo to see conversion. Young normal individuals don’t need vaccine. DM. HIV. Person exposed to active TB should immediately get baseline PPD. 3. then repeat PPD at 3 wk. first step is to order a complete lipid profile. vaccines. In a pt on HRT and high TG. which will give HDL and TG.above 50 yrs (65 since 2005 due to low budget). 11. or if h/o IGTT or gestational DM. Influenza vaccine. ie African or with f/h of 2 or more first degree relatives). Abrupt cessation is preferred to gradual decrease in smoking (cold turkey). PREVENTIVE MEDICINE 1. malignancy. Below 2. If conversion occurs. 3 yrly. household contacts of <6mo child. 8. FAP: ideal is total colectomy before the age of 20 yrs. Neither aspirin or statins or diabetes control or smoking cessation are as effective as control of BP. then CXR. or pregnant below 25 yrs. seatbelt. Repeat 5 yrly. . 9. then fasting lipid profile if TC is high. But if she can take rifampin coz she is on OCP. Repeat annually. or above 25 with multiple or new sexual partner. as even if they contract influenza. Calculate LDL by TC-(HDL+TG/5). 12. 4. monotherapy with INH prophylaxis. it is not going to be complicated. then DOTS. household member of person at high risk of developing complicated influenza. 2-3 trimester. or directly fasting profile if there is h/o CAD in family. and if CXR is positive. Glucosamine used for OA can cause problem with glucose control in diabetics. Primary goal is always treating LDL. 7. Children who have high lipid( TC>240) or CAD in family should have TC screening at 2 yrs of age. no use of screening as the diet is rich in fat at that time. 5. then a single dose of cipro is sufficient. importance of screening. Chlamydia screening in all women below 25 who are sexually active. Only if the statin cant control TG with LDL. with nicotine patch as the first choice. Health care worker exposed to such cases. but continue to follow the patient up to identify and treat any complication. 13. send her to nursing home. or old than 65 yrs should avoid alcohol to decrease the risk of lactic acidosis. If no relatives where she can live with. Baby born to HBV positive mother. Hypotension is common due to loss of sympathetic tone. 14. 40 if f/h of colon cancer. and it might cause harm’ as a physician duty is to protect from harm. after 40 yrs of age. Even if she refuses. normotensive.an old woman unable to care for herself. After that the probability of dying from other causes is higher. Colonoscopy is preferred to FOBT. but should be combined with mammogram. has serious illness. 25 if lynch syndrome and 15 if FAP. normothermic (not hypothermic).advise her against living alone. so no need of screening. renal or cardiac compromise. 15. (not sure. ma huang is the Chinese name for ephedra used for wt loss. so fluid replacement. Self breast exam has no benefit. Eg. also in patients with end stage COPD. and shouldn’t be hypoxic or hypercapnic. pancreatic or liver or heart disease or hyperTG or previous alcohol related problem. and total abstinence is not required either with DM or in patients on metformin.’ He must be screened for alcoholism. pul fibrosis and cardiomyopathy. Medical care for braindead patients is important till he is transported to transplant center to keep the organs viable. ETHICS 1. Pt should be kept in ICU. adult protective . Enzyme replacement therapy only if radiological evidence of panacinar emphysema or if the patient is symptomatic. Be the patient’s advocate. and if necessary pressors and inotropes are needed. which is specially dangerous in his profession. which has adr. Truck driver with DM on metformin drinks alcohol. Breast lump after the age of 35 should be evaluated with mammography. Pts with antitrypsin deficiency should be f/u 3 monthly with spirometry. 6. Repeat 1-2 yrly. 2. 17.what will you say? ‘Don’t drink alcohol’ is paternalistic. Total abstinence is preferable only if f/h of alcoholism. 4.Gonorea is very uncommon these days.say ‘don’t take the medicine.) repeat 10 yrly. If known herbs like ginseng. 3. Best response is ‘we must talk about your drinking and how it affects your driving. then 6 mo. as its benefit has not been proved. fluid loss and DI. Patient is taking unknown herbal medication on which no adequate research has been done. and should be started at age 50. but in a moderate manner’ is wrong as this justifies drinking which can cause many complications. then test for antigen and antibody at 9 mo to see if he has gone into chronic hepatitis. obtain a written agreement which releases the physician from any liability. 5. ‘You can drink. Send to hospice if life expectancy is six months or less.so pt should be kept euvolemic. till 70 yrs. or if the vaccination has to be repeated again. clinical breast exam alone also has no benefit. 16.HBIG and vaccine at 12 hrs. Those on metformin and with liver. as it predisposes to hypoglycemia. or 5 yrly if sigmoidoscopy. then at 2mo. If not . PT who is diagnosed with life threatening diseases like Huntington and Tay Sachs refuses to tell his family. THIS IS NOT THE SAME AS END OF LIFE SUPPORT. A pt involved in MVA couldn’t be extricated from the car. however difficult.else it will be insurance fraud. If a cometent adult woman says that her husband will sign the consent to any surgery for example. Body temp above 94. Nobody can leave a patient. but make the patient sign the refusal document. go to hospital ethics board.you needn’t inform the family. 10. 12. Jehova’s witness is refusing exchange transfusion to a diseased neonate which might develop kernicterus. 14. in the middle of a treatment. If multiple first degree relatives disagree on the treatment of an unconscious patient. Thompson test in Achilees tendon rupture: no foot plantarflexion on calf muscle compression. EEG isolectric for half hour. SURGERY 1. 8. and signs the advance directive.services can prohibit her from returning home alone. let it be. 2. A patient refuses basic life support and cardioversion in case he goes into arrhythmia during surgery. due to nonreconciliable difference between the physician and the advance directive. 15. Braindeath.absence of respiratory drive off ventilator for a duration that is sufficient to produce hypercarbic drive (PCO2 of 50-60). is unconscious and he started coughing up blood. putting other family members and siblings at jeopardy.first thing to do is secure the airway without spinal manipulation by jaw lift manuver.since it is not emergency but is urgent. then inform the adult protection services. 3. 7. Braindead patients can still have leg or arm movements due to spinal reflex. 11. Tell the truth not only to the patient.first thing to do is admit to distance from the abuser and to rehydrate.he cant do that without prior notice and arrangement to transfer him to another specialist. and then if necessary to court. A specialist is fed up with the drug seeking patient who slaps nurses and wants to leave him. Intubation is not needed as the patient has spontaneous respiration. but if they call.it is incorrect to proceed with the surgery. as it has the possibility to harm due to patient’s refusal of basic life support. and this should be explained to the family. Only then suction and stabilisation of neck.she has a right to choose her surrogate. Cholangitis: ampigenta or monotherapy with imipenem or levofloxacin. 16. Health care proxy or surrogate have the right to know all information of the patient. 13. but also to the insurance company. talk only briefly and ask her to come in for personal visit.its ok to transfer the patient to another specialist. consult the hospital’s ethics committee about seeking court injunction to mandate exchange transfusion. A dehydrated depressed elderly is probably abused. 9. no cerebral circulation on Doppler. Means surrogate are not only for end of life decisions. and 24 hrs in observation with anoxic or ischemic brain damage with negative drug screen. tachycardia. Hyperventilation to reduce ICP is contraindicated in those with head injury and ischemic stroke. IT presents with lateralised abdominal pain (periumbilical pain in mesentric ischemia). 11. 8. Fibreoptic laryngoscopy should be done.responsive. aortic root and diaphragmatic hiatus. 4.first thing to do is not CT but coagulation profile and blood match and cross match. atropine comes next. or clean wound and >10 yrs since vaccination. but perforating GSW needs laparotomy. 6. or if vaccination history is not known. surgical exploration should be done immediately.hypoxia is caused due to associated pul contusion and inc work of breathing due to muscle spasm. 5. MVA pt after intubation doesn’t have satisfactory oxygen saturation. Xred to see the presence of foreign body or bone involvement. Pt comes with knife sticking in his head. Exploration under local anaesthesia for stab wound. Also puncture wound. 12. Aortic injury is the most common cause of sudden death in steering wheels injury. 7. cat and human bites shouldn’t be closed primarily. Inhalation injury without any surface burn. So try to check the ETT placement. then think about pneumothorax. and on examination has hypoventilation on one side of the chest. do decompression with ERCP. and intubation if necessary. cyanosis with intact Breath sound probably has flail chest. Scrotal trauma with hematoma formation on examination. but due to hypotensive state. 10. and do a needle decompression. and withdraw it a few cm. and occurs in the area of lig arteriosum. bradypnea and HTN has cushing reflex. Polytrauma patient with shallow breathing. Pt who die due to lightning strike usually have asystole. and shouldn’t be primarily closed (except if dog bite on face. Pt with acute colonic ischemia are not due to embolism like mesentric ischemia. due to its vascularity infection and nonhealing is not common in the face). as it can worsen the neurological injury due to vasoconstriction. All animal bites should be thoroughly cleaned with NS.and the first thing to do is secure an airway with ETT to prevent respiratory arrest. and with hematochezia. 17. MVA patient with bradycardia. Compound clavicle fracture should be repaired by ORIF 13. no TT if clean wound and <5yrs since last dose. debrided. TT and ATS if contaminated and >10yrs since last dose. 14. Laparoscopy can be used to evaluate tangential gunshot wound. If that doesn’t help the oxygen saturation. 15. and not USG as USG has not been shown to be reliable. The first diagnosis should be bronchus intubation. 16. . Only TT if contaminated would and <5 yrs since vaccination. Pt who underwent lidocaine injection for PIVD came with fever. then epinephrine should be tried. Defibrillation will not help in asystole patients. so if they don’t respond to CPR. chest bruises. 9.the most dangerous complication is supraglottic edema. 18. ptosis and anisocoria.so the best step is FNAC. some edema. Scaphoid fracture on presentation. Antibiotic should be started. 22. ESWL is preferred for small proximal ureteric calculi. 21. because they can still have pelvic vein DVT.immediate surgery (rectosigmoidectomy) is needed. 19.its rectal prolabpse with strangulation and gangrene. Early treatement with a blockers like phenoxybenzamine. later leading to atrophyof tissues. If not strangulated. mobile. Smooth. Pneumatic compression alone is not sufficient in high risk patients to decrease risk of DVT. If fracture is really present. 24. 23. CT myelography is an alternative. This is due to SMP (sympathetically mediated pain). though the calcifications along its . 25. Removal is mandated if small but causing persistent pain even after analgesics. Proximal nonmetastatic rectal cancer can be treated with sphincter sparing surgery. soft. 29. 27. or USG if under 35.first thing to do is not casting. presenting like torn medial meniscus or maltracking patella. round. 28. aka Complex Regional pain syndrome (CRPS). mildly tender breast mass implies cyst and not fibroadenoma. Sister cannot be considered legal guardian of a child.and leg paralysis and anesthesia. while ureteroscopy with laser lithotripsy for large >1cm proximal stones. Elderly with BPH comes with protruding rectal mucosa with bluish discoloration and fraibility. or if urosepsis or renal failure. while distal can be locally resected only if mobile. any problem in fetus or in breastfeeding. Reflex sympathetic Dystrophy. 20. Silicone breast implant haven’t been associated with any connective tissue disease. Most common complication is nonunion and not AVN. 26. small and nonulcerated. Big tumors can be given neoadjuvant chemoradio to make them resectable. changes in skin blood flow and sudomotor activity (sweatin). First step is MRI with gadolinium contrast. chemical or surgical sympathectomy within 3 months and early physiotherapy helps to reduce its incidence. if pt refuses it. or application of granulated sucrose to decrease the edema. pain and sometimes rupture needing extraction.diplopia. Only problem is contracture of the capsule.ataxia and bulbar dysfunction. can try digital reposition under sedation. PICA aneurysm. It also doesn’t affect the mammogram criteria. <5mm renal stones pass spontaneously. we should treat the child anyway. causing vasoconstriction and ischemia.immobilisation after sprain or fracture. snapping and effusion related to prominent medial plica of synovium which gets trapped in the knee joint. PSA over 4 needs urology referral for biopsy. then thumb spica cast with wrist in slight radial deviation and neutral flexion. and we don’t take the sister’s consent.crepitus. but CT or bone scan to rule out fracture.he has epidural abscess. hyperalgesia. then mammo if over 35 yrs of age. causing allodynia. Immediate surgical exploration is needed.so in emergency if parents are not around. guided by CT aspiration or biopsy culture. Plica syndrome. Post communicating artery aneurysm. or varicocele that doesn’t disappear in the supine position. Doppler USG if equivocal. OSAS. If palpable and patient is anxious. at most before 2 yrs. CT of abd and pelvis to detect LN metastasis. eg OA and sexual dysfunction.if BMI >40. RAIU and Antithyroid drugs can infact cause initial enlargement of the gland. 38. usu due to Chlamydia these days.treatement is surgery. Pt showing multiloculated cyst in pancreas on Ct. but not hypogonadism as the Leydig cells are not affected. Pt with hard nontended scrotal mask suspected to be tumorFNAC or biopsy are contraindicated. and treatment is xone and doxy. depression decline. or varicocele can cause infertility due to the effect of temperature on the spermatozoa. sleep improvement. but it makes it easier to examine the testis. if decreased quality of life. 41. etc. CT or nuclear scan to see for remnant thyroid tissue is needed before Sistrunk operation for thyroglossal cyst. cremasteric reflex is absent. 35. 40.capsule can rarely lead to a false positive result. It doesn’t obscure mammogram or decrease its sensitivity. 31. Iodine or thyroxine don’t help. Undescended testis. Prehn’s sign positive (ie pain subsides on elevation). transillumination usually shows unilateral hydrocele due to reactive effusion. Pt with bilateral or right sided varicocele.no need to do CEA and CA 19-9. so do bone scan or MRI 34. which implies fibrocystic disease. Benefits of gastric bypass or gastric banding include better DM control. FNAC should be done. 32. Barometric surgery. 30. and fluid sent for HPE if bloody. 33. Before that. and tumor markers can be done. so are contraindicated. 39. 37. movement limitation or brittle diabetes. better lipid levels. 36. (severe in orchitis). Epididymitis: mild pain. Multinodular thyroid in a patient with short neck can be retrosternal and cause symptoms of dysphagia. as there is already considerable fibrosis in the gland. as they are very nonspecific. the risk of malignancy is still high. Directly send the patient to surgery. Congenital hernia due to persistent processus vaginalsis should be repaired as early as possible to decrease the risk of incarceration. Even after surgery. CT is preferred. Varicoceles are common in the left side due to the drainage of veins. Testis usually descends spontaneously within 6 mths. Breast lumps can be examined 4-10 days after menstruation for regression in size. Recurrent abdominal or thigh superficial tumor with mild pain is . testis is high riding. Reexamine in 46 wks for any regression or recurrence. Referral to urology for radical inguinal orchiectomy is the TOC. 42. should be investigated for clot or tumor obstructing the inferior venacava. else surgery is indicated. else we might remove the only functioning thyroid tissue inside the cyst. Orchiopexy does decrease the risk of infertility. March fracture: XR can be unremarkable for 2-4 wks. have lower risk of contracting all STD. to prevent seizure. but not testicular cancer.desmoid tumor. sweating and dyspnea). Lesbians. bicalutamide antiandrogen therapy and radio are reserved for advanced lesions. ie flexing the mother’s knee towards the abdomen. Chemo. tho the testis undergo atrophy. LSIL on Pap. which should be done if the TURP specimen shows evidence of malignancy. IF colposcopy is satisfactory (ie entire lesion and transformation zone visible). without evidence of invasion and satisfactory colposcopy. Condyloma are not c/I for vaginal delivery. can cause hot flashes and more importantly DVt. ESWL for gallstone if only 3 or less stones. If it fails. LEEP is the most favored procedure. 6. Risk of repeat preeclampsia is atleast 7 times higher. Klinefelter syndrome predisposes to male breast cancer. alprazolam helps for neurovegetative symptoms (dizziness. So should be stopped 72 hrs before any elective surgery.treatment is again Magsol. or if colposcopy is unsatisfactory. Urinary incontinence and erectile dysfunction are the complications of nerve damage due to suprapubic radical prostatectomy. Internal podalic version can be done to revert breech into cephalic position re………… 4. 46. electrohydraulic lithotripsy is very cumbersome. or even more if the . 44. Shoulder dystocia. Raloxifen (SERM) used for osteoporosis. HELLP syndrome. even if only adenocarcinoma in situ ! It should be done with LN dissection following sentinel LN sampling using technetium radiolabelling. then positioning and heart rate of the second should be assessed with USG. including cervical cancer. start oxytocin. Ablation is done in low risk lesion. 5. 2. Plasma exchange transfusion in persistent HELLP. If the lesion is persistent after 1 yr.first thing is to tell mother not to push. or if HSIL. Ablation can be cryo or laser. then reposition the fetus. 47. or Rubin or Wood’s maneuver or delivery of posterior arm first. metoclopramide increases gastric emptying and exacerbates the problem. If labor is halted. 43. 7. After the first baby of a twin is born. and then suprapubic pressure. They should still be given HBV vaccine. 45. McRobert’s maneuver. Retrograde ejaculation is the most common complication of TURP. GYNAECOLOGY 1. 3. expectant management with repeat cytology 6 mthly or HPVDNA testing at 1 yr.do colposcopy. ursodeoxycholic acid if small stones with functioning gall bladder. treatment with either ablation or excision is needed. and surgery is the TOC. low carb diet. Excision with a wide margin of resection is the TOC. HSV is an contraindication however. or there is progression. Zavanelli maneuver is replacing the fetus head in the pelvis before performing a CS. Dumping syndrome: high protein diet in small doses and frequent interval is the TOC. and excision can be knife or laser conisation or LEEP (Loop Electrosurgical Excision procedure). as long as they are not large enough to cause obstruction. Forceps is c/I if second amniotic sac is intact. with regular or lispro before meal. pregnancy. Menorrhagia is the most common complication of norplant. but this requires greater no of visit and delays diagnosis. every 4-6mth.start vitd and Ca supplement. or at 21 yrs of age. magsol is more beneficial than phenytoin in preventing seizure. If after 120 hrs. Treatment is improving caloric intake. Most effective strategy for severe preeclampsia is delivery. If it shows high risk HPV. hyper TG. DUB. Endothelin inc. DVT. Postmenopausal women. 9. and poor sperm transport. contraception. then vitD/Ca and OCP. start NPH at bedtime. HRT has fallen out of favor due to cardiovascular risk. PPH. or history of fragility fractures. drug use and emotional problems like anorexia and depression. if this is not effective. only then oxytocin.do colposcopy with endocervical curettage. HGSIL on pap. Use raloxifen or alendronate only if documentation of low BMD. Fasting glucose target in GDM is 60-90 and postprandial <120. 17. PE. due to thick cervical mucus and amenorrhea due to malnutrition. Retinal hemorrhage is considered the most ominous sign of preeclampsia. No consent needed from parents in treating a minor for STD. 14. then ablation or excision. Also PGI2 dec. 12. Relative c/I are migraine. IV hydralazine or labetalol for BP control. pregnancy. 20% women with CF are infertile. 21. and ampigenta don’t cover lactamase producing anaerobes. Postpartum endometritis. TXA2 inc. 19. tho the next best step is magsol. smokers> 35 yrs. eg due to myasthenia. Diazepam if magsol is c/I. vaginal and breast atrophy and infertility. or pt has chronic renal disease or HTN. Even after eclampsia occurs. and if this doesn’t help. Levonorgestrel is preferred to combined estrogen/prog for after morning pill. 16. vaginal spotting (less common). use copper T. ASCUS on pap. 15. as preeclampsia has other complications besides seizures. then bimanual massage. others being TTP. then colposcopy. if second pap is abnormal.first thing to do is pelvic examination for retained placenta. 95% of male are infertile due to impaired development of Wolffian duct. as metron is c/I in breastfeeding women. not PROM. Diabetes and f/h/o malignancy are not c/i. 22. 18.previous preeclampsia occurred earlier. Pap should be started only 3 yrs after assuming sexual life. Absolute c/I to OCP. abortion !!. then colposcopy.TOC is clindamycin and gentamicin. h/o estrogen dependent tumor. 20. and magsol only controls the seizures. 8.h/o of thromboembolism or stroke. and breast cancer. as HPV needs 3-5 yrs to cause SIL 13. poorly controlled HTN and anticonvulsant therapy.if this confirms HGSIL. Some recommend accelerated pap for ASCUS. . Glargine is contraindicated as it is teratogenic. active liver disease. valid upto 120 hrs. MI. The most important risk factor for endometritis is route of delivery. 11. else f/u in 1 yr. stroke. 10. NO dec.best next step is HPV testing. If higher. Athletes having amenorrhea due to low GnRH can result in osteoporosis. Even asymptomatic bacteriuria has to be treated to prevent preterm birth and neonatal sepsis and endometritis. Other cause is herpes gestationis. UTI in pregnancy. A lady with hemophiliac husband is worried and asks what is the risk of her child having hemophilia? The answer should be ‘none’. 27. tho the chance is very small. Trichomonas in postpartum period. 26. plus magsol. PUPPP (popular urticarial papules and plaques of pregnancy) is another and involves the stria gravidarum. Limb reduction defect associated with CVS depends mostly on the age. and risk of progression to pyelonephritis. 31. continue HAART. and withheld breast feeding for one day. tho the interval can be increased to 2 or 3 yrs after 3 or more consecutive normal pap. its better to withheld HAART. 33. Hyperreflexia is an ominous sign of severe preeclampsia and heralds eclampsia. eradication should be documented with urine culture. aka pemphigoid gestationis. HIV patients shouldn’t breastfeed. 29. Treatment is antihistamine. Monitor TSH and try to keep it at normal level. Contraindication of exercise in pregnancy are pul or cardiac disease. Gabapentin and valproate are safe to be used in pts on OCPother antiepileptics will decrease the efficacy of OCP. Anticholinergic like oxybutinin and biofeedback are for urge incontinence. 30. which manifests are urticarial veriscles around umbilicus. Scuba is c/I as it can cause decompression sickness in the child 36. After treatment. plus increased body mass and VOD in pregnancy. If in second trimester already.23. and should be observed with repeat USG in 1 week.alpha agonists like amitryptiline can help by increasing the sphincter tone. . followed by low dose nitrofurantion or cephalexin prophylaxis for the remainder of the pregnancy. as the child will be only a carrier if a female.give 2g single dose of metron. Annual pap is recommended even in lesbian.treatment of severe preeclampsia is hydralazine or labetalol. abruption placenta. 24.cephalexin. emollient. cervical incompetence. Subchorionic hematoma are diagnosed by USG. etc. 28. Topical steroids are the DOC. Stress incontinence. even if on treatment. preeclampsia. 34. twin. In pregnancy or if on OCP. 35. placenta previa. The most common complication of such hematoma is spontaneous abortion. Pregnancy is still possible in Turners. the dose of Thyroxine has to be increased due to inc TBG in the body. Preterm birth and IUGR are also possible. topical steroid. amoxicillin or nitrofurantion. Physiologic changes of skin are the commonest cause of general body pruritus in pregnant wome.higher risk with earlier age. Also treat the partner. 32. Pyelonephritis is treated with 10-14 days xone or ampi/genta. Local vaginal therapy are less efficacious coz it doesn’t reach the urethra and the periurethral glands. Premature labor. 25. and is not due to viral infection. If Pregnancy is detected early in first trimester in HIV patients. and normal if male. while cervical cancer is a very rare cause. conjunctivitis and pneumonia in the baby. and cytology of the discharge if it is bloody. preterm delivery. After that is clomiphene. tho there is no hard evidence.coz it can lead to endometritis. then quantify how much fetomaternal bleed has occurred by Kleihauer Betke test. Pt on antiepileptic becomes pregnant. and termination if affected. Also higher risk of spontaneous abortion and preterm delivery. 48. chorioamnionitis. Also antiepileptic is not a c/I to breastfeeding. The sudden drop in systemic vascular resistance with delivery will cause cyanosis in the mother. so is usually not the answer. endometritis. even if it is serous. Add folate (though benefit has been shown only in animal studies) and offer screening for NTD with serum fetoprotein. Testicular feminization. Adolescents dong comply with OCP mostly because of concern over wt gain.pt has breast development but no axillary or pubic hair. progesterone pills cause breakthrough bleeding and aggravate anemia. Sickle cell disease. NTD needs immediate surgery to prevent infection of CNS. 47. then endometrial ca. CVS doesn’t help with detecting NTD. plus it can be therapeutic too with bipolar coagulation. Almost half of pregnancies are complicated by either acute crisis. followed by orthopedic evaluation to correct patient’s posture and promote ambulation. ectopic. to rule out other pathology. unlike in constitutional delay. The MCC of postmenopausal bleeding is atrophic vaginitis. PID. 42. 38. amniocentesis and USG. Unilateral nipple discharge is cancer UPO. All pregnant women should be screened for Chlamydial infection in the first prenatal visit. and repeat in third trimester if the patient is below 25 yrs of age (donno why).elective termination of pregnancy should be advised. treat mother with erythromycin base (estolate is c/i)or amoxicillin for 7 days. so the best contraceptive is DMPA or norplant.never change the drug. 45. 40.OCP are not preferred due to thromboembolic risk. Weight reduction is the TOC for PCOD infertility. Only treatment is . then gonadotropins. and father with azithro single dose. though Phenobarbital and diazepam can be stopped for a few weeks if the child becomes irritable or sleepy. and if it doesn’t work. and to see the extent of the disease. It can be f/by FNAC or biopsy. as it is only for cytogenetic studies and doesn’t measure AFP levels. Eisenmenger syndrome is absolute contraindication to pregnancy. pyelonephritis or thromboembolism. Rosette test can be done to detect fetal RBC in mother in cases of isoimmunisation. so do mammogram. 43. 41. Adjust the dose of anti RH globulin accordingly. 44. 49. 39. Metformin is not studied enough.37. and if present. where such asynchronous delay is not found. 46. IUD also increases bleeding. If positive. Laparoscopy is always the first step in suspected endometriosis. and shows reduced RAIU test. initially. and karyotyping with CVS in 10 wks and amniocentesis in 16 wks. dyspareunia and a butterfly like atrophic white lesion on the vulva. and nothing needs to be done. and then undergo fetal testing and early delivery. as it decreases the menstrual flow. Regularly timed but heavy periods imply adenomyosis. just reassure her that is normal breakthrough bleeding. 53. tho prophylactic antibiotics can help prevent amnionitis. unlike IUD or minipill which increases bleeding. poorly controlled DM or sickle cell anemia. Intrahepatic cholestasis of pregnancy is associated with still birth. 62.always administer prophylactic penicillin for GBS. and is useful in those with fibroid. endo hyperplasia or polyp or fibroid. It also dec risk of PID and endometrial cancer. Some patient may complain that there is no withdrawl bleeding. Subacute lymphocytic (postpartum) thyroiditis causes only transient hyperthyroidism. Also betamethasone if between 24 to 34 wks. DMPA is the contraceptive of choice in pt with VWD or hemophilia. do LFT to rule out other causes. then expedited delivery is not warranted. A pt comes with primary amenorrhea. Tricky. Clonidine is useful for hot flashes. Gestational transient thyrotoxicosis (GTT) has mild increase in free T4 and only slight decrease in TSH. so in a ICP suspect. and that can result in vaginal dryness and dyspareunia. If TFT are normal. 54. PAPP-A in the first trimester. 50.increased nuchal translucency on USG in 10 wks. That is normal too. Downs diagnosis. due to the effect of hCG on thyroid stimulation. Air travel is c/I after 36 wks. Breastfeeding suppresses estrogen release from ovary. 56. Advice her to use condoms if she forgot to take her pill for 2-3 days. 59. 51. Delivery should be delayed until sign of infection develops to promote further fetal growth .TOC is unilateral oophorectomy and not TAHBSO. Elderly with burning. esp if there are any c/I to the use of HRT. 60. A pt recently started on OCP comes with spotting. Treatment is potent topical testosterone !! 58. Any preterm labor. preterm delivery. Meigs syndrome. she probably has anxiety disorder or something else. or lung transplant with intracardiac repair. and pt has typical symptoms of hyperthyroidism. 55. or if h/o HTN. and normal secondary sexual characteristics. Progestin has also been shown to be effective for hot flashes.heart lung transplant. quadruple testing ( with dimeric inhibin A) in second trimester. This is probably uterine agenesis and not imperforate hymen (Mayer Rokitansky Kuster Hauser syndrome) 61. no other symptoms like abd pain. 52. 63. as it is caused by a benign ovarian fibroma. 57. Just continue the OCP. has lichen sclerosis. Anovulatory DUB is characterized by irregular cycles. but causes mood disturbances. If a pt comes with PROM at say 28 wks. 65. But if more than 50 yrs. 74. but it has been shown to increase coronary event in the short term. preterm labor and PROM. c/I to daily aerobic exercise in pregnancy are significant heart disease. HRT increases HDL and lowers LDL. PREGNANCY always comes first in d/d. 67. 69. vasopressin if needed. 77.first thing to do is call for help. Postpartum telogen effluvium is common after 2-6 mo of delivery. Then McRobert’s maneuver by pushing the mother’s leg as far back as possible. A pt with normal mens hx comes with abnormal bleeding. restrictive lung disease. Alternative is iv clinda and iv genta. twins. 64. placenta previa. HTN. After the first trimester. still have to do biopsy or fine needle aspiration. LH:FSH ratio is not a very sensitive test for PCOD re. 78. 71. . IUD protects against endometrial cancer 75. 76. as it can compress IVC. 70. dec CO and cause uterine hypoperfusion. Beware of options with oral doxy. hypotension and anemia. Then epi. 68. It is most probably due to pregnancy. Breastfeeding is usually successful after reduction or augmentation mammoplasty or breast implant. So the first investigation is USG pelvis. If a pt is profusely bleeding pv. Pt comes with severe pv bleeding. incompetent cervix. preeclampsia. The preferred therapy for inpatient PID is iv cefoxitin and iv doxy. Below 40 yrs. breast lump if dismissed as having no abnormality by USG or mammo. so only short acting ones should be used in postpartum period. 66. heel knee position. thus dec cardiovascular mortality long term. so even if mammo is negative. If above 35 yrs. Shoulder dystocia and obstructed labor. it has a higher chance of expansion than if from father. followed by oral estrogen which is gradually tapered. Wood’s corkscrew manuvre. do endometrial sampling before starting estrogen to rule out endometrial hyperplasia or Ca. All SSRI are excreted in breast milk. If the permutation is transmitted from the mother. so nothing needs to be done. has 1% chance of malignancy. advise not to exercise in supine position.Tt is iv estrogen. Fragile X is a X linked dominant syndrome due to triple repeat expansion. so that patient can refrain from breastfeeding till the drug is in her system. n/v precluding oral treatment. 72. 79. 73. and not anovulatory bleeding. supriapubic pressure. it has >40% probability of being cancer. Amazing. which is a type of mutation. Rapid onset virilisation with clitoromegaly and frontal baldingits probably ovarian or adrenal androgen secreting tumor and not PCOD. pregnancy. Admission is needed in pts with peritoneal signs. Huntington on the other hand is autosomal dominant. BT. and finally pushing back the fetal head and CS if everything else fails. +/-metron if vaginal smear shows trichomonas. etc.and development. D&c gives a faster response to stop the bleeding than iv estrogen. then a CT abdomen. In a patient with partial spinal cord transaction. 95. Ondansetron is effective only if given before chemo. metoclopramide is more effective. 82. optic atrophy. 92. After an episode of pyelonephritis in pregnancy. macrosomia and stillbirth. Tt is low dose amitryptiline. Patients are unaware of labor due to absence of pain. resp distress. the biggest threat during pregnancy is developing autonomic dysreflexia. except if pt has PROM. For late onset emesis. No alteration in sexual practice is needed during pregnancy. Also carnivorous fishes like shark are c/i. It also increases the risk of GDM. Also can have meningitis. 83. The baby will be born with ? snuffles. Tubal ligation: failure rate is 5% and not 0. The modality with highest exposure to the fetus is a barium enema. 84. 86. 90. Maternal obesity increases the risk of NTD. the most important factor of the test that concerns the patient is the PPV of the test. 81. and only way of knowing is abd or leg spasm and SOB that accompanies labor. If it is high risk patient. but as early as age 18 if has risk factor like f/h of MI. 87. Pregnant women shouldn’t consume too much fish. rhagades and neurosyphilis (features of early congenital syphilis). due to risk of mercury poisoning. Lifelong tamoxifen is not used as it can cause endometrial cancer. then in a no risk patient. brady. ie how many with positive test th . and ACOG has actually set limits on the amount of fish in a week a pregnant woman can take. tho the reason is not known. The presence of endocervical cells on Pap is regarded as adequate sampling. then immediate delivery is warranted. repeating may be deferred till next years Pap. for lipid disorder starts at 45 if no risk factor. It can manifest with malignant HTN. None of the radioimaging are c/I in pregnancy except for radioactive imaging. Even supine position is not c/I re.1%. etc. If the flow is absent or reversed. chemo and radio. Screening for DM starts at 45 with three yearly RBS. uteroplacental vasoconstriction. as these are manifestation of late congenital syphilis. 94. 88. ER+ breast tumor needs tamoxifen for 5 yrs to reduce recurrence after surgery. placenta previa or premature labor history. so wt loss before conception is advised. Chronic vestibulitis is a cause of chronic vulvar pain and extreme tenderness. A pregnant mother is diagnosed with sec syphilis in her second trimester. A pt comes with IUGR. arythmia. sweating.80. the pt should be put on prophylactic antibiotic for the rest of her pregnancy. ie <10 percentile. Cranberry juice prevents UTI by inhibiting E coli from adhering to the urinary epithelium. else not. IF a HIV elisa comes positive. 91. If these cells are absent. not saber shin/Hutchinson teeth. 5-20 % pts regret later doing the ligation. then repeat immediately. then the first thing to do is Doppler velocimetry of the umbilical artery. hydrocephalus. 89. 93. 85. Severe or psoriatric arthritis is treated with MTX. Livedo can occur with hep C. pt with Anticardiolipin Ab can present with livedo vasulitis in the lower limb. nd DERMATOLOGY 1. aka trichoclasis. erythema and hemosiderin hyperpigmentation. diaphragm use or catheterization. with one dose every 2-3 days. 101. 80 yr female with stroke develops incontinence. which presents with painful purupura in the lower limb. This is functional incontinence due to impaired mobility so that the pt cant go to toilet.actually have HIV. nifedipine. Estrogen is relatively c/I as it increases the vasoocclusive crisis. as the treatment hasn’t been shown to be effective. Septate uterus needs hysteroscopic excision of the septum. Podophyllin is c/I in pregnancy. Tt of condyloma in pregnancy is TCA. IUDs are also not good. so do ristocetin cofactor assay. 104. Psoriasis is treated with potent local steroid. Dysuria with low level WBC in urine. pentoxiphylline or mini dose heparin. Systemic steroids are not used as they can induce pustular psoriasis. IFN and laser ablation in case of resistant infection. even during pregnancy. Dry gauze is not used as the fluid is thought to contain growth factors needed for reepithelialisation. Young woman on ACEI should be using contraceptives. 105. and presents with hematuria without pyuria. 100. or chemicals. 103. Gestational thrombocytopenia is one of the commonest cause. Bicornuate uterus needs no treatment before pregnancy. and didelphys needs reunification process. Topical metron is the TOC of rosacea. Treatment is low dose aspirin. dipyridamole. low bacteruria and negative leucocyte esterase is consistent with urethral syndrome.its probably not DUB but VWD. and . as it has shown to decrease the pain crisis. tetra like in acne. Heparin is preferred in pregnancy. Topical isotretinoin in popular or pustular lesions. DMPA is the best contraceptive in a pt with sickle cell anemia. antifibrinolytic and VWF concentrates. 97. then it signifies traumatic alopecia. with or without oral doxy. 96. A pt with menarche comes with heavy bleeding and shock. Post void residual volume is 70ml (normal). livedo reticularis with telangiectasia. Pressure ulcers are treated with moist saline soaked gauze packing. Tt is OCP. Traumatic cystitis occurs sex. Best treatment is communicating with caregivers about accessing the toilet. 98. which ulcerate and heal leaving atrophic scars. Pt with bac vaginosis on pap don’t need treatment if they are asymptomatic. 102. Extensive disease is managed with UVB with or without coaltar (Goeckermann regimen). Metronidazole is okay for 2 trimester use. protein C deficiency also. 4. Interstitial cystitis has a normal examination of urine. desmopressin. In pt with alopecia. erythro. due to trichotillomania. and low potency steroid like hydrocort if on face or intertriginous area. mino. 99. due to high rates of infection. 3. if the hair shows split ends. 2. cryo. pseudotumor cerebri. A pt went hiking. Moderate( or refractory mild) with topical retinoid and either benzoyl peroxide or topical antibiotic. vertigo and tooth discoloration 13. lithium. Rosacea can be associated with conjunctivitis. was bitten by insect. NSAID and hydration are the treatment for sunburn. not melanoma.its sporotrichosis. ACEI. Microcomedones need 8 wks to mature. followed by draining lesion. Tattoo removal. telangiectasis and brown liver spots. Dx is by inc urinary uroporphyrins.laser can cause scarring and hypo/hyperpigmentation.stop the medicine and replace from another group. and hence is replaced by permethrin. laser. Treatment is isotretinoin. whether induced by drugs or otherwise. A pt on OCP with chronic HCV comes with painless blisters on hand. Mild acne is treated with topical retinoid. 6. actinic keratosis. and topical steroids can be used 14. 7. 18. cautery. keratitis. so wait for 2 months for any therapy to work before switching. as it can cause pancreatitis. start oral isotretinoin. 16. which will remove the brown spots also. Oral fluconazole is once weekly and easy to take.permethrin has shown to help. Its porphyria cutanea tarda. 5. NSAID also limits the damage to the skin. Lindane used for scabies was found to cause aplastic anemia and seizures. chalazion and scleritis. 9. unlike the endothrix infection with T tonsurans. Psoriatic lesions are exacerbated by beta blockers. but can cause lupus like syndrome. reveals coral red fluorescence in Wood lamp. Photoaging causes coarse deep wrinkles (fine and superficial only due to aging). and stop if severe hyperTG. Erythrasma caused by corynebac minutissimum. 17. and scratched with a wooden stick. or IFN alpha in those with HCV infection. More severe with all three of them. or systemic antibiotic with topical benzoyl peroxide or retinoid. Oral Isotretinoin can cause hyperTG.deramabrasion. Diphenhydramine for itchng. 15.so monitor LFT and lipid profile. Smoking exacerbates photoaging. hypertrichosis and fragility of skin. Pregnancy is c/I with even topical isotretinoin. as it is the only fungus which can get inoculated. and hyperpigmentation. 8. 10. Oral Terbinafine 6wks for fingernails and 12 for toenails are the TOC for tinea unguium. Wearing protective clothing is more important than sunscreen since childhood to decrease the risk of melanoma. Sunscreen with SPF 15 have shown to reduce the incidence of only BCC and SCC. Blastomyces and Coccidiodes both have to be inhaled. NSAIDS. Minocycline doesn’t cause photosensitivity. 11. as demodex mites are frequently found in the lesions. Microsporum canis ectothrix infection is fluorescent in Wood’s lamp. Treatment is phlebotomy or hydroxychloroquine. though no LFT and lipid monitoring needed with topical therapy. 12. If no response in 3-6mo. Trichotillomania is characterized by bizarre pattern of broken . Itraconazole can be used. but is not as effective. 19. polio or Hib vaccines. pustular drainage and lymphangitis. 8. is painful. while the requirement in old age again increases. 2. 3. If it persists. Flexible kyphosis is commonly seen in adolescent. 9. shock. 11. give ZE or Z with quinolone for 4 mths. and is persistent after the above treatment. inconsolable crying and seizure within 24 hrs.TOC is Aspirin and IVIG. then give under caution. so apart from diet. Diaper rash is due to overhydration and friction. or second choice is barium meal showing double track sign. aka Scheuermann disease. treatment is to keep dry by frequent change of diapers. breastfeeding. If there is sharp angulation seen on forward bending. 6.if still elevated. PAEDIATRICS 1. it is structural kyphosis.if resistant to only INH. DTaP vaccine c/I if anaphylaxis of encephalopathy within 7d. pregnancy. jaundice. allergy to mercury (thimerosal) and egg are not considered contraindications. cyanosis. then repeat in venous blood. repeat in 12 and 24 hrs. asymptomatic HIV infection. but the child has not been . and IVIG for very severe cases.hair strands of varying length. as it resolves on its own. anaphylaxis to neomycin or gelatin. TB. HSP. steroids if severe. f/h/o seizures. eg following diarrhea. If high fever. 10. as it decreases the efficacy of the vaccine. thrombocytopenia after first dose. and needs Milwaukee brace if angle <7080. peritoneal dialysis.mild cases are self limiting. MMR c/i. Children need 1300 mg calcium daily. while face can be treated with laser for cosmetic reason. give rifampicin 4mo or RZ 2mo. severe immunodeficiency (not just HIV status). previous IVIG administration within 3-11 mo. ITP. or surgery for more severe angulation. and the child develops drowsiness. or low potency steroid. 4. 7. Candidal infection involves skin fold. pain or neuro abnormality. Bacterial superinfection presents with fever. Steroid and interferon sc have also been useful in large hemangiomas. If neonate at birth has polycythemia in capillary heel blood test. hypoglycemia. then hydration and exchange transfusion is needed. and barrier creams like petrolatum and ZnO. if resistant to H and R. poor feeding. Chemoprophylaxis for PPD conversion following contact with MDR TB. apnea. There are no contraindications to pneumo. Strawberry aka capillary hemangioma in places other than face can be left to regress by themselves.supportive. and is correctable by voluntary extension and prone extention test. Dx of CHPS aka IHPS is by usg. hypotonia. TTPplasmapheresis.severe febrile illness. steroid short course for severe cases. Kawasaki disease. PPD conversion. Adults typically need less. 5. HUS supportive and IVIG. and doesn’t need treatment. Mother found bat in the room of her child. 1gm calcium supplementation should be done in all. cefuroxime axetil or im xone. Lead levels>44 needs oral chelatoin. toxic megacolon and CNS depression. 16. suicidal ideations and pancreatitis.PEP with Ig and rabies vaccine is needed. and bone age is lower than true age. or has persisted for longer. 21. within 3 days (72 hrs) 12. 20. or if not possible. immediately unless the animal can be captured and observed for signs of rabies or sacrificed and autopsied. Behavioral modifications can be used to increase chance of success. hypothermia. but then he develops testicular atrophy and hypogonadism. First line therapy for AOM is amoxy.or GnRH pump. Child comes to Pediatrician with epiglottitis. quinolones for contact lens wearers and corneal ulcer to cover Pseudomonas. So watchful waiting only is needed. Same for cotrim. seizure. or with head and neck bites. Less than 44 needs only environmental and behavioral interventions. Blood lead levels are more sensitive than erythroporphyrin levels. Keep at home till discharge is cleared. PEP should be given within 5 days. VCU to see if obstruction or neurogenic bladder (latter appears as trabeculated bladder with Christmas tree appearance). and can persist for 3 mo after an episode of AOM. Loperamide can cause paralytic ileus. cystoscopy and urodynamic studies. Criteria for admission of pts with anorexia nervosa. 18. else tests are not needed for diagnosing zoster. 19. second line is clavam.dehydration. So TOC is ampicillin for Listera (tho uncommon in US) and cefotaxime. Normal Tympanic mb with decreased mobility signifies effusion. unless if the effusion is bilateral. so diagnosis needs PCR or IF of scraping. Delayed puberty is diagnosed if >14 yrs of age. wt<75%of average. arythmia. 17. Erythro oint or sulfa drops are TOC for bac conjunctivitis. Xone is not used in neonatal sepsis as it can displace bilirubin and aggravate sepsis induced cholestasis. so nothing needs to be done till then (right answer is to assure that the behavior is normal!). In immunocomp patients. tympanocentesis or myringotomy with culture if second line also fails. Clear liquid like juice has sugar. 13. Enuresis normally resolves by 5-7yrs. and >70 needs hospitalization and iv chelation. hypotension. HCG with HMG can be used in central hypogonadism like kallman’s syndrome.bitten. Nocturnal surge in LH and enlargement of testes are the first signs of puberty. 15. Pt with Klinefelter has normal puberty. Only after that investigations like USG to see residual urine. atleast 24 hrs after . brady. which increases osmolality. It can be constitutional if positive family history. psychosis. Constitutional puberty delay can be managed with testosterone mthly im injection for 3-6 mo (short therapy doesn’t affect bone growth). electrolyte abn. acute food refusal. for possible intubation 14. and other systemic illness are absent. esp for psychological reason.first thing to do is arrange for ambulance to send to ER. with limited sugars and fat. herpes zoster might resemble HSV. Hearing evaluation should be done if effusion lasts for more than 3 months. Child with diarrhea should be given normal diet. 29. and life long seizures. by contrast has absence episodes with myoclonic activity. other CNS tumors. 25. pubarche. McCune Albright syndrome has cae au liat spots. even with asymmetric Moro. 22. amenorrhea. If there is microcephaly. myalgia. delayed patellar reflex. esp if GTCS are absent. 30. but no evidence supports it. good response with treatment and remission with age. then MRI or neurosurgery as needed. Childhood Absence Epilepsy (CAE). hyperkalemia. 26. JME (juvenile myoclonic epilepsy). 33. Hyponatremia. Lack of pubic hair points toward hormonal imbalance. any age with first UTI. Serious complication is phrenic nerve involvement.axillary freckling. reflects that the lower roots are intact. fibrous dysplasia and ovarian cyst producing estrogen causing precocious puberty. Hirschsprung disease. USG. lisch nodules on iris. 28. NF1. A lean and thin patient with secondary amenorrhea. 27. Splenic sequestration is the most common complication. recurrent UTI or those who don’t respond to treatment. Benign premature thelarche is common in girls at 18-24 months age. Depression can be second possibility. and isosexual precocious puberty in male. asthenia. but the hyperpigmentation and amenorrhea points to Addisons. has a good prognosis. first thing to do is ophtho consultation. with dec axillary and pubic hair. IF we suspect NF1. Sydenham’s chorea can present after 2-8mo with pronator drift. dactylitis and . it cant be due to IUGR. VCUG is indicated in all children <5 with febrile UTI. optic glioma. 31. Erb’s palsy has a 80% chance of spontaneous remission. others being ischemic complications like asplenia due to infarction. 32. axillary freckling. Symmetric palmar grasp reflex. and leukemia. while adrenal tumors cause heterosexual precocious puberty in female (virilisation). Downs syndrome predisposes to endocardial cushion defect. bone dysplasia. hyperchloremia are present in aldosterone deficiency also. Hypothalamic hamartoma secrete GnRh and cause central isosexual precocious puberty.. Parents can deny vaccinations to their child. the doctor should document and sign the refusal. has to be due to intrapartum infections.its probably not anorexia but Addison’s disease. 23. adrenarche and menarche. facial jerking. acidosis. Always suspect child abuse if the child presents with new onset behavioral problem like sleeping poorly or wetting of bed. bone age.starting antibiotics. etc. Horner syndrome is seen with lower root injury in Klumpke’s paralysis. Renal Scintigraphy and IVP are not routinely recommended. crying or laughing inappropriately. dec tone. Thimerosal present in many vaccines were linked with autism. esp if the parents are alcoholic or uses drugs. treatment is again penicillin re. not accompanied by other features of isosexual precocious puberty like ht. Sickle cell disease rarely presents before 6 mo due to fetal hemoglobin. duodenal atresia and polyhydramnios. atlantoaxial instability and hypothyroidism. 24. developmental problems. Platelet is useless. 42. LDH is elevated. and IVIG if severe. prevention of household transmission by toddlers to pregnant women. Hb electrophoresis is the DxOC. and also has lower rate of relapses. Asymptomatics should be treated in special situations as outbreak control. Dural ectasia is the most common finding of Marfan syndrome re. Most improve fully but need long hospitalization for months. Dx is by rapid antigen detection of RSV in nasal or pulmonary secretions using ELISA antigen capture technology. Viral encephalitis. only then start the treatment. and asthma in the long run. Symptomatic ITP with plt<30. epinephrine).pentad of thrombocytopenia. See for diminished gag reflex in examination. 44. while HSV are usually seen only in adults. ultimately causing renal dysfunction. Pt with abd pain and HCO3<15. Lumbar meningomyelocele is associated with increased bladder dysfunction. esp if augmented by other behavioral approaches.lethargic. which needs airway protection to prevent aspiration.ischemic stroke.botulism. Acute coronary syndrome in these patients may be difficult to d/d from acute chest syndrome. 39. hospitalization if hypoxic or unable to feed (ng or iv feeding). and those with CF and hypogammaglobulinemia. 46. fluctuating mental status. 45. No increased recurrence of Turners is seen with women who had previously delivered a Turner. Alarm is more effective than medications in enuresis. TTP. severe wasting. Adenovirus or CMV only cause meningoencephalitis in immunocompromised patients. Sacral involvement can cause fecal incontinence. suspect DKA. T4/TSH should be routinely tested after 1 d of delivery. Pt has increased risk of AOM. California encephalitis. then aortic valve replacement is indicated to prevent dissection. Only symptomatic patients with Giardia in stool should be treated.needs . Aortic root dilation causing aortic dissection and ectopia lentis. Both TTP and HUS are in the same spectrum. 34. ARF and fever. 37.000 should be treated with steroids.5 cm. WEE. IF TSH is found to be high in the screening done from heel prick. They also need higher dose of thyroxine than the adults!! 40. Pt/PTT are normal. Baby can also contract it from contamination with spores in the soil. and both need plasmapheresis emergently. st Louis encephalitis. lethargy and weak cry. to prevent neurologic defect.TOC is respiratory isolation with bronchodilators (albuterol. 36. the next step is to do a regular blood draw. Serology doesn’t help as it detects maternal antibody. Colorado tick fever. Severe Malnutrition. 43. 41. Acute bronchiolitis. edema. If aortic root >4. Baby on honey and fruit juice develops poor sucking. and immediately treated if hypothyroid. 38. MAHA. Due to TSH surge in baby after delivery. 35. nor is there any increased risk with increasing age like Downs or Klinefelter. like EEE. Apneic spells are very common in bronchiolitis. requiring valve replacement.commonly due to enteovirus or Arbovirus. constipation. along with MVPS which can cause acute MR and CHF. only reassurance to the parents is needed. which helps differentiate it from bronciolitis. then immediate removal by endoscopy or fluoroscopy guidance is indicated. Erythromycin use. USg is the diagnostic modality. with interstitial pattern on XR. 57. Fever and wheezing are rare. duration>15 min. and iv trimetrexate if intolerant to both. Cellulitis is in between subcut tissue and fat. Febrile seizures in 6mo to 5yrs. its probably Chlamydia. Complex febrile seizure is accompanied by focal features like postictal paresis. 56. Pyloric obstruction can present with persistent vomiting in some cases.if it is lodged in any esophageal constriction. 51. FB ingestion. and inspiration between cough (staccato cough). Neonate presents with hemolytic jaundice. 2mo child presents with pneumonia. impaired consciousness and painful oral ulcers. and not based on duration of receiving therapy. eg in prophylaxis against pertusis. is usually preceded by respiratory infection. no intervention is needed mostly. 49. IV pentamidine if intolerant to cotrim. tho there is significantly increased risk of recurrent febrile seizures. so shouldn’t be used. and NG feeding. and aspiration is warranted if child has fever with hip effusion. 55. Aerosolized pentamidine has low efficacy and shouldn’t be used in treatment. IV cotrim is the treatment in PCP pneumonia in AIDS patient. has been shown to increase the incidence of CHPS 52.its Chlamydia. TBM should be treated for 12months. later changed to oral. so local anesthesia will not be helpful. Atovaquone can be used too. 48. Lumbar puncture is indicated if <18mo of age to rule out meningitis. lasts <15 min. esp if vomiting. and is associated with mild increased risk of epilepsy. 53. it is probably G6PD and not abnormal hemoglobin states like sickle cell or . temp>38. Breastfeed a newborn every 4 hrs. This is the reason why pregnant women should be screened and treated for Chlamydia. eosinophilia. High calorie or protein shouldn’t be started early as it can lead to heart failure. and iron shouldn’t be used in first week as it can cause GI ulcer and oxidation injury. warming. and watch for him to take his fingers to mouth to know that he is hungry. 3 wk child comes with purulent conjunctivitis and pneumonia. Search for h/o conjunctivitis in the neonatal period. (Erythromycin is the treatment) 58. Simple febrile seizure has no focal features. only in prophylaxis.hospitalization. while AXR in duodenal atresia or malrotation.child has pain on passive motion of the hip. even if given to the breastfeeding mother. If it has already gone to stomach. USG is the DxOC in CHPS. Open TB patients are considered noncontagious only after 3 consecutive negative sputum smears. Transient aka toxic synovitis of hip. 47. 54. usu first day of fever. correction of dehydration and electrolyties. 50. and upto 18 months if resistant strain. Continuous nasoduodenal feeding can be used as an alternative in those who are poor surgical candidates.Coombs negative. but to arrange for direct laryngoscopy and intubation under anesthesia. with coloboma. In any case of trauma to the nose. 3-4 café au lait spots don’t indicate NF.thallassemia. ELISA antigen test on stool is the test of choice for Giardia. AAP doesn’t recommend routine drug screen.start coamoxiclav for drug resistant Pneumo. atresia choana. 72. 59. retinal tears and lens subluxation. ant nasal cavity should be examined to rule out septal hematoma. It is usually due to internal femoral torsion or metatarsus varus. or aplastic crisis. 65. 67. if the pain and fever persists. Acute severe anemia in sickle cell pt can be due to either splenic sequestration crisis. Heimlich if more than 1 yr. 73. 69. and 1300 for 12 yr old 74. as Staph is overall the commonest cause. 61. hyphema. and needs no investigation and treatemtn. 66. or if recurrent AOM despite prophylactic antibiotics with half dose amoxy or sulfisoxazole. Absolute coobs angle is not a criteria for intervention. 63.beware. It is assoc with CHARGE syndrome. it can be Chlamydia pneumonia. or acute hemolytic crisis. as the atresia is oriented in a coronal plane. 10 pound wt. constipation. Choanal atresia suspect. 60. it needs more than 6.the first thing to do is not antibiotics. Epiglottitis suspect. 800 for 8 yr. as clinical examination is better to find displaced fractures. Cleft lip. as he can have commotion retina. Radiographs of nasal bones are not indicated. Very imp. retarded growth. if <1yr old. see the retics count. Intoeing usually improves on its own. and conjunctivitis. 4 wk infant present with acute bronchiolitis like picture. Ca requirement is 500 for 4 yr child. FB in resp tract.its probably Staph and not Salmonella. Blunt trauma to the eye. It might even have . Tympanostomy and tubing is indicated if OME persisting more than 3 months. Spinal curves like scoliosis need attention only if they are rapidly progressive or painful. and 10 g hemoglobin. Prune belly syndrome. severe AOM. Recurrence risk in subsequent pregnancy is 50%. as it shows the atresia best.rule of 10 says surgery at 10 wks of age. 68.do axial CT. even if no external deformity. then its treatment failure.back blows and chest thrusts after holding the baby upside down. it should be drained to prevent infection and saddle nose due to cartilage destruction. 62. If it is present. it doesn’t need treatment. 71. and if there is undisplaced fracture. 70.multiple urologic abnormality. OM in sickle cell pt. as the latter don’t present early due to presence of fetal hemoglobin. To differentiate. heart anomaly. After starting Amoxycillin for AOM. weak cough.always refer to ophthalmologist even if no apparent anomaly. Adolescent well visit should include dietary history. genital hypoplasia and ear anomaly. 64. as it needs 3 stool examination is needed for visualization. constipation. breast development precedes pubarche. I scan are not the best answer. first thing to do is examine genitalia for tanner staging. 92. If a child is obese and short its usually endocrine disorder. Tick bite. A child of 4 wks comes with a solid mass on his sternomastoid- . USG. first sign is increase in retic count.the biggest threat is hypoglycemia. 90. Hypocalcemia with nephrocalcinosis occurs with antifreeze poisoning. she should be warned of fetal death and hydrops.tick remains for days. tho if his mother is pregnant. they enter puberty early and are tall. or can later produce foreign body reaction. it is diagnostic if it’s a solid lesion and therapeutic if it’s a cystic one. 88. His parents implore not to tell him. 86. then say that telling him will make it easier for them to provide him the best care. VZIg needn’t be given to contacts unless they are immunocompromised. 76. 78. so if pubic hair is at higher tanner or sexual maturity rating scale. and produces a papule with erythematous halo. babesiosis and tularemia are other associated conditions. Also cerebral edema and seizure can occur. 77. 79. neutropenia. A child is brought with alcohol accidental poisoning. and c/e shows boggy turbinates. its primary amenorrhea (100%) and not coarctation (only found in 20%) 80.prescribe regular brushing and dental flossing. 83. Mild diffuse gingival inflammation and swelling. Lactose hydrogen breath test is superior to stool test or clinical trial in diagnosing lactose intolerance. 82. Isolation of contacts from immunocompromised relatives is required though. Abrasions over dorsal aspect of hands over knuckles signify bulimia. 84. Relapsing fever.its probably cocaine abuse. hypotension. esp in those with TPN for a long time. After starting iron in IDA.its probably bad hygiene and not vit C deficiency. listen to their fears. but overactivity and cold intolerance. 81. so the child can go to school .hyperinflation and eosinophilia. The pt must be told. 87. rickettsial infection. In normal obesity. Anorexia nervosa – pts have brady. Serum ferritin is the last to change. hypothermia. Copper deficiency can present as hypochromic anemia. Erythema infectiosum is not infectious after the appearance of the rash. 75. It can also transmit Lyme and erythema chronicum migrans can develop at the site of bite later. and the sign is called Russell sign.first thing to do is FNAC. 85. A pt comes with thyroid nodule. 91.if asked what is the most common complication. then there is a problem. he doesn’t have growth delay. occasionally bloody. A 10 yr boy is diagnosed with ALL and has life expectancy of 6 mo. What to do? Ask the parents why they don’t want to tell him. Turner syndrome. 89. In any male presenting with gynecomastia. In girls. A 16 yr male comes with rhinorrhea. 96.think Prader Willi syndrome. cataract. plus allows delivery of topical antibiotic. muscle hypotonia. Start antibiotics straightaway. So stretching exercise is needed. erythroblastosis and twin transfusion syndrome. and not anorectal manometry re. 101. Most pts need growth hormone supplementation. 105. excessive appetite and temper tantrums. 93. place the baby in a rear facing seat in the car. Hot water less than 120F will prevent any scald burn. A pt with mental retardation. as 25%of the time there will be an anomaly. He is asymptomatic. which if not treated will cause congenital torticollis. Its probably fibromatosis coli. 100. and parents. as it heats the milk unevenly. obesity. also seen in those with congenital toxoplasmosis. short stature. So in those with tube in . A baby is born with blueberry muffin spots. 106. A pt comes with mental retardation without any other systemic features. the investigation with the highest yield is chromosomal study. neuroblastoma. congenital leukemia. due to Togaviridae. but not more than 5 min each time. A child who is throwing too much temper tantrum. He has got BCG also. 95. petechiae all over. time out can be used. so without any other feature. Child comes with decreasing grades in class. 97. Also hypothyroidism. Hirchsprung suspect. 104. 103. D/d is branchial cyst. 98. In males<6mo and females<2 yr with fever without any apparent cause. even in the absence of any urinary symptoms. The blueberry spots are points of extramedullary hematopoeisis. but not casual visitors or his frens. transillumination and sinus XRs are not done. Recurrent otitis media. Until baby is 20 lbs. and that can cause esophageal and tracheal burn. and hypogonadism. 99. still he needs a PPD placed re.myringotomy tube helps reduce the frequency and severity. it doesn’t demand any investigation. including hospital staffs involved in intimate care like intubation or suctioning. 102. 94. In a child with c/f of sinusitis. or keep doing it and face the consequence re. Simian creases are found in 5% normal infants also.the next best step in diagnosis is suction biopsy of rectum. A pt comes from Haiti with complete immunization for well child visit. hepatospleno. Child who received chemoradio in early childhood are at risk of developing premature ovarian failure. behavioral problesm (neuropsychiatric symptoms). Don’t use microwave to heat the milk.TOC is to give him a choice. Downs child is at risk of atlantoaxial subluxation during horse riding and other things. osseous defects on XR. All close contact of a pt with Meningo meningitis must receive treatment. only after that in a front facing seat.stop the tantrum and you can go out for an icecream. urine culture from suprapubic tap or catheterization should be done first. its congenital rubella syndrome.which is slowly growing. deafness. 107. or surgery with splinting can be offered if exercise doesn’t help. CMV. very low yield as the sinuses aren’t developed that much. A pt with vit D deficiency and marked genu varum. metatarsus adductus. A pt is diagnosed with recurrent ankle sprain. flat foot. 114. Myomectomy of the septum is the last resort in case of severe heart failure. PANDAS. Scales in eyebrows can be removed with a cotton tip applicator dipped in shampoo and then rinsed with water. By contrast. If the baby is having rotaviral diarrhea. Cradle cap in an infant is a type of seborrheic dermatitis. that will ease the examination. 117. but if found at 2 yrs of age.treatment is brushing with a toothbrush to remove the scales. Treatment is iv antibiotic and IVIG. its better to obtain an XR to document no other fracture like supracondylar fracture or physeal separation is present. telangiectasia. steroid acne. 115. glaucoma. 110.pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection. and daily bath with baby shampoo. ortho referral is needed. but after ossification it limits subtalar motion and causes heel pain. Remember CT for TC coalition. 112. A person with h/o sore throat comes with guttate psoriasis. It needs CT to diagnose. unlike in functional constipation. which slows the heart rate.tho many reduce it without any investigation. 118. On examination. there is a bony growth along medial malleolus. Calcaneovalgus foot might be normal in early infancy. then the rectum will be devoid of stool. 113. Careful handwashing with ethanol is the prevention. XR wont show. then separate him from the parent and contact the authorities. Switch to oral or iv if no response only.treatment in symptomatic case is with negative inotropes like verapamil or beta blocker. A child who likes to be very neat comes with constipation. and applying baby oil or ointment before bathing to remove all the scales. 109. overriding 4 toe or toe walking are all benign and don’t need th . f/by balanced diet and behavior modification. Then do disempaction of stool. What should you advise? Let the parents be there. Don’t use high potency steroids like betamethasone. Treatment with penicillin will limit the psoriasis also. 111. Laundering clothes will not help (its for scabies only). Only boiling water wont help.place. cataract and systemic absorption due to high surface to volume ratio of the infants. but was associated with intussusceptions. Nursemaid’s elbow due to radial head dislocation. which decreases flow velocity and consequently decreases the degree of obstruction. Oblique XR shows calcaneonavicular coalition however. Vaccine was developed. and dec force of contraction. This is talocalcaneal coalition. AAP recommends that he can be sent to daycare if his stool can be contained in his diapers and don’t spill over. 116. It presents with OCD like syndrome and tics. but the parents wont allow. IHSS.do ASO and rapid strep testing. which allows increased LV filling.he not only needs dietary supplement. Initially the bar is unossified. but also long leg wt bearing XR and ortho consult. 108. Then after hx and c/e. Ask about whether he avoids school bathroom. only topical antibiotic can be used first. if abuse is suspected. If its Hirschsprung. It can cause atrophy. A resident suspects child abuse and wants to speak to the child alone. do wrist XR first to find if the bone age coincides with the pubertal age (chronological age is not imp). A pt with positive Barlow and Ortolani at birth. dehydration. so the TOC after rehydration is laparotomy.common in scalp and face area. diaphoresis.needn’t do USG as it is a clinical diagnosis. paralysis.suspect midgut volvulus. 128. tachypnea.its Kawasaki disease. IT should be removed. Steroids help in croup but not in bronchiolitis. Usually the clinical picture is so classic that imaging is not needed. with its resultant complications like liver cirrhosis. Thromobocytosis is an acute phase reaction seen in the blood. Same for safety pin. If it does. A 6 wk baby with bilious emesis. 120. but not of dermal nevus. meningitis. and he has a minty smell in his breath. 127.referral. worse on Mondays. 119. as it has corrosives. strawberry tongue.apart from topical antibiotics. and TPN for the rest of life. and no response to medication. 122. and then ortho consult. depending on his parent’s final height. Congenital hydroceles only warrant observation. A toddler comes with hyperthermia. Ribavirin is used only in those with underlying disorders like bronchopulmonary dysplasia. coagulopathy. If it is just a coin. If the pt is stable enough for evaluation. or viral culture of skin lesion. A child ingests a battery and is now stuck at mid esophagus level. systemic antibiotics for both gonorrhea and clamydia should be given. 129. A pt comes with short stature. 125. Neonatal herpes. prematurity or congenital heart disease. Dx Is by Tzanck smear.its probably psychogenic cough (not exactly school phobia.as most resolve by themselves. pneumonia. 124. and USG can be negative falsely. opisthotonus. without any h/o allergy. So the TOC is putting the baby in a Pavlik harness. Delay in treatment will result in shortgut syndrome.then its only constitutional delay. Cat scratch disease. and the parents have to reassured that he will gain a normal adult height eventually. slight distension of abdomen. 121. Its oil of wintergreen ingestion with salicylate poisoning. Neonatal gonococcal conjunctivitis. vomiting. or cipro or rifampin as alternative. tachycardia. A child comes with pink eye. but is otherwise doing well. and fatal if not treated. desquamation of hands and feet. A child comes with cough during daytime only. XRs are useless before 4mo as the femoral head is not ossified. NS nebulisation can act as an irritant and aggravate the condition. 131. 130. but normal growth velocity (eg height velocity). Tt is cotrim.then we can do f/u XR to see its safe passage. delayed puberty on examination. as this is not . A pt comes with acute bronchiolitis.the TOC is nebulised albuterol. can cause hepatitis. then a upper GI series with follow thru will demonstrate the abnormal position of the ligament of trietz. Wood lamp will accentuate the pigmentation of epidermal nevus. 126. 123.Bartonella. and later the child deteriorates. and leaves a hyperpigmented macule with scales . He has microcephaly. 146. A child comes with scarlet fever.see if the pattern matches the history or not. Rubella. but UVB exposure can hasten the recovery. abd mass. D/d are keratosis pilaris seen with atopic dermatitis. 134. and the neighbor decides to sue the doctor. he should return to sports only after a week.pt can get back to sport if asymptomatic for 15 min. A 12 yr comes with low grades in school. so c/I during pregnancy. and neonatal pustular melanosis which will show neutrophils. A child comes with abdominal mass that seems to arise from inf venacava. These patients are very sensitive to irritants and friction. but also in critical area involvement like face. second episode. Pityriasis rosea. 137. you have entered a doctor patient relation. ITP and encephalitis in some.evanescent rash that disappears within two or three days. A physician is approached by a neighbor for an advice about his child. post auricular and postoccipital LN. 11p13 deletion is the most imp cause. hand. Congenital Rubella syndrome if contacted during the first trimester. so only lukewarm bath and no rubbing with towel. 140. pubic area. Honeymoon period refers to mth after dx before insulin is needed. Live vaccine. The court will hold the doctor liable. arthritis in many. 144. or earlier if born with renal disease. and language delay. First thing to do is TORCH screen. Language delay can be due to both mental retardation and hearing problems. 138. Forscheimer spots are enanthem in Rubella.HPE shows eosinophils accumulation around the pilosebaceous follicles in the dermoepidermal junction. 133. Admission in burn in infants is mandated if BSA > 10% or 15% in older child. First episode of concussion during sports. Erythema toxicum neonatorum. By contrast neuroblastoma is due to mutation in Nmyc gene. 24 hrs of antibiotics is enough before going to school. Remember all scald burns are not abuses. 139. perineum. Human IG can be given for PEP to measles to children at special risk only. Vaccination at 12-15 mo and then at 11-12 yrs. 136. and presents with fever.no treatment available. 141. anemia and bone mets. Pregnant with Giardia can be treated with paramomycin.all other ill siblings should also undergo rapid strep testing and treatment. 135. and its your duty to fully examine the patient.a scientific term) 132. 142. 145. Incubation period between contact with TB patient and tuberculin skin test conversion is 2-12 weeks. coz once you have given advice. No need to test asymptomatic siblings though. he advises for free. wt loss. BP msmts are initiated after 3 yrs of age. Pt with IDDM can deteriorate during his puberty due to different hormonal changes. 143. its probably wilm’s tumor. and electric burn. after the pustule ruptures. Hydroquinone also blocks melanogenesis. called ochronosis. Cavernous hemangioma. 8. or location in planes of embroynal fusion. First thing to do in a new onset AF is TSH measurement. If it doesn’t help in 3 doses (total 2 mg). but it can cause hepatotoxicity. Tt is to limit wt bearing wth braces and cast. first thing to do is give atropine. then he needs DMARD. Treat with ether topical mupirocin or oral cephalosporin. Bullous impetigo. then comes subacute stage with bone resorption and finally fusion in chronic or reparative phase.get a MRI.MTX is the DOC. are caused by Staph aureus. When a pt with RA comes with erosions on XR. so can be used for hyperpigmentation or melasma. Then it goes into acute stage where there are periarticular fractures. Charcot foot in a DM pt with neuropathy starts initially in acute inflammatory stage like cellulitis with warmth. 6. Steroid for long time for psoriasis is not recommened due to side effect and due to tachyphylaxis. 151. 3. Inferior Mi patient develops brady and hypotension due to SA node suppression. Azelaic acid inhibits tyrosine kinase. if recurrence in a scar. especially following other dermatoses or chickenpox. MOHS is used in melanoma if tissue sparing is a concern. This can be seen with tabes. 150. 149. So early treatment is important with large hemangioma. like esophagus or trachea. 148. as they are at risk of hemosiderosis for unknown cause. can cause DIC and consumption coagulopathy with thrombocytopenia. Pts with chronic hep C shouldn’t be given iron supplementation. 7. liquid nitrogen or pulse laser. then joint dislocation. edema which disappear on elevating the foot which is pathognomonic. but prolonged use is associated with yellow brown permanent pigmentation. and with pernicious anemia also. 147. Its called Kassabach Merritt Syndrome. even only cms wide. and is a vascular reaction to infection. Its pyogenic granuloma.so monitor LFT regularly and give pyridoxine with it ! Low dose prednisone is used only if DMARD don’t show adequate response. then temporary pacemaker is indicated. 5. Girl comes with a pedunculated lesion on her face for a month. Azelaic acid can be used for hyperpigmented lesions like postinflammatory cases or melasma. It recurs after treatment . Volume replacement and dobutamine if hypotension doesn’t correct even after correcting the bradycardia. erythema.bleeds with scratching. MISCELLANEOUS FROM KAPLAN QBOOK 1. Another danger is compression of vital structures by rapidly growing hemangioma. as it is cheap. Treatment is destruction with curettage or electrodessication. UVA with either coaltar (Goeckerman regime) . 2. Hyperprolactinemia and amenorrhea cant be due to anorexia. 4. has increased risk of melanoma of choroid. 16. 14. ALT elevation asymptomatic. 20. and autoimmune screen and USG. 9. Nevus of Ota. if there are evidence of chronic liver disease.what do you do ? . iris. Pt develops necrotizing skin lesion with blisters and pus discharge. or has persistent elevation on further testing. if necrosis is present and pt is febrile. only in those who report symptoms despite aggressive management. Coronary angio is not indicated in all angina. aspirin. 21. then the best thing is to start MTX. Thyroid nodules that are not palpable but found on CT or USG need only f/u. 15. then we have to do liver biopsy. 10. Offer HepB vaccine in all with STD. no FNA or f/u CT. etc. ACEI. b blockers. Hampton hump is the opacity due to intranecrotic hemorrhage seen in XR after PE. Pt with DKA may have hyponatremia due to ECF dilution due to water shift from intracellular to ECF. esp along the branches of trigeminal nerve. Immunocompromised pt develops pneumonia which progresses from interstitial edema to necrotizing bronchopneumonia and then cavitation. If no clear diagnosis after serology for viruses.starting heparin is the TOC. not in asymptomatic nodules. It affects apocrine skin specially. dialysis patients and household contacts of pt with chronic HepB.its ecthyma gangrenosum. need only f/u after some months. but if there are systemic and joint involvements. Asymptomatic sarcoidosis with only erythema nodosum and hilar LN need no treatment. its Pseudomonas. So the hyponatremia needs no treatment. No debridement is needed however. only then do CT to see for any necrosis. nor a progressive one. 12. then do CT guided aspiration for culture of the pancreatic necrotic material.oculodermal melanocytosis involving face and sclera on one half of the face. do a stress testing to quantify the risk. rales. thyroid scan is indicated only if hyperfunctioning nodule. ie in the glabrous parts of body. 22. 13. skin and optic nerve. edema. as it is associated with hep C infection. only iv antibiotics after skin biopsy and blood culture are taken. like s4. with white lacy streaks on buccal mucosa (Wickham’s striae) in a sexually active patient. Unstable angina is the dx if pt comes with chest pain and s/s of failure. Pt with pancreatitis develops fever. BP control and smoking cessation have shown to increase lifespan in pts with angina. brain. Fatigue. stress and mens has shown to increase the pigmentation of the nevi.or antralin (Ingram regimen) can be used. and also in gay men. but not nitrates. other investigations are warranted only if >3-5 times raised. A court summons you to talk about your patient. Statins. 11. coz quadriplegia is neither a terminal condition. 18. 19.do hepatitis panel. Before discharge. 17.promptly take blood culture and start antibiotics (ampigentametro). A pt with quadriplegia cannot ask for voluntary refusal of fluid and food. Lichen planus. Guttate psoriasis can occur after Strepto throat infection. he can be force fed. M canis is less frequently seen these days. If pt doesn’t want any information to be given. Trichophyton tonsurans is the MCC of black dot tinea capitis in children. and causes inflammatory patch in the scalp with broken hairs.2 pregnancy test should be negative. Treatment is penicillin oral. and liver angiosarcoma. raindrop hyperpigmentation. Total cholesterol panel is these days recommended instead of screening random cholesterol. Psittacosis presents with similar clinical and radiological picture. scarring. shouldnot wax skin upto 6 mo due to risk of scarring. Arsenical keratosis in a patient who worked in smelting furnance. Butcher develops bright red lesion due to an accidental cut on hand. Self breast examination is no more recommended. Pt receiving Radioiodine for Graves disease shouldn’t have close contact with children.treatment is to avoid the hydrotherapy. like groin and axilla. Pt taking isotretinoin for acne. or Erythro with rifampicin if pt cannot tolerate penicillin. 24. A pt getting hydrotherapy for arthritis presents with itchy skin. 23. 33. its Erysepaloid due to Erysipelothrix. treatment is local steroid and not diabetes control. Debridement is not needed. 29. preservatices or paints and pesticides. and should be warned about myopathy and about driving in the dark. aka xerotic eczema. electronics industry. still appear in the court but don’t say anything about the patient. 34.hyperkeratosis of palm and sole (like corn). telangiectasia. polyneuritis. as it has no benefit. but has more systemic features like fever. and the adult can then contract the same on his skin from the child. Imipenem lowers seizure threshold 26. eg in day care job. 28.its asteatotic dermatitis. Hyperthyriodism in elderly maynot have tremor. as many have decreased night vision. Lanolin in different over the counter creams can cause allergic contact dermatitis. or 30 by most panels. .first talk to patient as to what information he wants you to divulge. 27. atrophy.treatment is to avoid exposure. ulceration. Corynebac minutissimum causes erythrasma in glabrous skin. Necrobiosis lipoidica diabeticorum: erythematous papule. and cancer of skin ( BCC and SCC). Epidermatophyton flocossum affects glabrous skin like in athlete’s foot. 32. with vesicles and smooth shiny plaques. and is known for coral red fluorescence on wood’s lamp. 35. Mees lines. should use 2 contraceptives. 25. 31. peripheral vascular disease culminating in blackfoot disease (gangrene). cannot donate blood upto 1 mo after stopping it. and is treated with doxy. in a person who clears bird cages. 30. Minimum screening age for cholesterol is 18. 36. exfoliative dermatitis. Allergic alveolitis. aka acute Hypersensitivity pneumnitis. 45. Flumazenil is only useful in acute overdose cases. In a pt with HIV and multiple stressors. should be put on long term acyclovir oral. can be discontinued. with mean. without LOC – player can return to the game within 30 min if normal exam and without symptoms. 39.vomiting or headache are not indications for further investigations. and if the frequency has decreased considerably. If the mean is very different from median. esp if hands and face are involved. 42. Data is given for effect of drug in lowering BP. In a pt getting methylprednisolone for multiple sclerosis.the best next step is to refer to a neurologist. Contact dermatitis. Pt on risperidone. causing overcoagulation or hypocoagulation. Pt comes with postconcussive syndrome. olfactory hallucinations signifying temporal lobe epilepsy. 44. 40. Then asked to find the degree of benefit of a patient. as you cant use potent steroid over those sites. Methylprednisone can be used in low dose with acute taper.37. then stop the drug. 51.so colonoscopy is still indicated 38. can cause chronic fecal impaction and overflow diarrhea. 49. A pt with symptoms of pneumonia but has normal XR. discontinue to see the frequency of outbreak. Pt who is not braindead but who is certain never to recover his functions. Transient global amnesia is a cryptogenic condition without any treatment. but shouldn’t be repeated for fear of significant rebound flares. if he comes with gait disorder but normal neuro exam except for a wide based gait. 43. keep him on insulin sliding scale.treatment is oral prednisolone. and a diabetic diet should be used. treatment of constipation by fiber supplementation is the treatment of choice. 46. median and SD. Mild concussion in a game. 41. Hemoccult test positive in an elderly patient with hemorrhoid can still be due to colonic polyp or malignancy. A pt on alprazolam for anxiety for yrs comes with BZD overdoseflumazenil shouldn’t be used in pts with physical dependence as it can precipitate seizures. Lifelong treatment is not needed. as well as rectal leakage. so the answer would be ‘cannot be determined from the given data’. its probably . unless they are persistent. and who can never be weaned off ventilator. then it is a skewed distribution.rehydrate him and then repeat the XR. 50. The pneumonia might show up. Chloral hydrate displaces warfarin from protein binding sites. monitor his blood sugar. 47. Pt should use barrier contraception to prevent transmission. A PT on treatment for pyelonephritis doesn’t respond to antibioticsdo CT to rule out perinephric abscess. Mag salts can cause excess and dangerous fluid shifts in elderly. Mineral oil is c/I as it can cause lipoid pneumonia due to aspiration. 48. on grounds of FUTILITY. so the rule of confidence interval doesn’t apply. even if not a diabetic. After about a year. Pt with recurrent outbreak of herpes genitalis. elderly. Ultraviolet keratoconjunctivitis in pts who ski. Examination is normal. Think. 3.N/3 saline.psychogenic gait disturbance. 59.15% are resistant to fluoxetine. You consult a neurologist on phone. coz that will make them doctor pt in relation. Rivastigmine has caused severe vomiting and even esophageal rupture. else he has no liability. he asks to discharge the pt on analgesic. For condyloma acuminata. >10 you .10 yr. This is conversion disorder related to the stress of pregnancy. 52. the nursing home should use the test with the highest sensitivity. 2. PMDD (dysphoric disorder) is the severe form of PMS.N/2 saline. Stye needs only antibiotic drops and warm compresses. 60. A pt who is undergoing CABG develops amaurosis fugax. Support is better than confronting the patient with the diagnosis.N/4 saline. Tacrine can cause serious hepatotoxicity and is rarely used these days. A pt comes with headache. Daily metaxalone is useful for tension type headaches. Cerebral palsy usually occurs in baby with normal wt at birth. Later the pt dies of aneurysm. TCA acid and not podophyllin. tho it can be used in pregnancy with caution. coz metro isn’t to be used in breastfeeding. Ablation is less reliable than excision in high grade lesions. For the test to include maximum patient s with risk of Alzheimer’s. 57.should undergo carotid ultrasound before surgery because these patients can develop stroke on bypass machine if they have carotid stenosis. first thing to do is starting antibiotic. but reflexes are normal and MRI is normal too. A pregnant patient comes with paralysis below the umbilicus. Donepezil is the DOC in Alzheimers due to least side effect. Clinda and genta is the TOC for postpartum endometritis. then CT to rule out mass lesion like abscess. and then only do LP. Best way is to reassure the patient that it will get better on its own. and not highest specificity or highest PPV. In a meningitis suspect. 7. 54. 5. neonates to 1 year. then detailed investigation is not needed). 61. 58. 56. 6. 4. that’s why LEEP is preferred over laser/cryo or even cold knife conisation.not IND 53. 55. and normal POG. LEEP is the TOC for HSIL or CIN II and higher. 1 to 4 yr. A nursing home wants to use a test inmates for highest risk of developing Alzheimer’s. Next step is cystoscopy and then urine cytology. coz the latter shouldn’t be applied to mucosal surface. in those cases alprazolam is the second line drug. There is very poor correlation with perinatal asphyxia or low APGAR scores.providing respite for the wife (with use of home services or nursing home for a short period of time) can delay permanent admission of the pt into a nursing home re. CT urogram ie with iv contrast is preferred over IVP nowadays for intial investigation of asymptomatic hematuria (if pt has s/s of infection or stone. Wife caring for a demented husband. 5. Gallantamine is c/I with hepatic or renal impairment. Some more 1. The court will indict the neurologist if he has directly spoken with the pt over the phone. 15. What to do? Transfuse. He is in dire need of transfusion.who should ask his family for organ donation? The organ donation network. A severely mentally retarded person denies screening colonoscopy even after explaining the benefits. but the family doesn’t consent to donation. Tell him that health service department doesn’t need or send immigration status. the doctor is also not obliged to tell them. 14. If the contacts call the doctor. 12.he is still considered competent to decide about his medical care. So if a patient comes with such form to fill out.he dies.as the latter will be conflict of interest on our part. Pt with syphilis has multiple sexual partners. 17. or donate them. 18. but not if they want something in return. Also the patient can refuse to give out the name of his contacts. Gifts by patients can be accepted to maintain doctor patient relation. 11. 16. Gifts under 100 dollars by pharmaceuticals are also okay.the warden calls you on the day of execution to start a iv line as they cannot do it.can give NS. 13.you are not required to do any treatment like dialysis which you think is futile.What to do? Report to the chief of staff. 20. An unconscious patient in ER without any previous records is wearing a shirt saying I am Je’ovah's witness. Employers have no right to order tests likeAPC gene without the consent of the patient. and DHS will inform the partners by mail or phone that there is a public health threat. but it will never reveal the name of the person. 10. A pt has organ donation sticker in his driver’s licence. 9. Pt in persistent vegetative stage and MODS.’’I am in this business long enough to know’’. unless . Illegal immigrant with TB worries if he is reported to the health department. ask the patient if he wants the test done and the result reported. even if it is against the family’s wishes. So its very important to tell your family about your organ donation wishes. for the safety of the society. What to do? Respect the wishes of the family. A pt is braindead. as the sticker only show’s the patient’s will but is not legally abiding. but cant sell the embryo. and not the physicians looking after him.can only donate it. he should report it to the Department of Health Services. You cannot do things that will lead to the patient’s death. Consent is automatically implied in ER settings.the attending says to you. Should the doctor inform the partners? No. Even attending the execution is unethical. then it will inform the immigration services and deport him. ETHICS 8.What to say? Say you will not take part in any of it. and we cant do anything about that. You can give anxiolytic to the patient the night before to allay his anxiety though. 19. plus he could have changed his mind after that. Don’t do it. You see a pt of CCF is not on beta blocker. A pt comes with gunshot wound.report to the police even if the patient disagrees. Any couple undergoing IVF can sell their sperm or ova. You work as a physician in a penitentiary. A doctor unintentionally gives wrong dose to a patient. A pt has no healthcare proxy or living will and gets unconsciousthere is no agreement among the family members about the best step in management. A bus driver with sputum+ TB consistently refuses to take DOTS.say. are contraindicated in patients with cocaine overdose. and is now refusing surgery to stop his bleeding. 30. NG and fluids in an unconscious patient.and shirt isn’t considered as a will. Best initial step for stopping drug abuse is sending the patient to drug rehab.he is responsible. 31.you can transfer the patient to another colleague. Your patient refuses a treatment.if the family members can be in unison about the substituted judgement about the care of this patient. as he is jeopardizing the health of others.overridden by will. 24. MISCELLANEOUS AGAIN. 26. 22. 33. as are the nurses and the pharmacist. What to do? Go to ethics committee. A pt is unconscious and has no proxy or will. DNR doesn’t mean discontinuing ventilation. maybe I can after you get a new doctor’’. 29. 32. Beta blocker. and can stop any treatment. HRCT and not USG is the investigation of choice for renal stones. What to do? Do the surgery. they can order anything. 25. Atleast the doctor patient relationship has to end before you can date her. Group therapy like AA is for maintaining abstinence and preventing relapse once detoxification is done. A patient in acute stress. Therapy can change his mind later. Never postdate your note.’’ I cant date you now. That’s the same logic why suicidal patients can be detained against their will. but you have to comply with it!! Hmm nice. and then to the court if necessary. BP control is most important to prevent cerebrovascular mortality. If you find error in your earlier note. 23. You donot have to agree with an adult patient’s wish. so save him first. A pt tried to kill himself by striking his car on a tree. Eg you are religious and oppose abortion. A patient wanting romantic relation with you. 35. What to do? Remove the patient from his duty and incarcerate and treat him in the hospital till his sputum is clear. including labetalol. Lipid . 21. 34. What should you do? Inform the wife!! Confidentiality ends when sb else would be harmed. and you are not comfortable with it. then you can refer your patient to somebody who is comfortable with it. 28. 27. is NOT competent to make his own decisions. write a new note with the correction. A pt is refusing to tell his divorced wife and kids that he has FAP. and not to group therapy. and who attempts to kill himself. as IDA might be the cause. PCOD. Pt comes with gross hematuria 3d following URTI. Screening for DM with FBS and not RBS is recommended 3 yrly in all patients above 45 yrs of age.urine Na<10 and urine osmolality>serum osmolality are diagnostic. 38.its primitive idealization. Dialectical behavioral therapy is one of the most effective treatment for borderline personality! TCAs are c/I as these patients have high rate of suicide. Paroxetine.its IgA nephropathy and not PSGN. 53. 41. Also CBT. a part of splitting. Interpersonal therapy is used for depression. 36.first treatment is ice packs. 47. and there is no HTN. 43. then phenylephrine injection every 5min (or epinephrine). Not FENa. 51. Reactivation with herpes zoster increases with age! 49. A pt with borderline personality says her doctor is the best and saved her life. 45. and other time thinks that a famous popstar will marry him and sings only for him. 42. 37. overweight. use D5W with low amt of bicarb as treatement. OCPs have no relation with depression. An elderly started on fluoxetine comes with severe side effects and want another drug with better s/e profile. 40. Urine immunoassays (and not gas chromatography) are employed for drug screening.he is having schizoaffective disorder! Like a person who is manic at one time. oral terbutaline is also effective but not TOC. Pts with AICD implantation-if they have PSVT due to panic attack. A pt has symptoms of mania with type A schizophrenic symptoms like delusions and hallucinations. but still are not as good as SSRI. 52. TCAs are less preferred in elderly also coz they are at high risk of suicide. but for those with family history.start him on sertraline and not nortryptiline or imipramine. dyslipidemia. even before psychotherapy. vascular disease. pre-renal ARF with hyperkalemia and acidosis. Hepatorenal syndrome. Pt with shock. citalopram. they can get repeatedly shocked by the ICD. as the latter have improved safety compared to amitryptiline. and earlier if risk factors like HTN. Priapism can cause ischemic necrosis and impotence. it should begin at age 45. Iron studies should be done in patients with restless leg syndrome. sertraline and new tetracyclic maprotiline all cause weight gain. SSRI are the TOC for depression. GDM. inactivity.control is the most important in preventing cardiovascular morbidity. and should be substituted instead of fluoxetine if the wt loss due to the latter is troublesome to the patient. 48. or African American or Hispanic race. Repeated hospital admission with polymicrobial(including anaerobic) bacteremia should be considered factitious disorder. 44. DMPA is suspected to have. PSA screening for prostate cancer begins at age 50. but the evidence till date is inconclusive. with patient injecting himself with fecal material. . family history of DM in first degree relatives. 46. 50. So tick the former in mcq!! 39. 61. has tenderness in infrapatellar region. 59. Patient with DM comes with hyperosmolar coma-the increased osmolality of blood will draw intracellular water causing dilutional hyponatremia. 66. Hypomagnesemia causes similar. with features of systemic sclerosis.with gas present in perinephric area. and inability to wean from the ventilator. 67. If there are split hair ends visible. coz exercise can cause rise in CPK too. and after the water is diuresed. A 75M comes with insomnia after the death of his wife. 60. its due to chemical reaction or due to trichotillomania. Patellar tendinitis. Lithium can cause alopecia. causing isolated rise of creatinine in the serum. muscle cramps etc. as it has a high false . In the absence of symptoms. ie there can be many false negatives. while prepatellar bursitis causes anterior knee pain with signs of inflammation. Steroids can infact increase the damage if used in high does. never do ANA. Corneal foreign body frequently test positive for coagulase negative Staph. as it increases the risk of falls and fractures. This is because dsDNA is highly specific. 63. 68. NG aspiration. but doesn’t cause split hairs. Anserine bursitis causes pain on the medial aspect. but is seen after diuresis.54.most effective measure to prevent renal disease is monthly BP measurement re. 62. crepitus and pain on deep pressure on patella.treat it like insomnia with psychotherapy. A pt with diffuse systemic sclerosis. add 1. 64. there will be hypernatremia. Stopping statin is only needed if it is increased more than 10 fold. Zn deficiency causes decreased wound healing and skin rash. associated with overuse. So for every 100 mg/dl of glucose above normal. convulsions. Probenicid and Trimethoprim cause inhibition of tubular secretion of creatinine. 65. with normal BUN! 56. aka jumper’s knee.6 mmol/l to the Na concentration. but has dsDNA negative and RA positive. and ACEI and ARB are only used if the patient presents with renal crisis. So in these patients hydration should be with half NS. Cimetidine. MCTD needs RNP antibody. aka trichoclasis. Hypocalcemia presents with increased DTR. with theater sign positive (climbing stairs or getting up after prolonged sitting). Trick question. Osgood causes pain over tibial tuberosity and not patella. Premature atherosclerosis is the MCC of cardiovascular mortality in patients with SLE.a pt who fulfills 4 criteria for SLE. Avoid drugs in elderly. PO4 depletion can cause severe muscular weakness (as no ATP can be formed). 55. its still SLE. DM patients can have emphysematous pyelonephritis due to E coli and Klebsiella. CPK shouldn’t be routinely ordered in pts on statins. 58. Patellofemoral pain syndrome aka chondromalacia patella is like Osgood Schlatter’s disease but in adults from 20-40 yrs. polymyositis and SLE all. but only 70% sensitive. 57. In a critical patient on dextrose drip and intubation. alcoholism and diarrhea. Nephrectomy is immediately warranted. first do TSH. Steroids only in severe disease with myocarditis etc. Though HLAB27 is positive in many. do USG to see if this is the only nodule or if it is the dominant nodule. hypoechoic. stop it. alarm features like microcalcifications. Rx of Reiters is antibiotics. But if he doesn’t respond in 6 wks. IF it comes positive. only then do lumbar XR. IF FNAC shows malignant.if the latter shows hot nodule. NSAID and steroid injection.positivity rate. If a pt on CCB comes with MI. then the first thing to do is XR of pelvis. or if f/h of thyroid malignancy. IF low.simple hydration with dextrose will increase endogenous insulin secretion. and the patient has no symptoms. 72. then do ESR to rule out malignancy or infection. with evanescent salmon colored rashes and spiking fever with myalgia and arthralgia. then no treatment or thyroxine to suppress TSH for cosmetic reason. even in 70 yr elderly. For thyroid incidentalomas found on USG. Tarasoff II is protecting the person from harm by detaining the threatening patient. which will help in metabolizing the hypertryglyceredemia that is causing the problem. Don’t use . NSAID are the TOC in adult Still’s Disease. and shouldn’t be left out considering it as sclerosis of the valve. IF RAIU shows cold. So before 6 weeks have elapsed. don’t label anybody as RA. do FNAC. If it is raised. Sjogren is associated with B and not T cell lymphoma. FNAC again. Tarasoff I is informing the person who is about to be harmed. coz there is no benefit. but it usually lasts for less than 6 weeks. 70. its not specific and hence is not recommended as the first step. 79. MTX or sulfasalazine and progressive exercise. and infact possibility of harm with CCB in such patients. Thyroid nodule. then dextrose insulin infusion can be started. do FNAC again. If this doesn’t work. 82. 77. Ergonomic keyboard have been proven not to help. irregular shape. Monitor LFT in patients on long term NSAIDS. XR pelvis is preferred to HLAB27 even in ankylosing spondylitis suspect. FNAC only if >1cm of size. surgery. eg reiter’s arthritis associated with UTI. if inconclusive. FNAC again. Parvoviral arthritis can present with weak RA factor positivity. 69. 81. ie cold nodule. no need to follow up with dsDNA too.hence should be put on prophylactic ciprofloxacin for a week ! 80. due to Hashimoto). IF USG is suspicious.iv labetalol is the DOC. 71. 83. do RAIU. Low back pain in <50 has <1% of being anything but musculoskeletal. then RAI ablation or followup if asymptomatic. Pts with cirrhosis admitted for variceal bleeding are at increased risk of SBP. IF TSH high( rare. as evidence of sacroileitis is needed for diagnosis. Acute aortic dissection. Symptomatic AS should be promptly treated with valve replacement. 76. 74. Pt on oral retinoids for acne comes with pancreatitis. 75. if its benign. If seronegative spondyloarthropathy is suspected. Arthritis due to IBD wont have conjunctivitis. So only bed rest and physical therapy. Life expectancy is not reduced and there is no overall functional disability re !!!! 73. If normal. and other infections too. Occupational rehab is important for patients with carpal tunnel syndrome who don’t respond to night time splinting of hand. 78. 88. If magsol cannot prevent the recurrence. Verapamil inhibits tubular secretion of digoxin. use diltiazem or B blockers and not digoxin. has no other risk factors. Also JVD.decrease warfarin dose by 25% 95. In pts with preexisting heart disease like CAD and AF. These are the highest risk factors. then do transvenous temporary pacing. as this is an independent CAD risk factor. prescribe metoprolol and not losartan. For acute rate control in AF. Orthostatis hypotension. as the contrast agent can precipitate renal failure. Ator and lovastatin should be changed to pravastatin in patients with hyperfibrinogenemia. and residual wall motion abnormality due to previous MI precluding the use of ECHO. and the best thing to do is early . Aspirin is sufficient to prevent stroke in patients with lone AF.5 to 3. while amiodarone is very safe in this regard. 87. or 10 in DBP 91. Warfarin has more risks than benefit in such setting.nitroprusside without beta blockade. MRI is the best modality to diagnose suspected coarctation of aorta. previous MI which precludes use of ECG. as it causes reflex tachycardia which can increase the dissection. dyspnea. A pt with h/o severe angioedema with DM and HTN.the first thing to do is not Holter but a simple hx and ex and an ECG ! 85. 90. dizziness. 102. Radionuclide imaging is preferred over stress ECHO in patients with angina and previous revascularization. 94. 100. more than reduced Na diet. as the former when given iv will act within 5 min. 89. Amiodarone and quinidine also cause digoxin toxicity. Amiodarone even if pt has hypothyroidism!! This is because other antiarrythmics can easily cause fatal arrhythmia in someone with preexisting heart disease. Amiodarone with warfarin. Thiazides are sulfonamides. coz that can herald the development of SLE. 98. Goal INR for mechanical aortic and mitral valves is 2. 99.as there is a low but present danger of angioedema even with ARBs. causing 100% increase in its levels and toxicity. eg with palpitation.the most effective nonpharmacological intervention for this patient is weight reduction. so can cause photosensitivity rash. give magsol irrespective of the magnesium level. amiodarone is the DOC for keeping the patient in sinus rhythm for long term! Rhythm control is preferred in patients who are still symptomatic on rate control.20 mm fall in SBP. Angina at rest and critical AS carry 20 points on preoperative cardiovascular risk assessment. while digoxin even if given iv will take hours to act. 101. An adult comes with syncope. so does spironolactone. which is diagnosed after all other causes of AF have been ruled out. 92. 84.advice to report any flu like symptom. 97. 86.thiazide should be discontinued in that case. Pt on hydralazine. Stop metformin in pts undergoing diagnostic cardiac cath.5. BMI of 30 with HTN and smoking and alcohol. In all patients with torsades. Recent onset angina is unstable angina. 93. better than CT 96. BP control comes second. start diet and atorvastatin stat. DM pt on metformin comes with acidosis and weakness. Also use of topical pseudoephedrine has shown to decrease barotraumas by 75%. 6mo if no risk factors identified. do antithyroid antibodies. as the steroid disappears from blood within a few days. and when she tried reducing her evening glargine. then its not DKA but lactic acidosis. The posterior bleeding is usually more severe. Pt on HRT comes with DVT. 115. 107. as this can cause DKA. A pt on glargine and lispro wants to exercise. He shouldn’t fly within 24 hrs of diving to prevent barotraumas. Reducing LDL is the most effective way of decreasing the CAD risk. 109. then DM control and smoking cessation. 103. Ant epistaxis. Clopid has been shown to be more effective than Aspirin in reducing cardiovascular mortality in patients with PAD (and probably other risk factors also). That’s why DM is categorized as CAD equivalent. A pt who got intraarticular steroid for gout 7d back comes with deranged glyccemic control. and not stress testing. So if LDL is above 100. Cilostazol also decreases the pain but is used only if supervised exercise fails. still glycemic control hasn’t been proved to be much useful. So the best thing to do is start the patient on unfractionated heparin. It should be tapered off. 105. If they are positive. 110. Insulin shouldn’t be stopped in the preop night in DMI even if NPO. . 114.don’t fall for the trap where answer says discontinue HRT immediately. then he should be put on beta blockers. T3(liothyronine) is not indicated for hypothyroidism re!! 113. In a pt with subclinical hypothyroidism.Little’s or Kasselbach plexus. then only holding the Coumadin for a few days will do. and common in adults with HTN. 111. which gives much flexibility to the patient. 104. then her prelunch and predinner sugar went up. Higher than that needs oral vit K. coz diabetics have a very extensive coronary blockade. then even subclinical disease needs thyroxine replacement. 106. but don’t use metoprolol. FFP and iv vit K is only needed if the pt is actively bleeding.with normal glucose and no hyperamylasemia. The mgmt is insulin pump. 116. PAD (PVD) is a CAD equivalent. The derangement is due to the stress and not steroid itself.Woodruff’s plexus. Also for exercise pain. especially if the pt is diabetic. Pt with hypothyroidism shouldn’t postpone emergency surgery. but not above 5. use combined alpha-beta blocker as they will not cause vasoconstriction. If INR is high in a pt on warfarin. 108. But DM is the single most important predictor of bad cardiovascular outcome. but is facing hypoglycemia after exercise in the morning. Oral thyroxine can be replaced after surgery. especially because his ETT wont function properly due to the edema related to the rhinitis. A pt with allergic rhinitis is going for scuba diving. the best therapy is supervised exercise program. like labetalol and carvedilol. Refractory hypoglycemia due to sulfonylurea is treated with sc octreotide.coronary angio. Warfarin is needed for atleast 3mo in patients with reversible risk factor. Also advise for snack before exercise. Pentoxifylline is a third choice.so send ABG and lactic acid levels. 112. not discontinued abruptly. and lifelong if repeated. post. formed by sphenopalatine artery. If this pt has MI. more precise is the study. or starts after exertion like sex. and if it fails. 2. A pt who is hypothermic or in shock or hepatic or renal failure can have severe hypocalcemia when being transfused blood. cerebral angiography. 125. carotid Doppler. If its effectiveness decreases.it delays the progression of disability. To find the true effect. Eg Rocky Mountain wood tick and American dog tick.the best next step is to do nasal cytology re! Eosinophils point to allergic rhinitis. do technetium brain perfusion scan as the second confirmatory test apart from the apnea test and caloric testing and CT. as the citrate cannot be metabolized by the liver and the kidney. 118. Otitis externa with lots of wax. induction chemotherapy f/by RT can be tried to preserve the Vc. Accuracy and . especially in elderly. 124.then add levodopa. Attributable risk percent indicates the excess risk in exposed population that is explained by the risk factor. BIOSTATISTICS 1. we have to calculate the adjusted rates. One study found high risk of colorectal ca in those who consume saturated fat (RR=4). point to vasomotor rhinitis ! 120. 3. A patients seems to be brain dead. It is a disease modifying drug. What percentage of colon ca can be attributed to fat consumption? ARP=41/4=75%. b. A pt comes with allergic rhinitis. or doesn’t imrove with appropriate medication. as these drugs are shown to be teratogenic. Suicide rates in physicians are found to be higher than in general public. or electrolyte anomaly or hypothermia.in such patients in whom the criteria is not met. MS patients who present initially with only sensory or optic symptoms have good prognosis than other presentation. Excision with CO2 laser can be done too.first step is to clean the wax and debris with cerumen wire loop or cotton swab! Irrigation only if TM is visible and intact. This is because of the confounding by high socioeconomic status. and evoked potential in median nerve! 121. a. Tighter the confidence interval. Tick borne paralysis after hiking in the woods can resemble GBS. 119. and if absent. then total laryngectomy should be done. Only then topical antibiotics. Start selegiline first in patients with mild symptoms of Parkinsonism. A pt with terminal cancer (and Cheyne Stokes) respiration shouldn’t be resuscitated. In t3. on grounds of futility.117. Amantadine and trihexiphenidyl are not the first choice. aka standardized rates. 123. 122. but has hypothyroidism. T1 laryngeal tumor is treated with RT mainly. Increasing the sample size increases the precision of the study. Other secondary tests that can be used are EEG. but it doesn’t affect the accuracy. Headache doesn’t need cT or MRI unless it is debilitating.dx is by finding tick after careful skin examination. to preserve the vocal cord. Pts on disease modifying drugs for MS like glatiramer or interferon should be using contraceptives. Hemilaryngectomy for T2 or those involving anterior commissure. Upright supine position is more effective than left lateral in preventing aspiration in coma. Unacceptability bias. 15. then its likelihood ration is 9. for eg one study showed that pts with AIDS only have mild symptoms.asking leading questions( you don’t like your doctor. Effect modification: effect of estrogen on the risk of DVT is modified by smoking. If a test has sensitivity of 0. Pygmalion effect. Respondent bias. Prevent by stratifying by severity.9. Can be avoided by double blind studies.10. 17.validity represent the measure of systematic bias. and hence mode>mean. 9. A distribution with 10.sample is not representative of the population. coz they know that smoking is harmful. do you?).medical students may not uncover their smoking status in a study.40. Prevent by measuring back end survival. 6.9 and specificity of 0. Lead time bias: false estimate of increased survival when the disease is uncovered by a screening test at an early stage. people included in the study are significantly different from those not in the study( Non-respondent bias). ie a positive result is 9 times more likely in a patient with disease than in patient without it. better the test performs at ruling out the disease. 13. Several Acid-Base scenarios that can be tested on USMLE Step 3 are A) Identifying the acid base disorder B) Identifying the etiology of acid-base imbalance in an Multiple choice question by elimination process of other choices based on the acid-base characterestic. Late look bias.experimenter’s expectations are communicated to subjects. as most of the entries are clustered on the left (low end). Eg predicting population prevalence by hospital studies (Berkesonian bias).when the outcome is obtained by the patient’s response and not by objective msmt. 4. Confounding 12.20. and the tail is on the right end. 14. Smaller the likelihood ratio. Loss to follow up will cause selection or sampling bias.patients fail to accurately recall the events in the past. Likelihood ratio for a negative test is given by (1-sensitivity)/specificity. C) Diagnosing mixed acid-base disorders by applying simple formulas D) Causes and treatment of increased anion gap acidosis E) Causes of Non-Gap Acidosis F) Renal tubular acidosis and identifying the etiology of the RTA from subtle .20.severe pts die and are not included in the study. Likelihood ratio is TP/FP rate. Preventioncontrol group/placebo 7. Hawthorne effect (subject’s behavior changes bcoz they are being studied). 10. Wider the CI.50 is positively skewed. Accuracy is when test-retest reliability is good. 8. How to prevent it? Randomisation 5. 16. Recall bias. Measurement bias.?? ACID BASE DISORDERS: Acid-Base disorders require understanding of the underlying pathophysiology as well as familiarity with some formulas. or sensitivity/(1-specificity). more accurate and less precise is the test. 11. Sampling bias.10. there is a compensatory increase in the chloride there by. Anion gap greater than 12 indicates increased anion gap metabolic acidosis. .Uremia (U) . Memorize the following formulas: 1) Anion gap = (Na+)-{(Cl-)+(Hco3-)} Normal gap is 4 to 12.GI vs.clues in the question stem.Diabetic Ketoacidosis ( D) . G) Osmolar gap and using this concept to identify the etiology in metabolic acidosis and in toxicology. you can further focus only on the relevant causes.Methanol (M) . This indicates no foreign substance but it is because of the loss of bicarbonate either through the GI tract ( Diarrhea) or Renal system ( RTA). renal insufficiency. hypoladosteronism.Recovery phase of DKA Concept of Urine Anion Gap Now. But there are two important causes of normal gap acidosis as you have already seen earlier . So. keeping the gap normal. let us say you have a metabolic acidosis and the gap is normal --> you know that this is normal anion gap acidosis. How do you differentiate between the two? For this.Ethylene Glycol (E) . small bowel fistulas. If there is acidosis ( low bicarb <>It is important to know the distinction because the causes of increased gap metabolic acidosis are different from non-gap acidosis. once you know whether the gap is increased or not. This indicates the presence of a foreign substance causing acid-base imbalance.Gastrointestinal loss of Bicarbonate : Diarrhea.Lactic acid (L) .Isoniazid ( I) .Renal causes : Renal tubular acidosis. you will need to know URINE ANION GAP Urine Anion Gap (UAG) = {(urineNa)+(urineK+)}-(urine Cl-) Normal values for UAG is -10 to +10. Causes of Increased Gap Acidosis ( MUDPILES) .Salicylic acid ( S) Causes of Non-Gap acidosis : The gap here is normal because when the hco3drops. These causes are: . urinary diversion . Renal . Propylene glycol ( P) . .Paraldehyde. 5 once serum HCO3 is less than 16 .e. it is important to know how to differentiate between different RTAs and their causes. you will be tested on the etiology of that RTA. hypercalciuria. Remember that Distal RTA can never acidify the urine so. this is most likely Type 4 ( because low aldosterone causes decreased renal excretion of acid and potsssium) If the potassium is normal or low. K citrate Type II RTA . urine pH >5.Hyporeninemic Hypoaldosteronism . then the RTA could be Type 1 (Distal) or Type II (Proximal).5. If urine Na+ is low ( which you would expect in dehydration. normal anion gap acidosis and normal urine pH . nephrocalcinosis and stones .Proximal RTA : .5. So. HIV and tubulo-interstitial disease .5.Urine pH > 5. Type 1 ( distal) Type 2 (proximal) Type 4 (hyporeninemic hypoaldosteronism) On the exam. you are most likely dealing with Proximal RTA.A logical approach here is to look at the urine Na+. diarrhea etc).Distal RTA : .negative UAG in bowel (GUT) causes. hyperglobinemia states and hereditary .Treatment: alkali i.5. urine anion gap tends to be more negative and points towards GI losses ( such as diarrhea) So. Acetozolamide. If you have difficulty remembering this.Failure to reabsorb filtered bicarbonate in the proximal tubule . if a MCQ gives a urine pH of less than 5. the Urine pH is never less than 5. but it will be less than 5. So. a UAG < -10 ( more negative gap) indicates a GI cause for Non Gap Acidosis where as a UAG > +10 indicates a Renal Tubular Acidosis.Causes: autoimmune diseases ( scleroderma). To differentiate between various RTAs.Causes: diabetes mellitus. Ifosfamide Lead. remember neGUTive . once you identify a metabolic acidosis and then identify an RTA. There are different types of RTA. Renal Tubular Acidosis ( RTA) A normal gap metabolic acidosis with positive urine anion gap ( UAG) could be due to RTA. hypokalemia.Present with normal anion gap acidosis. You will need to look at the urine pH to differentiate between Distal and Proximal RTA.Causes: Multiple myeloma.Presents with Hypokalemia and normal gap acidosis .Present with hyperkalemia. Type 1 RTA . copper Type IV RTA . If K+ is high in an RTA . first look at the serum potassium. cadmium. e. he has . you expect him to breathe fast and wash out the Co2 so as to maintain the pH in normal limits . you will need to be familiar with Winter's formula.. Logically.metabolic acidosis + metabolic alkalosis. then a patient has both nongap+increased gap acidosis. if it is 10 now. so... --> this means when your anion gap has increased by 8 your bicarb has fallen more than 8 i.where diarrhea causes non gap acidosis but shock can lead to lactic acidosis which increases the gap . that means your patient is washing out more C02 than expected ---meaning.that means some other factor apart from the factor responsible for increased gap acidosis is also contributing to acidosis here! . For example. if the serum bicarbonate (Hco3-) falls more than the change in the anion gap. you will need to know the concept of "Delta Gap" . if the anion gap is 20 --> you can say the change in the anion gap is 8 ( because normal anion gap is 12. then the patient has mixed disorder .s formula : Expected pCo2 = {1. A classic example is diarrhea with shock . ) In this scenario let us say if the MCQ gave serum hco3. You need to compare this expected Pco2 with the real value of Pco2 obtained on the arterial blood gases ( measured Pco2).this is called "Compensation". for calculation normal serum bicarb is taken as 24. if you are seeing a normal pH in a metabolic acidosis . Compensation brings the serum pH towards the normal but never makes it completely normal . 14). drop in the serum bicarb here is 14 ( remember. The expected Pco2 in the above formula is the one that is expected as a comprnsation if your patient has low bicarbonate or metabolic acidosis.5(Hco3-) +8} +/-2 If your patient has metabolic acidosis.as 10. things can co-exist! B) To understand if your patient has a mixed disorder of metabolic acidosis + respiratory acidosis or metabolic acidosis + respiratory alkalosis.this suggests co-existing increased anion-gap+normal-gap acidosis . the drop in bicarb is obviously.Identifying Mixed Acid-Base Disorder in Metabolic acidosis A) To understand if a patient has both increased anion gap acidosis and non-gap acidosis at the same time or metabolic acidosis + metabolic alkalosis at the same time.. Winter. If the serum bicarbonate falls less than the change in the anion gap. you can right away say that you are dealing with a Mixed disorder rather than a compensation alone.so. Pearls for answering questions on Mixed Disorders: A) If measured Pco2 is lower than the expected Pco2. by 14.. Delta gap is logically explained in the video clip below.so. eg: If Hc03 . eg : Salicylate Toxicity If Hc03 .35 to 7. Traditional Intravenos Pyelogram. The guidelines have been updated recently and there is an increasing trend towards CT Urogram even in asymptomatic hematuria ( please check the explaination below). Cystitis etc) E. Identifying benign hematuria and its approach B.Many get confused about the initial test for upper tract imaging becauses several sources state several different things. Students are stuck between the choices CT urogram vs.45 A. those at high risk for urological malignancy.is 16.is 16. If upper tract imaging for Asymptomatic Hematuria is chosen. However. the expected PCo2 as per Winter. B) If measured Pco2 is higher than expected Pco2. let us say your patients Pco2 on the arterial blood gas is 20 --> you can call this metabolic acidosis + respiratory alkalosis. Normal ph is 7. that means your patient is retaining Co2 which means he has a co-existent Respiratory acidosis along with metabolic acidosis ( eg: Cardiac arrest can cause such mixed acidosis because reduced respiratory drive causes CO2 retention leading to respiratory acidosis where as shock because of cardiac arrest causes lactic acidosis which is metabolic acidosis). However. All the recommendations are taken from AUA. normal anion gap is 12. the expected PCo2 as per Winter. D. Test of choice for symptomatic hematuria ( Urolithiasis. what is the initial test of choice? . let us say your patients Pco2 on the arterial blood gas is 44 --> you can call this metabolic acidosis + respiratory acidosis. Here is a summary on how to approach Hematuria on your exam as well as in your office. Hematuria: The following Q and A aaproach will help you understand the principal concepts of Hematuria. How do you test for Hematuria? . Evaluation of Asymptomatic Microscopic Hematuria in normal patient population vs. eg : Cardiac arrest NOTE. Correct interpretation of "Dipstick" Hematuria C.s formula should range between 30 to 34 ( see the above formula).s formula should range between 30 to 34 ( see the above formula). and normal bicarb is 24. Evaluation of Asymptomatic Hematuria F. American college of radiology guidelines on appropriate imaging choice.respiratory alkalosis co-existent with metabolic acidosis ( one example of such mixed disorder is Salicylate toxicity) . paprika) b) Drugs like Rifampin or Phenazopyridine derivatives ( remember these drugs only cause reddish urine but NOT a positive dipstick). it excludes abnormal hematuria ( false-negative results are unusual with dipstick testing). Any patient with gross hematuria should . Benign causes of "Red" urine but negative dipstick test . rhubarbs. the next step is to do urine microscopy. a dipstick hematuria should always be confirmed with urine microscopy! If dipstick is negative for blood.Understand the causes of painless hematuria are different from painful hematuria. dipstick positive for blood and urine microscopy shows RBCs. Gross Hematuria: Reddish or Tea colored urine. Painless hematuria is often from tumors of the urinary tract. In order to know if there is true hematuria. So.The initial office test that we use to detect hematuria is "Dipstick". Dipstick is highly sensitive but not specific. Occurs in : a) Ingestion of red pigmented foods ( eg: beets. Painful hematuria is often associated with urolithiasis ( renal calculi) or inflammation/ infection of the bladder ( Cystitis). False negatives are very rare but false positives are common.In some conditions. If the urine reveals RBCs then there is true hematuria. This is just reddish discoloration of urine. berries. if the CPK is also elevated it suggests that the etiology of blood on the dipstick is Rhabdomyolysis. it is important to determine the nature of hematuria so that you can limit investigations to the real and pathological hematurias. you may see a red urine resembling "Gross hematuria" but dipstick is negative for blood. So. So. please do not automatically assume that everything that stains as "blood" on a dipstick is an RBC.either myoglobinuria ( rhabdomyolysis) or hemoglobinuria. bladder cancer or glomerulonephritis. Dipstick detects "BLOOD" but it does not say whether this "blood" is an RBC or a Pigment. This should not be called hematuria. c) Diseases such as "Porphyria" Causes of a Positive Dipstick but no true Hematuria: Here Dipstick stains positive for blood but no RBCs in the urine a) Myoglobinuria ( Rhabdomyolysis. if the dipstick reads "blood" and if the urine did not reveal RBCs on microscopy then you are dealing with a pigment . Black water fever) can stain as "Blood" on dipstick. At this point. What will be the approach to identify the source of Hematuria? . However. vigorous exercise) b) Hemoglobinuria ( Intravascular hemolysis) Is the Hematuria associated with pain? .The work up for hematuria may involve invasive and expensive approaches. Remember that pigments such as myoglobin ( as in rhabdomyolysis) or Hemoglobin ( as in hemoglobinuria. patients may be observed for resolution however. So. Minimal microhematuria ( i. Repeat urinalyses to establish whether significant hematuria is present must be done within 3 to 6 months of the initial test. E) Benign Prostatic Hypertrophy F) Prostatitis . Even in this setting of infection. Microscopic Hematuria is often intermittent and most causes are usually benign.treat it with antibiotics and repeat urinalysis after the infection has cleared. Runner's hematuria or March hematuria is another benign condition that presents as gross hematuria after a severe physical activity. if the hematuria is persistent or if the patient has any risk factors for having a urological malignancy. it is important to define a significant microscopic hematuria that requires further investigations. In such cases. one or 2 rbcs per HPF ) in asymptomatic young adults does not require any evaluation. if there are risk factors for urological malignancy the patient should still be referred for further evaluation ( since hematuria from cancer can also be intermittent). urine looks normal. must be referred to a urologist Microscopic Hematuria: Grossly. ( many studies have indicated that small amounts of blood may be released into the urine of persons with no detectable pathology in the urinary tracts) In patients with risk factors for having a urological malignancy. Some benign causes of Microhematuria : A) Exercise B) Sexual activity C) Menstruation D) UTI If UTI is present ( symptoms and dipstick for leucoesterase are clues that point towards infection) . If a woman has gross hematuria but the urine dipstick also reveals leucoesterase or nitrite or if the woman has symptoms of UTI ( dysuria etc) or if the cultures are growing bacteria. Microhematuria is defined as three or more red blood cells per high-power microscopic field (RBCs/HPF) in two out of three properly collected and prepared specimens. a microhematuria even in one or more samples must be considered significant and be evaluated. Dipstick positive for blood and urine microscopy reveals RBCs.e. this can be treated as UTI ( cystitis) with antibiotics with out referring for further evaluation.always be referred for urological evaluation unless this is secondary to an infection. further approach should be defined based on the patient's risk profile.Presence of other findings on the microscopic urinalysis such as RBC casts or Dysmorphic RBCs or proteinuria or the labs revealing elevated serum creatinine suggests a the hematuria is originating from the kidney/ glomerulus itself ( eg: Glomerulonephritis. Heavy somkers 2. Asymptomatic MicroHematuria : Patients without the classic flank pain of urolithiasis should be evaluated extensively. Once benign causes such as infection and the kidney ( glomerular) origin are ruled out. carefully look for other charecterestics of urinalysis . B) If the patient is a high risk of having a urological malignancy. Previous use of Cyclophosphamide ( increases the risk of bladder cancer where as ongoing use often causes hemorrhagic cystitis as a adverse effect) What imaging studies should be done as initial step in evaluating . ultrasound can be performed to avoid radiation exposure. History of pelvic irradiation 5. the next step in evaluating hematuria is referral to a nephrologist ( not urologist) and a renal biopsy.Now. History of Gross hematuria 4. A) For patients with low risk of urological disease. If infection is absent or if there is a pain similar to renal colic ( classic flank pain) . In pregnant women.consider renal stones as the cause of Hematuria. Sensitivity of urine cytology is only 48% but remember that if it is positive it is highly specific for urological cancer ( 94% specificity) Risk factors for urological cancer ( bladder ca): 1. Analgesic abuse 7. a less extensive work-up may be appropriate ( First do upper tract imaging and if this is negative. Urine cytology should be obtained in all patients with asymptomatic hematuria since it is an easy and non invasive step. IgA nephropathy). Age > 40 years 6. extensive work-up is needed ( see the risk factors below) --> Upper tract imaging + cystoscopy+ urine cytology all are needed. Further Approach to Microscopic Hematuria Symptomatic Hematuria: In painful hematuria --> first rule out infection and renal colic. In such cases. Occupational exposure to aniline dyes 3. add urine cytology+cystoscopy). Presence of irritative voiding symptoms 8. The best initial step in evaluating the cause of painful hematuria that is not explained by UTI is Non-Contrast CT scan (Spiral CT) ( test of choice for imaging renal calculi). Students often confuse this with other choices such as ultrasound and Intravenos pyelogram.Asymptomatic Hematuria? For both high risk and low risk patients. IVP and ultrasound are good to image the urinary tract but they do not completely assess the renal parenchyma. If you order an IVP. upper tract imaging must be performed as an initial step. you may eventually need to order a CT urogram again to image the parenchyma better . . non-contrast CT followed by contrast CT imaging from kidney to bladder) is best recommended initial test now to evaluate asymptomatic hematuria. For upper tract imaging. in order to avoid ordering multiple studies.so. CT urography is less affected by overlying bowel gas and is more sensitive for detecting small tumors and calculi than the IVP. IVP used to be the best preferred test for upper tract imaging in hematuria evaluation but now CT urogram is becoming the preferred method. CT urography ( i. CT urogram is recommended as the best initial test.e.