Asters Notes I

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USMLE step 3 CCS cases list

• Step 3 CCS cases part 1

• Step 3 CCS cases part 2

• Unorganized list of CCS cases

Other step 3 CCS resources

• Asters Notes I

• Asters Notes II

• Asters Notes III

Asters Notes for USMLE These notes are a concise and highly abbreviated notes believed to be a summary of a popular Qbank. They are good for both Steps 2 and 3 of USMLE step.

USMLE Wiki

• Usmle Step1 | Usmle Step2 | Usmle Step3

• List of Cases > CSA&CS | Step3CCS

Popular: Usmle Step 3 CCS | Usmle Step 3 CCS cases part 2 - over 70 solved cases

Asters Notes > Asters Notes I | Asters Notes II | Asters Notes III

Other resources: Usmle Q Banks | Residency Wiki

List of patient cases

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Recommended Study Material for Step3

Textbooks

1.Crush the Boards 5 days

2.Swansons Family Practice 15-20 days

3.Ethics in Medicine (U of W site) 1 day

4.Biostatistics 2 days

5.Blueprints in OBG 2 days

6.Blueprints in Peds 2 days

7.Compass Surgery & Trauma Notes 1 day

CCS

1.USMLE 2003 CD (Software Tutorial + Sample Cases)

2.KAPLAN CCS TUTORIAL

3.VETANS LIST OF CCS CASES

4.list of recent cases

MCQs

1.Swansons Family Practice

2.USMLE 2003 CD – sample MCQs

3.Kaplan Step3 CD – 200 sample MCQs

4.NMS Review – 750 questions

5.Kaplan Qbank for Step

6.www.familypractice.com.

Asters Notes 2 of 111

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Critical aortic stenosis : virtually zero chance of successful CPR.

Gout with h/o peptic ulcer disease: Rx of choice – colchicine (not indomethacin)

pseudocyst

<6w: external rainage >6w: internal drainage

St. Johns Wort is a herbal medication with some efficacy in treatment of depression

(no FDA Approval)

Vaginal d/c pH < 4.5 : Consider Candida

ph > 4.5 : Consider Bacterial Vaginosis

Maternal Smoking / Alcohol: Symm IUGR

Maternal HTN: Symm IUGR

Physiological Jaundice / Exaggerated Physio / Breast Milk Jaundice: no risk of

Kernicterus

Kernicterus occurs @ 1% x Birth Wt. (in grams)Bilirubin Level

PKU screen can be negative at 48hrs of life

(requires a repeat screen after 48 hrs. to confirm)

Maternal SLE: Congenital Lupus & 3rd degree Ht. Block (Anti-Ro)

Respiratory Failure: <60 mmHg O2 >60mHg CO2

Maternal Solvent Abuse: assoc. with nail hypoplasia

PDA closure achieved by Indomethacin

NEC: Pneumatosis Intestinalis

Neonatal CMV: confirm by isolation of virus from urine

Transplacental spread is highest in primary HSV,.

Asters Notes 3 of 111

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very low in recurrent HSV

Breast Milk (cf. Cows Milk)

high carboydrate

low protein

low iron, but more bioavailable

inadequate Vit. D, Vit. K

supplement Iron @ > 6 m in exclusively breast fed

Infants of Diabetic Mothers with proteinuria, hematuria:

? Renal Vein Thrombosis (ass. with maternal DM)

Transfusion Reactions:

Febrile Reaction: WBCs in Donor Blood (Acetaminophen)

Anaphylaxis: Proteins in donor blood (Antihistaminics, SQ Epinephrine)

Hemolysis: Mismatch (Hydration & Diuresis)

Infantile Colic: Wessel Criteria

3 m child; 3 hrs/day; >3 days/week; > 3 wks. duration

ADHD:

1.Methylphenidate / Dextroamph / Mg Pemoline

2.TCA / SSRI (second line)

3.Dont use Benzodiazepines

4.consider “drug holiday” on weekends

ACEIs contraindicated in preg.

HyperTG Rx: Gemfibrozil

Hypercholesterolemia (Drug Rx):

>190: 0-1 risk factors

>160: >= 2 risk factors

>130: CAD equivalent / CAD

if > 15% reduction reqd: “statins”

if < 15% reduction reqd: (Low HDL) Niacin

(normal HDL) Cholestyramine

Obesity in Children Triceps Skin Fold Thickness

OCP induced hepatic adenomas : tendency to rupture

(Surgical resection).

Asters Notes 4 of 111

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ELISA â-hCG (Urine) is (+) 14 d post conception

RIA â-hCG (Serum) is (+) 14 d post conception

Symptomatic Gallstones: Lap Cholecstectomy

Ca. Tail of Pancreas: Poorest Prognosis

Lobular Ca in situ is not premalignant

Digitalis Toxicity is enhanced by:

HYPERcalcemia, HYPOkalemia, HYPOmagnesemia

Infant of HIV + mother (steps to derease transmission)

1.Intrapartum I/V AZT

2.LSCS delivery

3.AZT prophylaxis to child x 6 m

4.No breastfeeding

5.HIV test at 6m - 12 m

Finkelstein Test: Chr. Stenosing Tenosynovitis (deQuervains Disease)

Rx for Chlamydial Ophthalmia: ORAL Erythromycin

(to prevent chlamydial pneumonia)

Commonest Hernia: Indirect Inguinal Hernia

T4 / RTU / FT4-I move up or down together unless there is a derangement in TBG

CPK-MM is increased in hypothyroidism (proximal myopathy)

Fetal Weight Determination:

HC, BPD, AC, FL

Fetal Age Determination:

Transcerebellar Diameter

RA: associated with atlanto-axial subluxation

(“drop” attacks)

PTE: (A-a) O2 gradient is always abnormal

even if PaO2 is normalhighly sensitive.

Asters Notes 5 of 111

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Fever 24-48 hrs. Postop: #1 Atelectasis

(D)EH / (B)CP / BR

Pneumococcal Vaccination is required in CSF Leak

Nephrotic Syndrome: Fatty Casts

Pyelonephritis: WBC Casts

Cystitis: WBCs

GN (PSGN): RBC Casts

CRF: Broad Casts

Cold Antibody: IgM - Inravascualr Hemolysis

Warm Antibody: IgG - Extravascular Hemolysis

Addisons: ACTH Simulation Test

Cushings: Dexamethasone Suppresion Test

Conns: Salt Loading Response

Diabetes Insipidus: Water Deprivation Test

Hemophilia A: aPTT increased, BT normal

vWD: aPTT increased; BT increased

(Ristocetin Cofactor Assay)

Factor VII def.: PT increased, BT normal

Aspirin: prolonged BT, no effect on CT

spiking fever despite antibiotics, 1 wk. postLSCS

?Septic Pelvic Thrombophlebitis (Mx: i/v Heparin)

Mx of Myesthenia Gravis: PYRIDOSTIGMINE

(not PHYSOSTIGMINE cuz of CNS effects)

vWD & Aortic Stenosis: ass. with Angiodysplasia

Alcoholic Cirrhosis: â-gamma bridge

d-xylose test: abnormal in small bowel malabsorption, normal in pancreatic disease

screening for malabsorption: 24 hour fecal fat

? Penicillamine increases survival in Scleroderma.

Asters Notes 6 of 111

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Congenital Syphilis may be associated with severe osteochondritis. Child may refuse to

move limbs (Pseudoparalysis of PARROT)

Abciximab: decreases restenosis rates post-PTCA

PTCA: no effect on morbidity or mortality

Diabetes Mellitus : assocation with hyperTG

First line management of newly diagnosed diabetic: DIET (not drugs)

DM+HTN: ACEIs

Hypercalcemia: I/V Hydration + Loop Diuretics

Obesity: BMI>27g/m2 or 120% of ideal body weight

Caloric Intake increase:

300 kCal (Pregnancy); 550 kCal (Lactation)

Pulmonary Embolism: i/v Heparin mandatory, fibrinolysis

COPD excacerbation: H.flu, Pneumo., Moraxella

Long term stabilization of exercize induced asthma: Salmetriol & Zafirlukast

Severe acute asthma: < 50% best PEFR

Moderate acute attack: 60-80% best PEFR

Mild acute attack: >80% best PEFR

No 1 community acq. pneumonia: S. pneumoniae Ideal sputum sample: <10 epi./HPF & many PMNs

GERD: Transient relaxation of LES

Always perform an EKG for any adult with chest pain (esp. with risk factors for CAD)

Esophageal Ca.: most common type is AdenoCa. (Barretts Esophagus)

Sulfasalazine:

effective in UC & Crohns colitis / ileocolitis.

Asters Notes 7 of 111

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(not small-bowel Crohns)

Celiac Sprue:

villous atrophy & reactive crypt hyperplasia

Dermatitis Herpetiformis (Mx: Dapsone)

H. pylori association:

DUODENAL > GASTRIC

Serology (Past or Present Infection)

Fecal Antigen Detection (False- with PPI)

Urease Breath Test (False- with PPI)

Triple Therapy, esp. for non-NSAID ass. ulcers

1 st episode of PUD: emperical therapy (H2 -> PPI)

Recurrent PUD: H. pylori eradication

Infectious mononucleosis

EBV, Sore Throat, LN, Splenomegaly

Atypical Lymphocytes (also in CMV)

Monospot (+): positivity wanes with time

Serology: increased Anti-EA; increased Anti-VCA IgM

â blockers decrease variceal bleed in portal HTN

Ascites: Salt Restriction, Diuretic: Spironolactone

narcotic analgesic switching

use 1/5 equianalgesic dose

Graves: Rx – Radioactive Iodine

children & pregnant: Propylthiouracil

WHO analgesic stepladder

1 st LINE

Aspirin, Acetaminophen, NSAIDs

2 nd LINE

Hydrocodone

Codeine

3 rd LINE.

Asters Notes 8 of 111

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Morphine Sulfate

Hydromorphone

Fentanyl

Methadone

Ca. ass. cachexia & anorexia: Prednisone, Magestrol

Agitated Depression Rx: sedating TCA (not SSRI)

Rx of choice for narcotic induced costipation: Lactulose

Nephropathy Incidence: IDDM (40%) > NIDDM (20%)

but #1 cause of Diab. Nephropathy is NIDDM

(cuz NIDDM prevalence is much higher than IDDM)

Prevalence Inreases: PPV of test increases

(NPV of negative test decreases)

Screening for GDM

Oral 50g Glucose: Bl. Glu. @ 1 hr. > 140mg% (+)

F/U with Oral 100g Glu. 3 hour GTT

values > 105 (0h) / 190 (1h) / 165 (2h) / 145 (3h)

guide lines have changed to=

Screen with 50-gram glucose challenge test: 1-hour plasma glucose >140 mg/dL positive; >120 mg/dL suspected

F/U with 100gm oral GTT, 100 gram oral glucose tolerance test after 8 to 10 hours overnight fast: Fasting plasma venous Glucose >95 mg/dL, 1 hour >180 mg/dL, 2 hour >155 mg/dL, 3 hour >140 mg/dL; two abnormal values required for diagnosis; if one abnormal, consider self-monitored blood glucose for 7 days; if average fasting blood glucose >95 mg/dL or average 2-hour post-meal >120 mg/dL, re-evaluate for gestational diabetes mellitus.

Obese Diabetic: Diet/Wt.Loss -> Metformin

(ass. With Lactic Acidosis)

Insulin in DM

Initial dose: 15-20 U

2/3 of total : AM dose (2/3 regular, 1/3 intermediate)

1/3 of total : PM dose (2/3 regular, 1/3 intermediate)

Conns syndrome Mx

Adenoma: Sx resection

B/L hyperplasia: Spironolactone

"cold nodules]] on thyroid scan: ? Malignant

1 Thyroid Study: Serum TSH (yields max. info.) Multiple Sclerosis:

2 attacks more than 24 hours apart

> 1 area of damage (Oligodendrocyte damage)

m/c variant: relapsing-remitting type.

Asters Notes 9 of 111

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CSF mononuclear pleocytosis, CSF IgG increase

Oligoclonal Banding of CSF IgG

Myelin Breakdown Metabolites

Headache on stopping NSAIDs:

Analgesic withdrawl headache

Jaw Claudication & Scalp Tenderness: GCA

ESR increased

Visual Loss

Start Glucocorticoids without waiting for Bx results

Aspirin in febrile children: Reyes Syndrome

Continue anticonvulsants till seizure free for 4 years

Menorrhagia with hemodynamic compromise:

i/v conjugated estrogen

normal Hb in women: 12.0

normal Hb in pregnancy: 11.0 (1 st & 3 rd trimester)

10.5 (2 nd trimester)

m/c variant of Hodgkins : Nodular Sclerosis

Hodgkins: Supraclav. node

NHL: epitrochlear node / likely to be extranodal

Osteoarthritis

Joint space narrowing

sclerosis

subchonral cysts

osteophytes (mere osteophytes are not OA)

OA: Isometric exercizes are better than isotonic

Chronic Fatigue Syndrome : T cell activation -> CNS effect of cytokines

nonREM sleep anomaly

(also seen in Fibromyalgia)

Gout prophylaxis: required for recurrent attacks

(not indicated after first attack).

Asters Notes 10 of 111

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Strep Sore Throat Rx: can prevent Rh. Fever

NOT PSGN!!! [ PSGN is caused by both pyoderma and sorethroat streptococcal strains , so the preceding statement is not valid. Yes there is no need for antistreptococcal prophylaxis in children with history of PSGN]

Potassium sparing diuretics can cause severe hyperkalemia in CRF

SULINDAC: NSAID with no nephrotoxicity

Asymp. Bacteruria in Pregnancy : Treat with antibioticsAmoxycillin is safe (high risk of

pyelonephritis)

Give Chlamydia Rx in Gonorrhea

-> i/m Ceftriaxone + PO Doxycycline

Biophysical Profile : TBMAN

Tone, Body Movements, Breathing, AFI, NST

Early Deceleration: Head Compression

Variable Deceleration: Cord Compression

Late Deceleration: Uteoplacental insufficiency

GU+NGU: 1 g Azithromycin stat

ACNE Mx

Benzoyl Peroxide

Topical Tretinoin

Topical Antibiotics

Systemic Antibiotics

Systemic Isotretinoin

Acne Rosacea Mx

Topical Metronidazole -> Systemic Antibiotic

[Benzoyl peroxide & Tretinoin can aggravate rosacea]

Female Infertility (Hormonal)

Hyper-estrogenic: CLOMIPHENE CITRATE

Hyper-PRL: Bromocriptine (PIH)

Narcotic Dependence: Methadone replacement.

Asters Notes 11 of 111

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External Hemorrhoids: Excision with elliptical incision

Internal Hemorrhoids: Banding

2 nd trimester eclampsia: Molar pregnancy

Molar pregnancy: hyperemesis gravidarum

Most important obstetric measurement:

Diagonal Conjugate (at least 11.5 cm)

Amniotomy: perform after enagement of fetal head

Rx of HTN in preg.: á-methyldopa, hydralazine

BP reduction goal in pre-eclampsia:

Lower diastolic to 90-100 mmHg (lowering to 80mmHg could jeopardize placental

perfusion)

1 maternal disease causing IUGR: Maternal HTN

1 cause for 1 st tri. abortions: Chromosomal ab(n) Postpartum Blues: < 2 weeks

Postpartum Depression: > 2 weeks

Major Depression: >= 5 symptoms for > 2 weeks

Mania: >= 3 symptoms for > 1 week

Primary Type 1 Osteoporosis: # vertebrae

Primary Type 2 Osteoporosis: # neck femur

HRT

Progesterone required only if uterus is present

Estrogen: dec. LDL, inc. HDL

Progesterone: inc. LDL, dec. HDL

Estrogens cardioprotective effects of estrogen are not mediated through cholesterol.

Estrogen promotes EDRF synth. In vascular endothelium

Repeat Pap: if reqd., no sooner than 6 weeks

Hormonal contraception if h/o DVT/PE (+):

Norplant & DMPA (Progesterone based), not OCPs.

Asters Notes 12 of 111

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Jarisch Herxheimer reaction: Syphilis Rx (chills)

HPV: condyloma acuminata

HPV 18: fastest progression to Ca. Cx

Acute Epididymitis:

1 cause: Chlamydia trachomatis

1 bacterial cause: E. coli (m/c in >40 y age) Depression: Cognitive Psychotherapy + SSRI

Drug Rx of Bipolar Disorder:

Li, Carbamazepine, Valproate,

Gabapentin, Lamotrigine (ass. With SJS)

Lithium: Hypothyroidism, NDI

Atypical Antipsychotics are especially useful for negative symptoms of Schizophrenia

Drug Dependence: WITHDRAWL & TOLERANCE

Mx of DTs

Intermediate acting BZDs (Diazepam)

IV saline (no glucose containing fluids)

IV thiamine

BZD in Hepatic Enceph.: Oxazepam

Fluid Deficit in Burns = 4mL/kg x %BSA (Parkland Formula)

1 st degree:

2 nd degree: clean, sulfadizine, nonadhesive dressing

3 rd degree: refer to plastic surgeon for escharotomy

Heat Cramps: ORS

Heat Exhaustion: IV Fluids

Heat Stroke: neurological dysfunction & absence of sweating (may not be

dehydrated)

Hypothemia: Osborne (J) wave on EKG

Mild: (32-35 C) Passive External Rewarming.

Asters Notes 13 of 111

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Moderate: (27-32 C) Active External Rewarming

Severe: (< 27C) Active Core Rewarming

Depression: Cognitive Psychotherapy

Anxiety Dsorders: Behavioral Psychotherapy

Adjustment Disorder: Supportive Psychotherapy

Social phobia: bea blockers & assertive training

Specific phobia: systematic desensitization

Panic: SSRI & Alprazolam (short T1/2)

Na Lactate can mimic a panic attack

use alprazolam for panic, not GAD

may be associated with rebound anxiety

OCD: (associated with anxiety) SSRI

OC PD: insight-oriented psychotherapy

Somatization Disorder:

4 Pain, 2 GI, 1 sexual symptoms

(associated with abuse in childhood)

Depression: SSRI + Cognitive Psychotherapy

Atypical depression: MAOIs are first-line

Generalized Anxiety: Buspirone (selective anxiolytic)

Sexual Dysfunction

Young Males: Premature Ejaculation

(Mx: start and stop penile stimulation, not SSRIs)

Older Males: #1 Erectile Dysfunction

Females: #1 Hypoactive Sexual Desire

Young males with sexual dysfunction: Psychogenic

Older males with sexual dysfunction: Organic

The PATIENT is the head of the healthcare team

ADHD associated with:

Conduct Disorder and Oppositional Defiant Disorder

(also with Tourettes Syndrome).

Asters Notes 14 of 111

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ADHD with (+) h/o or F/H tics

DO NOT USE STIMULANTS

Phototherapy isomerizes bilirubin to a state that can be excreted in urine & bile

unchanged. (does not enhance conjugation)

Water Supply > 1 ppm fluoride: No supplementation

Retrocecal Appendicitis: poorly localized pain

Appendicitis

1 cause : lymphoid hyperplasia Mx: Surgery

Yersnia enterocolitis can mimic appendicitis

Painkillers & antibiotics can alter presentation

Preg. With appendicitis: atypical location of pain

Elderly: higher chances of perforation

Appendiceal abscess: Delay surgical intervention

If on lap., some other cause is found – do an appendectomy anyway, to prevent

confusion in future

Oral Dissolution of Gallstones

URSODIOL

single floating cholesterol stones in functioning g.b.

Asymp. Gallstones: DO NOTHING

Symptomatic Gallstones: Lap. Cholecystectomy

1 complication of Lap Chole: Bile Duct Injury Choledocholithiasis: ERCP with sphincterotomy

idications of ERCP:

small stones

dilated CBD

palpable stones in CBD

jaundice

Plantar Warts: Cryosurgery

Venereal Warts: Podophyllin (not in pregnancy)

Cullens Sign: periumbilical discoloration

Grey Turner Sign: flank discoloration.

Asters Notes 15 of 111

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1 radiological signs in pancreatic disease acute pancreatitis: sentinel bowel loop

chronic pancreatitis: pancreatic calcification

Crucifer intake reduces Colon Ca.

Ca. risk of polyps is dependent on villous content

1 risk factor for pancreatic ca. : smoking

1 cause for chronic low back pain: idiopathic bed rest has no role

no need for imaging (X-Ray / CT / MRI)

prescribe an exercize program (can temporarily excacerbate symptoms)

Acetohydroxamic acid: urease inhibitor

(acidifies urine in patients with struvite stones)

HTN with BPH: Terazocin (á blocker)

Vestibular Neuronitis: NO hearing loss

Menieres Diseass: Tinnitus, Vertigo, Hearing Loss

Ac. Labrynthitis: Ac Hearing Loss, Nystagmus, Vertigo

Acute Bacterial Sinusitis:

Pneumococcus

no role of imaging (Dx by h/o & PE)

? antibiotics – PO Amox x 7-10 days

Antidep. of choice in depresion in elderly: TCA (Nortryptaline) - minimal side effects cf.

other TCAs

Alzheimers Rx: DONEPEZIL (OD) & Tacrine Cholinesterase Inhibitors

Polymyalgia Rheumatica: Oral Steroids

Giant Cell Arthritis : I/V Seroids

Elderly black HTN: CCB & Thiazide Diuretics

Parkinsons with Tremor has a better prognosis than pts. with symptoms of

Postural Instability & Gait Disturbance.

Asters Notes 16 of 111

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Perform Postvoid Residual Urine measurement on every elderly patient with Urinary

incontinence to r/o Urinary Retention

Alzheimers & Parkinsons cause Detrusor Hyperreflexia : URGE INCONTINENCE

@ high risk for pressure ulcers: reposition q2h

low-risk patients: reposition q6h

USPSTF

prenatal ultrasound not mandatory

? role of PSA & DRE in screening of asymptomatic individuals

Hyperlipidemia screening:

NONFASTING SERUM CHOLESTEROL

if elevated: do a FASTING LIPID PROFILE

á-FP estimation at 5-17 weeks to r/o NTD

increased: ultrasound (can detect 80% anomalies)

decreased: does not necessarily indicate Downs

QUIT SMOKING before starting Nicotine replacement

Transdermal Nicotine Replacement:

21mg -> 14mg -> 7mg

[Pts. with CAD, start with 14 mg.]]

[Nicotine is vasoconstrictor, risk of MI]]

Pesticide exposure has been linked to Prostate Cancer

HTN increases the risk of stoke > CAD

2% reduction in CAD for every 1% decrease in serum cholesterol

Cancer mortality is increasing

stroke/CAD mortality is decreasing

HAART drug interactions

“statins”, Antihistaminics, Ergot alkaloids

AIDS in infants: better prognosis cf. adults

d/o/c for malaria prophylaxis: MEFLOQUIN

once-a-week (1 w before travel & 6 weeks after).

Asters Notes 17 of 111

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Influenze A: adults

Influenza B: children

Influenza epidemics: Influenza A

Influenza vaccine: A & B

Amantidine protects only against “A”

(Rimantidine preferred in patients with renal failure)

Oseltamivir (Tamiflu ® ) protects against both “A” & “B”

In the United States, four antiviral medications (amantadine, rimantadine, oseltamivir, and zanamivir) are approved for treatment of influenza. When used for treatment within the first two days of illness, all four antiviral medications are similarly effective in reducing the duration of illness by one or two days. Only three antiviral medications (amantadine, rimantadine, and oseltamivir) are approved for chemoprophylaxis of influenza. Zanamavir is not approved for chemoprophylaxis.

Annual influenza vaccination for age > 65 y

1 cause of travelers diarrhea: ETEC

Cardiac Arrest: 1 st step – initiate 911 call Cardiac Arrest in Children: Assess, 1 min. on CPR Initiate 911 call

Mx of Respiratory Acidosis: Increase Ventilation

(Use of NaHCO3 is not wise to Mx Respi. Acidosis)

1-person CPR: 15:2

2-person CPR: 5:1

symptom to treatment time: <60 minutes

ED to needle time: <30 minutes

A. Fib.: (Unstable): Sync. Cardioversion

V. Fib.: Async. Defib.[[200 -> 300 -> 360 mJ]]

SVT: Vagal Maneuvres -> Adenosine

V.Tac.: Lidocaine, Procainamide, Bretylium

V.Tac.: (Unstable): Cardiovert

V. Fib:

Defibrillate,

Epinephrine

Defibriallate again

Lidocaine

2 nd line antiarrhythmic

Asystole:

Immediate transcutaneous pacing

Epinephrine -> Atropine -> Consider Bicarbonate.

Asters Notes 18 of 111

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Use intra-osseous route in age < 6 years

DKA

Insulin 0.1U/kg/hr + NS

Add K +

when Blood Glucose approaches 250, shift to 5%D

m/c cause of abdo. Pain in elderly: CONSTIPATION

Use activated charcoal with 70% sorbitol in poisonings

Cuffed ETT for age > 7yrs

1 Poisoning: OTC Analgesics Naloxone: Short acting

Naltrexone: Long acting

(used in rehab programs, not acute overdose)

Urticaria: Subcutaneous edema

Angioedema: Mucosal edema

Colles #: Dinner Fork abnormality

(Splint in Neutral position)

Suspected Scaphoid # & X-Ray (-)

APPLY THUMB SPICA CAST anyway

Ankle Inversion Injury

- Lateral Ligament Sprain

- Anterior Talofibular Ligament

McMurray Test:

Meniscal Tear

Joint Line Tenderness

Lachman Test:

Anterior Cruciate Ligament Injury

Dislocation of Shoulder:

Anterior.

Asters Notes 19 of 111

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associated with axiallry artery injury

NBT (-) : CGD (SXR) -> IFN-gamma

Prostatic Mets.: BONE SCAN > SKELETAL SURVEY

MYELOMA: SKELETAL SURVEY

(Bone Scan is useless, does not detect lytic lesions)

1 cause of death in myeloma: Pulmonary or UTI Duration of Maintenance Pharmacotherapy for depression (even for single episode)

should be at least 6 months.

Desert Rheumatism: C immitis

Mx – Conservative

Rx required only for dissemination / lung lesions

1 Kidney stones: Calcium Oxalate (radiopaque) [Square Crystals]]

URIC ACID stones are radiolucent

CYSTINE crystals in urine are always pathological

Crohns: associated with gallstones & kidney stones

[increased absorption of oxalates from the gut]]

1 complicatin of chickenpox: 2º skin infection Postop Fever @ 24 hours: atelectasis

Postop Fever @ 5-10 days: wound infection

(early wound infection: clostridia / pesudomonas)

Neonatal Meningitis: S. agalactiae (Gp B Strep)

C1 esterase inhibitor deficiency:

hereditary angiodema

depleted C4 levels

Mx: FFP/e-ACA/Stanozolol

Maintain: ANDROGENS (inc. synthesis)

Suspect endometrial cancer:

gynecological referral for enometrial biopsy.

Asters Notes 20 of 111

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Pap misses 60% of endometrial Ca.

Cryoprecipitate: replaces Fibrinogen & Factor VIII

FFP: replaces all coagulation factors

Reversal of warfarin action: FFP (chronic: Vit. K)

Reversal of heparin action: Protamine

sterile subdural effusions: H. influenzae meningitis

pneumonia with effusion / empyema: Staph. aureus

Lipase is more sensitive and specific than amylase

Serum amylase elevated for 2-4 days

Urinary amylase elevated for 7-10 days

1 cause of sensorineural hearing loss: PRESBYACUSIS

1 cause of conductive hearing loss: OTOSCLEROSIS

osteomyelitis after foot puncture wound:

Pseudomonas

Acromegaly

Inability to supress glucose

no stimulation of GH with levodopa

paradoxical increase of GH with TRH

1 intracranial mass lesion: METASTASIS

1 brain malignancy (adult): Glioblastoma multiforme

1 brain malignancy (child): Astrocytoma adult: supratentorial

children: infratentorial (#1 supratentorial in children is craniopharyngoma)

SVC Syndrome: Think Bronchogenic Ca.

AML with DIC: M3 variant of AML

AML with gum chloromas: M5 variant of AML

Hairy Cell Leukemia: TRAP+ (Rx: Cladribine).

Asters Notes 21 of 111

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Port Wine Stain: Sturge Weber Syndrome

CSF has a higher Cl - content compared to plasma

Rocky Mountain Spotted Fever:

Dx – Indirect IF

Rx – DOXYCYCLINE (< 8y: Chloramphenicol)

Neurofibromatosis:

> 6 cafe au lait spots[[or 1 spot > 5cm]]

Tuberous Sclerosis:

Cardiac Rhabdomyomas

Angiomyolipoma of Kidney

Subungal Fibromas

Decreased Haptoglobin:

Intravascular Hemolysis

Very Severe Extravascular Hemolysis

OSTEOPOROSIS: Serum Ca ++ & PO 4 3- are normal

Testicular Torsion: affected testis lies horizontally

Mx – Surgical Fixation of BOTH Testes

Torsion of Testicular Appendix: BLUE DOT

Mx – Exploration of other scrotum not required

m/c Thyroid Malignancy: Papillary Ca. Thyroid

MEN Syndrome: Medullary Syndrome

Hematogenous Spread: Follicular Ca.

Patella dislocates laterally

Mx PTSD with Group Psychotherapy

(not BZD : high risk of BZD abuse)

Fever without Focus:

1 cause: Occult Bacteremia due to Pneumococcus

due to Otitis Media.

Asters Notes 22 of 111

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Signs of Occult Bacteremia:

Temp > 40C

WBC < 5000 or WBC > 15000

Acute Otitis Media: Strep. pneumoniae (Amoxicillin)

1 Pediatric Gastroenteritis: Rotavirus

1 Pediatric (Bacterial) Gastroenteritis: C. jejuni Recurrent Otitis Media:

definition: >3 in 6 months or >4 in 1 year

Amox prophylaxis -> Myringotomy & Tubes

Indications of Tonsillectomy:

1 episode of Quinsy (Peritonsillar abscess)

> 7 proven streptococcal pharyngitis

airway obstruction

decreases recurrent sore throat, not URI

Suspected Strep Sore Throat:

Sore throat, fever, cervical LN, tonsillar exudates

Only 15% of sore throats are streptococcal

Rapid Strep. Test (HIGH SPECIFICITY)

even If (-), start treatment & perform a throat swab

Simple Diarrhea

No role of Stool Culture:

Stool Culture indicated only if:

bloody diarrhea

persistent diarrhea

(+) tenesmus

h/o foreign travel

Mx: Oral Rehydration Solution

(not juices or carbonated beverages)

Children with no dehydration – age-appropriate diet

Gp A â-hemolytic Streptococci are usually susceptible to Penicillin (this is not the case

with Staphylococci)

Strep viridans sensitive to Ampicillin + Gentamycin

German Measles (Rubella).

Asters Notes 23 of 111

---

Measles (Rubeola)

Roseola infantum (Exanthem subitum) HHV 6

high fever, rash appears after fever subsides

Lead levels > 10 : environmental abatement

start chelation therapy @ higher levels (? > 25)

single umbilical artery associated with renal ab(n)

Caput crosses midline; cephalhematoma does not

HbS Disease: Prophylactic Penicillin till 5y age

Stranger Anxiety: 6-9m

Separation Anxiety: 12-15m

Encopresis: >4 y

Enuresis: >5 y

Simple Febrile Seizures:

Single Seizure

Nonfocal

< 15 minutes durations

associated with high fever

Rx: antipyretics (NOT ANTICONVULSANTS)

F/H (+)

Can recur

Meningococcal Contacts: Rifamp/Cipro prophylaxis

(#1 cause) Seasonal Allergic Rhinitis-Ragweed

(#1 cause) Perennial Allergic Rhinitis-House Dust Mite

Choanal Atresia

cyanosis with feeding

relieved by crying

Dog & Cat Bite: P multocida (Rx: Amox-Clav)

Cat scratch disease: Bartonella henselae

Cushings Syndrome: #1 Iatrogenic

Cushings Disease: #1 Pituitary Microadenoma.

Asters Notes 24 of 111

---

Dx: 24 hour urinary free cortisol

to diff. Pituitary & adrenal cause: Overnight DST

Picks Disease:

Dementia / atrophy of frontal & anterior temporal lobes

[early psychiatric manifestations]]

Dementia with Lewy bodies:

(Alzheimers + Parkinsonism features)

DO NOT USE ANTIPSYCHOTICS

[they can excecerbate parkinsonism features]]

Dialysis Dysequilibrium Syndrome:

associated with rapid correction of uremia

HTN in elderly African Americans: CCB + Diuretics

HTN in young African Americans: Diuretics

====[[Asters Notests Disease of the bone:

extent is delineated by Tc 99 scan

Wounds < 12 hours old, clean: primary closure

Wounds > 12 hours old, contaminated: debridement and secondary closure

concomitant use of I/v heparin with thrombolysis:

Ac. anterior MI & Left Venticular Thrombus

Pts. with non-Q wave MI & previous CABG do not benefit considerably from

thrombolysis

High risk features post-MI

1. Post MI angina

2. Non Q Wave MI

3. CHF

4. LVEF < 40%

5. > 10 PVCs / min

e/o Significant Ischemia on Exercize Stress Test:

1.ST segment depression

2.< 6 METS work

3.@ < 70% predicted maximum heart rate

4.Hypotensive Response.

Asters Notes 25 of 111

---

LDL is the most important “lipid” risk factor for CAD

Cholesterol: < 200, 200-240, > 240

LDL: < 130, 130-160, > 160

treatment of choice for hypercholesterolemia: DIET

Basilar & Hemiplegic Migraine

DO NOT use SUMATRIPTAN

(also c.i. in IHD/MI, Pts on SSRI/MAOI/Li)

Acute A. Fib.:

(Stable) â-blockers & CCB

(Unstable) Sync. Cardioversion

Obesity is a risk factor for Endometrial Ca.

Surgical intervention for obesity : BMI > 40 kg/m2

Heparin: keep PTT 1.5-2.0 x control

Warfarin: keep PT 1.5-1.8 x control

Enoxaparin (LMWH): No PTT monitoring required

COPD : smooth muscle hyperplasia (as in asthma), but Methacholine challenge test is

negative

REID INDEX: ratio of thickness of bronchial glands to bronchial wall thickness

(increased in chronic bronchitis)

Nicotine enhances growth of H. flu

Most effective long term pharmacotherapy for COPD: Ipratropim bromide

COPD excecacerbations: H. flu, Pneumococcus, Moraxella

LONG TERM HOME OXYGEN THERAPY

Only Rx in COPD that enhances survival

indications:

Resting PaO2 < 55 mmHg

Resting PaO2 < 60 mmHg with tissue hypoxia

(cor pulmonale / polycythemia).

Asters Notes 26 of 111

---

Acute Bronchitis in healthy non-smoker:

no Investigations, no treatment (no antibiotics)

Early phase of asthma: primary mediators

Late phase of asthma: secondary mediators

Prophylaxis of exercize induced asthma: Albuterol

Long term stabilization of exercize induced asthma: Salmetrol (long acting) +

Zafirlukast

Mycoplasma pneumonia:

minimum physical findings

B/L lower lobe infiltrates

Cough (+)

Mx: Macrolide

Cold Agglutinins (IgM) Inravascular hemolysis

Pnenumonia in elderly debilitated alcoholic:

Lower Lobe: Strep pneumoniae

Upper lobe: Klebsiella

(currant jelly sputum, hemoptysis, cavitatory lesion)

Normal Semen analysis

vol. 2-5 mL

sperm conc. > 20 million / mL

morph > 30% normal

motile > 50% motile

1 cause of dysphagia: lower esophageal ring (in the absence of risk factors for esophageal cancer)

Systemic Sclerosis associated with severe GERD

UC (Dx): Colonoscopy

Crohns (Dx) : air contrast barium enema

Alcoholic Hepatitis: AST >> ALT (ratio > 2.0)

Malignant Neuropathic Pain

Sharp Stabbing: R x anticonvulsants (Carbamazepine)

Dull Aching: R x TCA (Desipramine).

Asters Notes 27 of 111

---

Mx of Chemotherapy induced Emesis: ONDANSETRON

Pain control : round-the-clock dosing > cf. PRN

TPN: no mortality/morbidity benefit in cancer pts.

Vestibular Nausea Rx: Cyclizine

Radiotherapy assoc. diarrhea: Loperamide / Codeine

Narcotic induced constipation: LACTULOSE

1 symptom in avanced cancer is weakness (ASTHENIA) SSRIs can make agitated depression worse

(Use sedating TCA & Anxiolytic PRN)

1 metabolic derangement with advanced malignancy: hyperCa ++ (long PR, decreased QT, wide T waves)

Type 1 DM is HLA DR3/DR4 associated

Type 2 DM - Obesity & Family History

OHAs

Biguanides

decrease Glucose production & increase peripheral utilization (Metformin)

Sulfonylureas

stimulate Insulin release (Glibenclamide)

Glitazones

DECREASE INSULIN RESISTANCE

(Troglitazone)

á-glucosidase inhibitors

decrease carbohydrate absorption (Acarbose)

MODY

pts. are normal to underweight

< 40 years age

AD inheritance

F/H (+) in 50%Dx of DM

Diagnosis of Diabetes Mellitus.

Asters Notes 28 of 111

---

FBS (2 values) > 126 mg%

RBS (1 value) > 200 mg%

GTT (100g oral glucose): 2 hour value > 200 mg%

Li induced NDI : stop Li -> start Carbamazepine

1 feature of Cushings: Truncal Obesity (90%) Pathophysiology of Migraine:

CNS Platelet aggregation with Serotonin release

Very Severe Migraine (abortive): SUMATRIPTAN

Moderately severe Migraine (abortive): DHE

Status migrainous: migraine lasting > 72 hours

Cluster Headaches: Sumatriptan / O2 inhalation

New onset seizure

< 40 y age: #1 Idiopathic

> 40 y age: #1 Brain Tumor

Discontinue anticonvulsants after seizure-free for 4y

(confirmed by absence of epileptiform activity on EEG)

Grand mal: Phenytoin

Petit mal: Ethosuximide

Thrombotic Stroke: slow and continuing (m/c variety)

Embolic Stroke: sudden

1 risk factor for CVA: HTN

Carotid End Arterectomy for Symptomatic Carotid Artery stenosis > 70%

Fe deficiency anemia (most sensitive Ix): S. Ferritin

1 inherited bleeding disorder: vWD Inherited hypercoagulable state

Factor V Leyden (most common)

Prot C def. / Prot. S def.

Anti-thrombin III deficiency.

Asters Notes 29 of 111

---

Anti-PL antibodies: can cause arterial Thrombosis

TTP: do NOT give platelet transfusion

vWD: Factor VIII (cryoppt.)

DIC: FFP

COX-2 (Celecoxib): less GI side effects cf. NSAIDs

Exercize program in OA

Graded, Active Exercize, Isometric

Fibromyalgia

tenderness in 11 of 18 defined points

r/o comorbid depression

ass. with sleep disorder

(á-nonREM sleep anomaly) -> also in CFS

Mx of Chronic Fatigue Syndrome:

NSAIDs

nonsedating TCAs

Both FIBROMYALGIA & CHRONIC FAIGUE SYNDROME have á-nonREM sleep

anomaly

Gout prophylaxis: only for recurrent attacks

(> 2-3 attacks)not after first atack

1 cause of Chr. Renal Failure: DM Mx of uncomplicated UTI: 3 days of TMP-SMX

Artificial Donor Insemination

Store semen for 6 months

Check donor for HIV @ 6 m

If still (-), proceed with insemination

1 step in Obstructive Sleep Apnea: Weight Reduction BZD can worsen Obstructive Sleep Apnea

Narcolepsy Mx:

Methylphenidate.

Asters Notes 30 of 111

---

Dextroamphetamine

Mazindol (TCA)

Long T1/2 BZD are associated with lower incidence of rebound anxiety (e.g.

Flurazepam)

Bisphosphonates

Oral - to be taken in the morning on empty stomach with 8 oz of water (to prevent

esophagitis)

Alendronate (FDA approved)

Etidronate (less efficacious)

Pamidronate (I/V infusion)

SERMs (Raloxfene):

Estrogenic on Bone / Lipids

Anti-estrogenic on Uterus & Breats

Marjolin Ulcers: squamous cell ca. in old scars

Immunosuppression is a risk facor for Sq Cell Ca.

PRCA (Pure red cell aplasia) may be associated with thymoma

Aplastic Anemia causes <3% fall in Hct / week

[>3% fall in Hct / week: Hemolysis / Hemorrhage]]

Hereditary Spherocytosis:

AD

Spectrin

Microcytosis

increased MCHC, increased Osmotic Fragility

Lifelong FOLATE supplementation

Rx: SPLENECTOMY

PNH:

acquired defect in DAF

Dx: Sugar Water Test

prone to hepatic & mesenteric vein Thrombosis

may progress to Aplastic Anemia / AML

Bloody Nipple d/c: DUCT EXCISION

(no role of ductography).

Asters Notes 31 of 111

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G6PD def.: older RBCs are deficient in enzyme, hemolysis is self-limited

G6PD def. (Mediterranean Variant): all cells are deficient - severe and chronic

hemolysis

MYELOFIBROSIS:

poikilocytosis

giant abnormal platelets

dry bone marrow tap

“Clustered Polymorphic Microcalcification” on Mammography is s/o Breast Cancer

Mammography is never a substitute for BIOPSY. Mammo is for detection of other

lesions and screening the contralateral bereast. It does not rule-in or rule-out cancer

HbSC disease:

increased incidence of Proliferative Retinopathy

decreased vaso-occlusive and pain crisis

Fever in Neutropenia: consider infectious

Rx of acute promyelocytic leukemia: RETINOIC ACID

Serum LDH is a prognostic marker in Lymphomas

multiple myelomas with no paraprotein : 1%

(very aggressive)

TTP & HUS: normal coagulation studies (cf. DIC)

Uremia is asscoaited with qualitative platelet defect

Hemophilia with low platelet count:

??? HIV associated immune-thrombocytopenia [ makes no sense ] Hemophilia with no improvement with Factor VIII infusion: ??? suspect Factor VIII

Inhibitor activity

[Serum Mixing Test]]

Mx: Steroids or Cyclophosphamide

Vit. K dep. factors:

Factor II, VII, IX, X

(Vit. K def.: corrected by Vit. K administration).

Asters Notes 32 of 111

---

Liver Disease:

decreased vit. K dependent factors & Factor V

(coagulopathynot corrected by Vit. K administration)

1 Unit of Packed Red Cells

300 mL volume = 200 mL of Red Cells

raises Hc by 4%

When Typo “O” blood is being used (universal donor): use packed red cells, not

whole blood

Constipation

<50y: increase fiber or osmotic laxatives

>50y: FOBT

If (+), Colonoscopy (Sigmoido/Ba enema)

Mayonnaise/Salad Dressing: S. aureus food poisoning

Small Bowel Diarrhea: Voluminous, Bloating

Large Bowel Diarrhea: small volume, LLQ Cramps

Methylene Blue stain of stool detects Fecal Leukocytes, so basically presence of fecal leukocytes in a stool sample of a diahorrhea victim means presence of an invasive organism like shigella, salmonella, eiec, camp jejuni, yersinia enterocolitica etc]

Follow-up Rx of DKA with ANION GAP

not serum Ketones)

ketone estimation detects only acetate and acetoacetate

the predominant ketone in DKA is b-HAP [ beta hydroxy butyrate]

as DKA Rx progresses, b-HAP converts to acetoacetate and estimation of serum

ketones might suggest paradoxical worsening ketonemia

Osmotic Diarrhea: decreases with fasting

Fecal Fat > 10g/24hours : s/o Malabsorption

UGIH

1 Peptic Ulcer

2 Variceal Bleed (#1 cause of death from UGIH)

LGIH

1 (>50y) Diverticulosis (#2: Angiodyslasia) LGIH Dx

<50y: Anoscopy or Sigmoidoscopy

>50y: Colonoscopy (Sigmoido/Ba enema).

Asters Notes 33 of 111

---

Ascitic Flluid: SAAG > 1.1Portal HTN

Spontaneous Bacterial Peritonitis

> 500 cells / ìL

> 250 PMNs / ìL

Total Protein < 1g / dL

Mx: i/v Ceftriaxone (no anaerobic cover required)

prophylactic FLUOROQUINOLONES to

prevent recurrences

Familial Mediterranean Fever:

Turks, Armenians, Arabians

recurrent abdominal pain (resembles acute surgical abdomen)

attacks resolve in 24-48 hours

associated with serositis & pleuritis

recurrent attacks cause secondary amyloidosis

Rx: COLCHICINE

Uncomplicated GERD: H2 blockers (1 st line) -> PPI

Complicated GERD: PPI (1 st line)

Preferred procedure for portal decompression is TIPS (Transvenous Inrahepatic

Portosystemic Shunt)

associated with maximum decrease in rebleeding rate (> banding, sclerotherapy, â-blockers)

Non-invasive tests for H. pylori

serology (past & present infection)

fecal antigen detection

urea breath testing

PPI can cause False (-) fecal antigen & breath test

Duodenal ulcers heal faster than gastric ulcers

Long term PPI Rx not required in PUD

Long term PPI Rx required in GERD

H. pylori eradication: PPI / Amox / Clarithromycine

50% of H pylori isolates are Metronidazole-resistant

10-14 days of H. pylori eradication followed by 4-8 weeks of PPI for Rx of PUD.

Asters Notes 34 of 111

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Rx of Whipples Disease: TMP-SMX for 1 year

Giardiasis can cause Lactase deficiency

Ogilvies: acute colonic pseudo-obstruction

Gastric malignancy

1 Gastric adenocarcinoma

2 B-cell lymphoma Celiac Sprue

increased incidence of intestinal T-cell lymphomas

Carcinoid Syndrome: small bowel carcinoid with hepatic metastasis (increased urinary

5-HIAA)

£increased right sided valvular lesions

Abdominal Pain relieved by defecation: IBS

Cl. difficile: watery diarrhea (Dx: Toxin Assay)

Budesonide:

high potency steroid

low systemic side efects

(due to high first pass metabolism)

useful in nflammatory bowel disease

When UC/CD diff. is difficult

UC: pANCA (+)

CD: ASCA (antbodies to s. cerevisiae)

UC: assoc. with PSC (PSC is an independent risk factor for colonic malignancy in UC)

APC Gene:

AD

Polyps -> Adenomatous Polyps -> Ca

small bowel polyps (low malignant potential) & gastric polyps (no malignant potential)

may also be found

FPC: begin screening colonoscopy @ 12-20 y age

Peutz Jeghers:

colonic polyps have no malignant potential

increased extraintestinal malignancies.

Asters Notes 35 of 111

---

(Breast, Gonads, Pancreas)

HPNCC:

Colorectal Ca (+)

(few, flat, fast-progressing adenomas)

40% lifetime risk of endometrial cancer

Right sided Colon Ca: Bleeding

Left sided Colon Ca: Obstruction

Hep D superinfection is more severe than co-infection

HAV infection: may have relapses

Acute Hepatic Failure: Encephalpathy in < 8w

Subacute Hepatic Failure: Enceph. in 8w - 6m

Chr. Hepatitis: > 6m

Anti-HCV: EIA -> if (-) -> confirmatory test RIBA

Chronic HBV: IFN-á or LAMIVUDINE

Chronic HCV: IFN-á with RIBAVARIN

Chronic HCV infection:

ass. with cryoglobulinemia and Type2 DM (NIDDM)

Individuals with Hemachromatosis are susceptible to V. vulnificus, Listeria, Y

enterocolitica infections

Dx of Budd Chiari syndrome: Duplex Doppler U/S

Left Heart Failure:

increased liver enzymes (ischemic injury)

Right Heart Failure:

increased Bilirubin & Ascites (>> periph. edema)

Gastric Varices without Esophageal Varices: Splenic Vein Thrombosis

Mx: Splenectomy

1 organism causing pyogenic liver abscess: E. coli.

Asters Notes 36 of 111

---

OCP associated Liver Adenoma

(Mx: RESECTION even for asymptomatic cases)

Meperidine: least Sphincter of Oddi spasm

UC with pruritus: consider PSC

S. amylase can be increased in MUMPS ue to salivary gland involvement without

involvement of pancreatic gland[[but S. Lipase would be normal in cases of

extrapancreatic elevation of amylase]]

Antibiotic of Choice in Pancreatic Infections: IMIPENEM

Tamoxifen:

decreases Breast Ca. / increases Endometrial Ca.

SERMs (Raloxifene):

decreases Breast Ca. / decreases Endometrial Ca.

Medical Adrenalectomy

Aminoglutethemide + Corticosteroids

HRT after Breast Ca. -> Raloxifene

IgE is not involved in anapylactoid reactions

(e.g. radiocontrast allergy)

CD3 : pan T cell marker

CD19: pan B cell marker

Dx of CREST syndrome is clinical

(not based on anti-centromere antibody)

Of all HLAs - HLA-DR compatibility is essential for long term graft survival

Cyclosporine:

decreases CMI & decreases IL-2 (T-cell activation)

Steroids: decrease CMI

Cyclophosphamide: decreases CM as well as HMI

IFN-á: HCL, HepB & C, Kaposis, CML

IFN-beta: Multiple Scerosis

IFN-gamma: CGD, cml.

Asters Notes 37 of 111

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Acidosis due to Organic Acids is not assoc. with HyperK + (cuz they freely permeate the

cell membrane)

Renal Glycosuria, Hyphosphatemia, Hypouricemia: FANCONIs

Commonest TA: Type IV RTA

(Hyperchloremic Hyperkalemic metabolic acidosis)

Thyroid Scan: I-123

Thyroid Ablation: I-131

Prerenal Azotemia: BUN/Cr > 20.0

L4: Knee Jerk & Sensory on Medial Calf

S1: Akle Jerk & Lateral Foot

PIVD L5 compression:

DORSIFLEXION of foot affected

PIVD S1 compression:

PLANTAR FLEXION of foot affected

[Ca]][PO4]] > 64 : predictive of metastatic calcification

Mx of Myedema Coma:

300-500 microg bolus of i/v thyroid hormone

followed by 50 microgram daily

Panhypoptuitarism presenting with Myxedema coma:

first give HYDROCORTISONE

then THYROID REPLACEMENT

(to prevent Adrenal Crisis)

Allopurinol potentiates the action of Azathioprine: if used together, reduce

Azathioprine dose by 75%

Routine PIVD: MRI not indicated

(conservative Mx – resolve in 1-4 weeks)

PIVD with neurological deficits: MRI.

Asters Notes 38 of 111

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Lumbar Spinal Stenosis:

Discomfort in Thighs on walking / standing

pedal pulses preserved (PSEUDOCLAUDICATION)

Ix: MRI

Phaeochromocytoma

Urinary Catecholamines: sensitive

Urinary Metanephrine: specific

Urinary VMA: least useful

Mx of Fibromyalgia: TCA (NSAIDs are ineffective)

1 functional pituitary adenoma: PROLACTINOMA Pain in sole of foot after getting up in he morning: Plantar Fascitis (Mx: Arch Support /

NSAIDs)

SLE

ANA- sensitive

Anti-Sm: specific

Ant-dsDNA: correlates with disease activity

1 vitamin deficiency: Vit. D Polymyositis associated dysphagia:

oropharyngeal (striated muscle)

Scleroerma associated dysphagia:

esophageal (smooth muscle)

Muscle Biopsy findings in Dermatomyositis:

lymphoid infiltrate AROUND muscle fascicles

Muscle Biopsy findings in Polymyositis:

lymphoid infiltrate INSIDE muscle fascicles

Ix of choice: Muscle Biopsy (not EMG/NCV)

Woman with Joint Pains and Dental Caries : Sjogrens syndrome

GCA: associated with increased incidence of

Thoracic Aortic Aneurysms.

Asters Notes 39 of 111

---

Ank. Spond. vs. SI joint involvement in Psoriasis:

lack of calcification in Psoriasis

Prompt Rx of NGU:

associated with decreased indcidence of REITERs

Whipples: Joint symptoms precede GI symptoms

Synovial Fluid WBC count

< 200 normal

< 2000 noninflammatory (OA)

2000-50000 Rheumatoid Arthritis

50000-100000 Septic / Gout

> 100000 Septic

1 Septic Arthritis: N gonorrheae

1 non-gonococcal arthritis: S. aureus

1 with IVDU/arthroscopy/prosthesis: S epidermidis Recurrent Gonococcal Arthritis:

? C5-C8 deficiency

1 cause of Osteomyelitis: S. aureus

1 renal involvement after URI: IgA nephropathy (1-2 days after URI)

PSGN occurs 1-3 weeks after Strep. infection

Nephrotic Syndrome:

1 (Children): MCD

1 (Adults): MGN Dialysis :acquired renal cysts (? malignant pot.)

Enthesopathy:

inflammation of Ligaments / Tendons

(Ankylosng spondylosis / Reactive Athritis)

Polycystic Kidney Disease:

associated with Berry aneurysms in circle of Willis

(SAH)

Multile Myeloma & Kidney:.

Asters Notes 40 of 111

---

Myeloma Kidney - LIGHT CHAIN Renal Toxicity

(light chains are not detected by urine protein dipstick)

Renal Amyloidosis - Heavy Chains excreted

(heavy chains are detected by urine protein dipstick)

Aging: decreasd GFR but S. Cr. remains constant (cuz Lean Body Muslce Mass

decreases too)

Initial Hematospermia: Prostate

Terminal Hematospermia: Seminal Vesicle

RBCs: Hematuria

WBCs: Cystitis

RBC Cast: GN

WBC Cast: APN, Pyelonephritis

Acute Bacterial Prostatitis:

NO Prostatic Massage or Catheterization

Chronic Bacterial Prostatitis:

Prostatic massage -> C/S of expressed secretions

(Mx: TMP-SMX)

Ureteral Stones < 6mm:

Conservative Mx for 6 weeks

Asymptomatic Renal Stones: Conservative

F/U with serial X-Rays

Symptomatic Renal stones (Fever/Pain/UTI):

< 3cm: ESWL

> 3cm: PCNL

Urinary Incontinence:

Total: Sx

Stress: Sx is curative (Kegel/Pessary/Estrogen)

Urge: Antispasmodic / Anti-Ach / TCA

Overflow: Catheterize

Sildenafil (Viagra) c.i. in patients on Nitroglycerine

Right Ventricular Infarction:

Nitroglycerine precipitates HYPOTENSION.

Asters Notes 41 of 111

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Mx: I/V Fluids

70y old man with urinary obstruction and backache:

? Prostatic Ca with mets

Prostatic Biopsy: U/S guided biopsy > finger-guided

Prostatic Ca: Transrectal U/S = MRI for staging

(CT has no role)

Prostatic Mets: Radionuclide Bone Scan > X-Ray

Ix for suspected Bladder Ca.: CYSTOSCOPY

MEN II: hyperparathyroidism is due to HYPERPLASIA, not PARATHYROID

ADENOMA

Testicular Neoplastic Mass:

Children: Embryonal Cell Ca.

Adult: Seminoma

> 50y: Lymphoma

Intracranial Hage (< 48h. duration):

CT without contrast is superior to MRI

Cerebellar Vermis:

Axial ataxia

Cerebellar Hemisphere:

“IPSILATERAL” Appendicular Ataxia

Frontal Lobe Lesions:

Personality Changes

Temporal Lobe Lesions:

Hallucinations/ deja vu / emotional changes

Parietal Lobe Lesions:

cortical sensory loss (astereognosis)

Occipital Lobe Lesions:

macular sparing field defects &

UNFORMED VISUAL HALLUCINATIONS.

Asters Notes 42 of 111

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Acoustic Neuroma:

first symptom is IPSILATERAL hearing loss

To measure severity of ASTHMA attack:

Peak Expiratory Flow RatePEFR (not ABG)

Alcohol can temporarily decrease symptoms in BENIGN ESSENTIAL TREMOR

(intention tremor)

Myersons Sign:

2 per second tap on nose -> sustained blinking

(seen in Parkinsonism)

Shy-Drager:

Parkinsonism + Autonomic Insufficiency + Neurological Deficits

Progressive Bulbar Palsy (CN Motor nuclei): TONGUE WASTED

Pseudobulbar Palsy (UMN):

TONGUE SPARED

ALS : UMN + LMN

Peripheral Neuropathy:

AXONAL (NCV normal)

DEMYELINATION (NCV decreased)

TT Leprosy: Neuropathy in area of skin lesions

LL Leprosy: Neuropathy > Skin Lesions

Tarsal Tunnel Syndrome

Pain, Paraeshesiae on bottom of foot

(Sparing of the HEEL)

Cervical Rib:

Thenar Wasting

Pain & Numbness on medial 2 fingers

(ulnar side of forearm)

Myotonic Dystrophy:

AD

stiffness

cataracts.

Asters Notes 43 of 111

---

baldness

Mx - Quinine, Phenytoin, Procainamide

Neuropathy: DISTAL ± Sensory Loss

NM Junction: Fluctuating Deficits

Myopathy: PROXIMAL weakness (NO sensory loss)

non-enhancing white matter lesions without mass effect (in AIDS): PML

Ix of Valvular Ht. Disease:

ECHO foll. by Catheterization (definitive Dx)

ILD

Non-productive Cough

Exertional Dysnea

Fine Expiratory Crackles

decreased DL CO

increased A-a gradient

gold standard for diagnosis: LUNG BIOPSY

Dx of Malignant Mesothelioma: Pleural Biopsy

100% of small cell ca. occur in smokers

Complicated Parapneumonic Effusions

Gross Pus

Gram Stain (+)

Glucose < 50 mg%

Pleural Fluid pH < 7.0

Severe Hyperkalemia Mx: Calcium Gluconate

Mx of Mg toxicity: Calcium Gluconate

1 st test in asymptomatic hematuria:

URINE CULTURE -> IVP

1 st test in suspected pneumonia:

CXR -> Sputum C/S

Currant jelly sputum: Klebsiella

Rusty sputum: Pneumococcus

Smokers / COPD: H. influenzae.

Asters Notes 44 of 111

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Interstitial infiltrates: Mycoplasma

Empyema / Rapidly progressive: Staph. aureus

Pneumonia Rx:

Community acquired: Macrolide

> 60y or COPD/smoker: 2 nd gen cephalosporin

Nosocomial: 2 nd / 3 rd gen cephalosporin

ICU (severe): Macrolide + Antipseudomonadal

Uncomplicated UTI: 3 day course of TMP-SMX

Native Valve Endocarditis - S. viridans

[â-lactam + aminoglycoside]]

Prosthetic Valve Endocarditis (Early) - S. epidermidisVancomycin + Aminoglycoside

Prosthetic Valve Endocarditis (Late) - S. viridansVancomycin + Aminoglycoside

IVDU - S. epidermidis / S. aureus

[Vancomycin + Aminoglycoside]]

IE prophylaxis:

- Amox 2g 1 hr. before Dental / GI / GU procedures

- penicillin allergy -> Clarithromycin

Dont delay antibiotics in Meningococcal meningitis

(even if LP is not done)

HAART: AZT+3TC & Indinavir

AIDS - avoid all live vaccines except MMR

Abdo. Pain: 1 st investigation - AXR

UC: Pseudopolyps, Crypt Abscesses

CD: Skip Lesions, Fistulae

ddI can cause Pancreatitis.

Asters Notes 45 of 111

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RA: PIP involvement (DIP sparing)

OA: DIP involvement

Ix of choice in Osteoporosis: DEXA scan

Vaginal Candidiasis:

Topical Miconazole / Systemic Fluconazole (recurrent)

(Oral agents eliminate rectal reservoir of yeast)

Trichomoniasis:

PO Metronidazole 2g stat (Rx male partner also)

Bacterial Vaginosis:

PO Metronidazole 250-500mg x 7 days

(cf. single dose in Trichomoniasis)

Pap shows LGSIL (F/U reliable):

repeat Pap 4-6 months later

Women Smokers should always have annual Pap

Primary Dysmenorrhea: within 2 years of menarche

inreased Prostaglandins

arteriolar spasm

uterine hypoxia

Mx: (sexually active): OCPs

Mx (sexually inactive / OCP c.i.): NSAIDs

1 cause of DUB: Anovulatory Cycles Mx: Hormonal Therapy===>Endometrial Ablation

Severe acute DUN with orthostatic hypotension

I/V Conjugated Estrogen

1 STD: Chlamydia trachomatis Ectopic (hemodynamically stable / no rupture):

Methotrexate

Ectopic (Unstable / rupture):.

Asters Notes 46 of 111

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Salpingectomy or Salpingotomy

OCPs:

decrease Gonococcal STD

may increase Chlamydial STD (cervical ectropion)

Vaginal Spermicides:

decrease Gonococcal & Chlamydial STD

(no effect on HIV transmission)

Breastfeeding & OCPs: can use. Use low-dose OCPs

(cuz of effect on milk production, not because of infant safety consideration. Estrogens

do pass into milk in small quantity, but they are safe)

Hormonal Contraception for h/o DVT/PE:

Norplant & Depo-Proverano OCPs

PID

in-patient:

I/V Cefoxitin or Cefotetan + Doxycycline

out-patient:

I/M Ceftriaxone + PO Probenecid + PO Doxycycline

Depression: Cognitive Psychotherapy

Adjustment Disorder: Supportive Psychotherapy

Anxiety Disorder: Behavioral Psychotherapy

Antidepressant Ladder:

SSRI

another antidepressant (except MAOIs)

best tolerated agent + LiCO 3

MAOIs

ECT

Lab Test for Cocaine:

Urine Benzoylecgonine (Cocaine metabolite)

Genital Herpes transmission occurs even in asymptomatic state

(Acyclovir decreases freq. of recurrences)

Hagic crust on molluscum like lesions in HIV pts. : Cutaneous Cryptococcosis.

Asters Notes 47 of 111

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HPV (Genital Warts)

Heaperd up lesions flesh colored lesions on penis

female partner has increased risk of Ca. Cx

Leprosy with painful red patches on extremities that become nectrotic and ulcerate:

LUCIO REACTION (seen in unreated leprosy, responds to Steroids)

Excessive use of Aluminium containin laxatives:

risk factor for postmenopausal osteoporosis

KOH Prep meatball-and-spaghetti appearance: Tinea versicolor

binge eating and purging behavior

(even without depression) : SSRI

Factitious Disorder : assoc. with child abuse

Somatoform Pain Disorder :

limit analgesic use

best managed in a multi-disciplinary pain clinic

Rx of choice for Panic Disorder: PAROXETINE dependence might develop with

Alprazolam

Mx of Social Phobia:

â-blockers + ASSERTIVE TRAINING

Mx of OCD: SSRIFluvoxamine

Clomipramne is no longer the first line drug

Mx of PTSD: >1m; assoc. with life-threatening event

Group Psychotherapy

Anorexia nervosa:

75% have Depression, 25% have OCD

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Asters Notes II

Asters Notes III </translate>