Asters Notes II

Part II of Asters Notes for USMLE step 3

Buckman's 6 steps of Breaking Bad News

1. Getting started

2. find out how much the pt. knows

3. find out how much the pt. wants to know

4. share the info. a) Give Warning Shot

5. respond to pt.'s feelings

6. Plan F/U - give hope.

Aster's Notes 48 of 111
Skew: depends on direction of tail (not hump)

± 1 SD 68%

± 2 SD 95%

± 3 SD 99.7%

To increase power of a test: inrease sample size

Nominal or Ordinal Data:

Non-parametric Tests [Chi Square]

Interval or Ratio Data:

Parametric Tests [T-test, Z-test, F-test]

Correlation coefficient

Ordinal Data: Spearman Rank Order

Interval or Ratio Data: Pearson product-moment

r=correlation coeeficient

r 2 (square)=coefficient of determination

(proportion of variation in one variable explained by variation in other)

Causality is only proven by properly conducted experimental studies

A test can only be 100% sensitive and specific if there is no overlap between

measurements in normal and diseased states

Higher the prevalence of a disease:

Higher the PPV of a (+) test

Lower the NPV of a (-) test

Untreated apendicitis in young female can cause infertility (peritoneal adhesions)

Appendiceal abscess: delay

Sx till inflammation has subsided

[the acute process has been walled off]

Cholangitis (ass. with CBD stones):

ERCP with Sphincterotomy + Lap Chole.

Skin Suture: cutting needle.

Aster's Notes 49 of 111
Deeper Layer Suture: Taper Needle

Ingrown Toe Nail

first episode:

antibiotics, elevation of edge -> wedge resection

recurrent:

Nail Removal

Anal Fissure: Local Steroid Cream / Sitz Bath

Anaesthetic of choice for skin lesion removal: Lidocaine + Adrenaline

(No Adrenaline for fingers and nails)


 * 1) 1 type of breast Ca.: Infiltrating Ductal Ca. (80%)

Mx of Fibrocystic Disease: Low Dose OCP

Mx of Fibroadenoma: Biopsy (Excisional)

Danger Signs in Chronic Low Back Pain

- Bowel or Bladder dysfunction

- Impotence

- Ankle clonus

- NIGHT PAIN

- Weight Loss

- Lymph Node enlargement

- Buttock claudication

- New Onset in age > 50 y

No imaging for routine chronic low back pain

Mx of Chronic LBP:

TCA's have the best cost/benefit ratio

[Muscle relaxants and NSAIDs have low effectiveness]

Dx of Childhood PCKD: > 2 cysts in EITHER Kidney

Dx of Adult PCKD: > 5 cysts in EACH Kidney

C/I to thrombolysis

- Sx < 2 weeks

- Unconrolled HTN

- Aortic Dissection

- h/o CVA / 'aic stroke / CNS tumor / AVM

- prolonged traumatic CPR

- allergy to thrombolytic agents.

Aster's Notes 50 of 111
- pregnancy

Risk Stratification in Unstable Angina

(Outpt.) Low - Onset < 2 weeks

(Telemetry) Medium - Onset < 2 weeks, Pain > 20 minutes but resolved @ present

(CCU) High - Rest Pain > 20 minutes and not resolved @ present

(CHF / Pulm. Edema / ST changes / Mitral Regurg.)

1 st episode of syncope / low risk of heart disease:

NO FURTHER EVALUATION

Emperical Rx for IE:

Nafcillin + Ampi + Genta

(add Rifampin for Prosthetic Valve)

IE prophylaxis not reqd. for:

1. small ASD of secundum type

2.MVP without Mitral Regurg.

Acute Asthma:

Give Albuterol, O2, steroids -> assess response (PEFR, O2 sat.)

Good Response

PEFR > 80% of best (discharge with â-agonist)

Moderate Response

PEFR 60-80% of best

(hospitalize and continue medications, O2)

Poor Response

PEFR < 50% of best

(ICU admission)

(prepare for Intubation if silent chest, altered sensorium, respiratory failure)

Chronic Asthma

Mild Intermittent:

<2/week, nocturnal symp. < 2/month

(Inh â 2 -agonist)

Mild Persistent:

>2/week, nocturnal symp. >2/month

(Inh â 2 -agonist + Anti-LT)

Moderate Persistent:

Daily, PF 60-80%

(Inh â 2 -agonist + Inh. Steroids/Inh. long acting â 2 -agonist).Aster's USMLE Step3 Notes

Aster's Notes 51 of 111
Severe Persistent:

Continuous, PF<60%

(Inh â 2 -agonist + Inh. Steroids + Inh. long acting â 2 / Anti LT)

SPN: Conservative Mx

Age < 45, nonsmoker, no inrease in size, size < 4cm

Psoriasis:

Pustular: ACITRETIN

Plaques:

ŒEmollients / Keratolytics / Corticosteroids

ŒTar / Calcipotriol / Anthracin

ŒUVB

ŒPUVA

ŒMethotraxeate / Cyclosporin

ŒHydroxyurea

Rx of Onychomycosis: PO Terbinafine

Acute Mastoiditis develops 2-3 w after acute otitis

Mx: Ceftriaxone / Sx drainage

Acute Bacterial Sinusitis: Pneumococcus

Chronic Bacterial Sinusitis: S. aureus

most serious form of sinusitis: FRONTAL sinusitis

d/o/c for Alzheimer's :

DONEPEZIL (OD dosing, no liver toxicity)

Upper Lips: BCC > SCC

Lower Lips: SCC > BCC

RCA stenosis: Saphenous grafts

Anterior Duodenal Ulcers: Perforation

Posterior Duodenal Ulcers: Bleeding

Acute Meseteric Ischemia: Embolization

Chronic Mesenteric Ischemia: Atherosclerosis.

Aster's Notes 52 of 111
Carcioid: Appendix > Ileal

(Ileal have higher chances of metastasis)


 * 1) 1 GI malignancy: HCC (not colorectal Ca.)


 * 1) 1 Liver neoplasm: Cavernous hemangioma


 * 1) 1 Breast Lesion: Fibrocystic Disease


 * 1) 1 Breast Malig.: Infiltrating Ductal Ca.

Indications for Hormonal Therapy for Breast Ca.

- Postmenopausal

- Nodes --

ER +

Aortic Aneurysms

Thoracic:

Type A: Sx

Type B: Sx if > 6 cm

Abdominal:

Sx if > 5cm


 * 1) 1 Congenital Heart Disease: VSD


 * 1) 1 Cyanotic Heart Disease: TOF

ASD: Fixed Splitting of S2

Biliary Atresia:

Jaundice @ 2 wks of life, dark urine & acholic stools

Rx: Surgery (Roux-en-y portoenterostomy)

Neck Injuries:

Zone I : Arteriography -> Sx

Zone II : Sx

Zone III : Arteriography -> Sx

Mortality in Burns = Age + % BSA

1 st degree: Leave Open

2 nd degree: Clean,Sulfadiazine,nonadhesive dressing

3 rd degree: Escharotomy + Skin Grafting

Sprain: Ligament Pull.

Aster's Notes 53 of 111
Strain: Muscle Pull


 * 1) Neck Humerus: Axillary Nerve Damage


 * 1) Shaft Humerus: Radial Nerve Damage

Quick Neuro Exam

AVPU:

Alert

Responds to Verbal Stimulus

Responds to Pain

Unresponsive

Rescusitation:

O 2, 2 large bore IV lines, IV fluids, EKG

- 100 mg Thiamine

- 1 amp 50% Dextrose

- 0.4 mg Naloxone

C/I to Foley's Catheter: (do retrograde urethrogram)

1. Blood at tip of urethral meatus

2. Perineal Eccymoses

Abdo. Trauma


 * 1) 1 Injury in Blunt Trauma: Spleen


 * 1) 1 Injury in Penetrating Trauma: Small Bowel

Indications for Exploratory Laparatomy in Abdo. trauma

1. Shock with Abdo. Injury

2. Pneumoperitoneum

3. Gunshot

4. (+) DPL

- Blood

- RBC > 100,000/mL

- WBC > 500/mL

- Food

- Bile

- Bacteria

Referral for Burns

- 3 rd degree burns > 10% BSA, < 10 y, > 50 y

- 2 nd degree burns > 20% BSA

- Electrical burns / Chemical burns.

Aster's Notes 54 of 111
- Inhalation Injury

- Perineal burns

- Radiation burns


 * 1) 1 symptom of Parkinsonism: Tremor (Resting)

Benign Essential Tremor

ŒIntention Tremor

ŒFamilial

ŒHead Nodding

Œtemporary decrease with alcohol intake

S. pneumoniae: Rx - Macrolide or newer Quinolone (Levofloxacin / Gatifloxacin)

Majority of elderly patients with sepsis:

URINARY TRACT is the culprit


 * 1) 1 cause of death in hospitalized elderly: UTI


 * 1) 1 cause of death in institutionalized pts.: Bacterial Pneumonia


 * 1) 1 cause of Urinary Incontinence: Urge Incontinence

Clean pressure ulcers with Normal Saline

(avoid Povidone-Iodine, Hydrogen Peroxide etc.)

Unimmunized with infected wounds

3 TT + 1 ATS

Stroke mortality is higher in WHITES than in BLACKS

indications for pneumococcal vaccine

1. Splenectomy

2. Sickle Cell

3. > 65 y

4. Chr. Cardio / Pulmonary / Renal Disease

4. Hodgkin's Disease

Continued Gastric Lavage for : PCP overdose


 * 1) 1 Foods causing angioedema: Nuts / Seafood


 * 1) 1 Drug causing allergy: Aspirin

Electronic Fetal Monitoring & Intermittent Auscultation of Fetal Heart have similar

outcomes.

Aster's Notes 55 of 111
NST (Non-stress Test)

> 2 accelerations (in 20 minutes)

15 bpm lasting > 15 sec

CST

>= 3 consecutive late decelerations in 10 minutes

< 20w. POG with HTN: Essential HTN

(not PIH or pre-eclampsia)

Pre-eclampsia:

Bed Rest / (L) lateral position /

pharmacotherapy [á-methyldopa / labetalol]


 * 1) 1 indicator of perinatal outcome in IUGR is:

presence of vertical pocket of Amniotic Fl > 3 cm

0-8 weeks : Embryo

8w-term : Fetus

0-14 weeks: 1 st Trimester [Routine Ix]

14-28 weeks: 2 nd Trimester [GDM Screen]

28-40 weeks: 3 rd Trimester [GBS Culture]

<24 weeks: Previable

24-27 weeks: Preterm

37-42 weeks: Term

> 42 weeks: Post-term

Cervical Incompetence:

- Cerclage @ 12-14 weeks, till 36-38 weeks POG

Bishop Score:

<= 5: Prime (with Prostaglandins)

> 8: Induce Labor


 * 1) 1 cause of PPH: Uterine Atony

Preterm ROM: @ < 37 weeks POG.

Aster's Notes 56 of 111
Premature ROM: > 1 hr before onset of labor

Prolonged ROM: > 18 hours before onset of Labor (Mx: Antibiotics)

Mastitis in breasftfeeding:

continue breastfeeding, Cloxacillin

Early Breast Milk Jaundice

ŒExaggerated Physiological Jaundice

ŒOnset < 4 days of life

Late Breast Milk Jaundice

ŒBreast Milk Jaundice

ŒOnset 4-14 days

Œcompetitive inhibition of glucuronyl ransferase by nonesterified long chain fatty acids in

reast milk

ŒMx: Stop breastfeeding for 2-3 days /

Give Formula Milk [Jaundice comes down quickly] -> Resume Breastfeeding

Any jaundice @ Birth is PATHOLOGICAL

Success of Contraceptives

Norplant > OCPs > Barrier

Norplant: quick return to fertility

DMPA: 18 months for fertility to return

Complete Mole:

Diploid; 46, XX; has higher malignant potential

Kernicterus never occurs with:

Œphysiological jaundice

Œexaggerated physiological jaundice

Œbreast milk jaundice

Features of Pathological Jaundice:

Œpresent @ birth

Œincrease in bili. > 5 mg/dL/day on first day

ŒBili. >12 mg/dL [term] or Bili. >14mg/dL [preterm]

Œpersists > 1 week of life

ŒConjugated Bili. > 1 mg/dL @ any time.

Aster's Notes 57 of 111
Wessel Criteria for Infantile Colic

Unexplained Crying:

Œ> 3 hr/day,> 3 d/week, > 3 weeks, 3 m old child

ŒDo Urinanalysis

ŒReassure

ŒNo treatment necessary

ŒBottle-fed infants have higher incidence

ŒDicyclomine: risk of apnea

After a feed, allow "burping" and lay the child on

(R) side of abdomen

Introduce Solid Foods @ 6 months age

Vaginal pH < 4.5: Candida

Vaginal pH > 4.5: Bacterial Vaginosis

Transfusion Reactions

Fever: Leukoagglutination (donor WBCs)

Mx: acetaminophen

Anaphylaxis (donor proteins,severe in IgA-deficiency)

Mx: Epinephrine, Steroids

Hemolysis (ABO mismatch)

Mx: stop transfusion, hydration & diuresis

Familial Short Stature: NORMAL BONE AGE

Constitutional Delay: DELAYED BONE AGE

Short Stature with Webbed Neck is seen both in Turner's (XO) & Noonan's (normal

Sex chromosomes)

Budesonide has proven to be beneficial in Croup (along with racemized epinephrine)

Rx of choice for AOM in primary practice:

Amox ===> Cefaclor (if no response to Amox)

Transmission of Common Cold:

Indirect Spread is more important than Aerosol spread

Absolutely no antibiotics in common cold

(even if patient demands it!).

Aster's Notes 58 of 111
Erysipelas: Gp. A â-hemolytic Srep.

Impetigo: Staph. or Strep. [Bullous - Staph.]

Coxsackie A16: Hand Foot Mouth Disease

Pitryasis rosea: Herald Patch

PNEUMONIA

2 wks: GBS

2 wks - 4 m: Chlamydia trachomatis


 * 1) 1 Bacterial: Strep. pneumoniae

4 months - 4 years: Mycoplasma pneumoniae


 * 1) 1 Bacterial: Strep. pneumoniae

> 4 years: VIRAL


 * 1) 1 bacterial: Strep. pneumoniae

Antibiotic Rx of Occult Bacteremia

does not decrease the occurence of meningitis

Yersenia entercolitica: can mimic acute appendicitis (no Rx necessary - self limiting)

ROTAVIRUS G/E is preceded by URI symptoms

Rec. Abdo. Pain Syndrome

- 10% prevalence

- school phobia

- no organic signs

- no Rx necessary

Growing Pains

- B/L deep pains

- can awaken child from sleep

Mx: exercize program

SCFE

Œoverweight and sedentary "teenage" BOY

ŒGroin Pain/ Knee Pain

Dx: X-Ray

Mx: Surgical fixation.

Aster's Notes 59 of 111
LCP

ŒAvascular necrosis of femoral head

ŒLIMP

Œhip pain or referred knee pain

(knee is NOT TENDER to palpation)

Osgood Schlatter

Œtenderness over tibial tubercle

Œaggraveated by activity

Œoccurs in pysically actve males around puberty

Mx: Limit activity, NSAIDs;

(if severe) Knee immobilization splint

Teenager with knee pain aggravated by climbing stairs: Patellofemoral Syndrome

Child with Limp / Hip Pain

- preceded by URI

- Fever (+)

- normal ESR

TOXIC SYNOVITIS [Sterile Hip Effusion]

Mx: Rest / NSAIDs (NO ANTIBIOTICS)

Foot dorsiflexes easily

banana shaped sole: Congenital calcaneovalgus

kidney bean shaped sole: Metatarsus adductus

Intoeing

patella points forward: Internal Tibial Torsion

patella points medially: Excessive Femoral Anteversion (#1 cause of intoeing in

children)

CTEV: inability to dorsiflex

Mx: progressive serial casts,

posteromedial release of heel cord


 * 1) 1 substance of abuse: Alcohol

Nocturnal Enuresis

Œ> 4 years

Œmajority of children do NOT have any physical or psychiatric disorder

ŒMx: Behavioral modification

Bell / Buzzer system

d/o/c: dDAVP (no longer IMIPRAMINE).

Aster's Notes 60 of 111
Encopresis: > 4 y.

Enuresis: > 5 y.

Allergic Rhinitis:

ŒHyperemic Nasal Mucosa

ŒClear Discharge

ŒBluish-purple rings around eyes (SHINERS)

ŒIx: Nasal smear for Eosinophils

ŒMx: elimination / inra-nasal corticosteroids

Child with rash on introduction of "whole milk":

Atopic Dermatitis

Mx: Cow Milk > Formula Milk > Soy Milk

(Cow milk allergic might show allergy to soy milk, too)

Diaper Rash

ŒCandidal: Satellite lesions

ŒSeborrheic

ŒPrimary Irritant Dermatitis:

maceration with sparing of henitocrural folds

(Mx: frequent changing, washing,

no occlusive plastic pants, ZINC OXIDE,

NO ANTIBIOTICS)

Innocent Murmur in Children

Œprevalence: 50%

Œaccentuated by sitting, anxiety, fever, tachycardia

Œmid to low sternal border

Œsystolic

Œno thrill

Œvibratory or musical in quality

[Still's Murmur]

Common Cold: Steam Inhalation provides superior relief of nasal congestion cf.

antihistaminics

£Decongestants (sympathomimetics) :

can cause CNS overstimulation

£Cough Suppressants (Dextromethorphan) :

can cause respiratory depression in children


 * 1) 1 complication of sickle cell disease

Painless Hematuria (Paillary Necrosis).

Aster's Notes 61 of 111
Priapism in Sickle Cell Disease

> 6 hrs. : Hospitalize

no effect on future erectile function

may respond to Nifedipine / NTG

Complications of Sickle Cell Disease

- Hemolytic Crisis

- Vaso-occlusive crisis

- Aplastic Crisis

- Splenic sequestration crisis

- CVA

- Renal Papillary Necrosis

- LOwer extremity skin ulcers

- Proliferative retinopathy

Mx of HbS disease

ŒOxygenation

ŒPneumococcal vaccination

ŒFOLATE supplementation

ŒProphylactic antibiotics (Penicillin till age 5)

ŒNarcotic analgesia for pain crisis

ŒCVA: Exchange transfusion

ŒPainless Massive Hematuria: e-ACA

ŒHydroxyUrea for frequent vaso-occlusive crisis

ŒBone Marrow Transplantation

(Age < 16, availability of Bone Marrow Donor)

STROKE / TIA in Sickle cell disease is an indication for exchange transfusion to keep

the HbS < 50%

HbS disease 'per se' can lead to restrictive lung disease -> hypoxemia -> increased

sickling tendency

Avoid use of MEPERIDINE in severe chronic pain (short T1/2)

Malignant Hyperthermia:

Mx-Dantrolene

Symp. AORTIC STENOSIS: high perioperative risk

In preop pts. with A. Fib. : achieve rate control

In preop pts. on Diuretics : Get Electrolyte Levels.

Aster's Notes 62 of 111
Avoid elective surgery in patients with

significant hepatic dysfunction

Indications for Intra-op Insulin

- IDDM : any surgical procedure

- NIDDM on Insulin : any surgical procedure

- NIDDM on OHA : major surgical procedure

Prophylactic preop antibiotics only decrease the incidence of wound infection

(no effect on postop pneumonia, UTI, sepsis) : CEFAZOLIN is a good choice

elderly with repeated falls with dementia / seizures:

look for chronic SDH

stool impaction can cause urinary incontinence

Breast Cancer with BRCA1 gene: Better prognosis

Breast Cancer with HER2/neu gene: POOR prognosis

Kaposi's: HHV8 (Male Homosexuals)

Cyclophosphamide: Mesna

Methotrexate: Leucovorin

Cisplatin: Amifostine

Doxorubicin: Dexrazoxane

Mx of chemotherapy induced dry mouth:

Pilocarpine Hcl 5-10 mg PO TDS

Assessment of Doxorubicin toxicity: MUGA scan

Neutropenia:

requires antibiotic prophylaxis for G(-) / fungus

Competent individuals @ the end of life have right to refuse nutrition and hydration

Cutaneous absorption of drugs is 3 times more in children than in adults

Topical drugs c/i in pregnancy

1. Podophyllin

2. Isotretinoin

3. Lindane.

Aster's Notes 63 of 111
most appropriate initial investigation in â-Thalassemia: CBC with red cell indices

SLE: decreased C3/C4

Dumping Syndrome post-Bilroth II

- Dietary modification

- Octrotide

- (fails) Bilroth I conversion

75%-95% of AAAs are infra-renal

- Dx: U/S abdo.

Food poisoning: < 6 hrs. after food intake

- S. aureus (mayonnaise / salad dressing)

- B. cereus (fried rice)

> 16 hours / poultry consumption: C. jejuni

Carbamazepine intoxication

- QRS prolongation : predisposes to

- QT lengthening

Defib. followed by pulseless electrical activity

- Hypovolemia

- Hypoxia

- cardiac tamponade

- pneumothorax

- massive pulmonary embolism

- drug toxicity

- hyperkalemia

- acidosis

- massive MI

Coarctation of aorta is associated with

Bicuspid aortic valve in 70% cases.

Aster's Notes 64 of 111

 * 1) 1 cause of GI h'age following AAA repair is:

Colonic Ischemia (not stress gastritis)

Early onset wound infections: Strep / Clostridium

Dementia:

Visuospatial: Alzheimer's

Gait disturbance / Urinary Incontinence: NPH

Delayed DTR: Hypothyroidism

Myoclonus: CJD (Creutzfeld Jacob Disease)

Alzheimer's with agitation: use HALOPERIDOL

(not BZDs -> they can aggravte agitation)

Testicular tumors

Œ#1 seminoma

Œincreased incidence in cryptorchidism

Œmetastatize to retroperitoneal nodes

Œinguinal nodes involved only with scrotal spread

ŒChildren: Embyonal Cell Ca.

ŒAdults: Seminoma

Œ> 50 y: Lymphoma

ŒDx: Testicular Ultrasound (no BIOPSY)

Mx: Inguinal exploration & cross clamping of cord

& Orchiectomy

Pregnancy:

Œincreased tidal volume

Œdecreased BP (decreased TPR – progesterone)

ŒHb decreases (dilutional effect)

TV U/S > sensitive cf. Abdo. Scan for ectopic preg.

Fat Embolism: associated with Eosinophilia & Lipiduria

Shoulder Pain

Rotator Cuff Injury:

best elicited by positioning of the reater tubercle of humerus beneath acromion

Subacromion bursitis:

elicited by palpation over deltoid

Biceps tendinitis:

aggravated by flexion or supination of elbow

Acromioclavicular arthritis:.

Aster's Notes 65 of 111
elicited by crossed arm adduction against resistance

RANSON CRITERIA

at admn. @ 48 hours

Age > 55 Fall in Hct > 10%

WBC > 16000 Fluid deficit > 6L

Bl. Glu > 200 S. Ca ++ < 8.0

LDH > 350 PaO 2 < 60 mmHg

AST > 250 BUN increase > 5 mg/dL

Base deficit > 4 mEq/L

Rx of sigmoid volvulus: Sigmoidoscopy

(Sx required if s'copy fails)

Hemodialysis in CRF

ŒUremia

ŒPericarditis

ŒAcidosis

ŒHyperkalemia

ŒUnresponsive Volume Overload

AIDS Chemoprophylaxis

CD4 < 200: PCP

CD4 < 100: Cryptococcus

CD4 < 50: MAIC

Cryptococcal Meningitis: very high CSF pressure

(serial lumbar punctures may be warranted)


 * 1) 1 cause of inracranial mass lesions:

Metastasis (not primary brain tumor)


 * 1) 1 benign liver neoplasm:

HEMANGIOMA (not Hepatic Adenoma)

Propylthiouracil: can cause agranulocytosis

smoking is a relative c.i. to OCPs - not absolute


 * 1) 1 cause for osteomyelitis: S. aureus

Bed Rest has no proven benefit in chronic low back pain & threatened abortion.

Aster's Notes 66 of 111
Significant Hematuria: > RBCs/HPF

Significant Pyuria: > 10 WBCs/HPF

increased PEEP causing hypotension/hypoxemia -> consider pneumothorax

Confirm erythema nodosum by SKIN BIOPSY (Conservative Mx) -> Steroids for

persistent Pain

Change in Antipsychotics should be done

within 2-4 weeks, if no desired effect

Ice should not be applied on snake bite site ->

can delay efflux of venom by causing vasoconstriction

Severity of AS: late peaking murmur & delayed and weak carotid upstroke

Hymenoptera anivenom is not available

Even after treating anaphylaxis with S/Q Epinephrine -> monitor patient in ED

(patient is not risk-free, complications can develop)


 * 1) 1 cause of fever in AIDS, without overt symptoms: MAC (Rx Ethambutol +

Clarithromycin)


 * 1) 1 cause of Seizures in AIDS: TOXOPLASMOSIS


 * 1) 1 cause of dysphagia in AIDS:

Candidal Esophagitis

Suspected child abuse:

inform child protective services

(Hospitalize only if child's conition requires it)

ITP : improvement with splenectomy but platelet counts falls again (Ix:

radionuclide spleen scan for splenic remnant)

HSP: usually remits in 1 week (Mx is conservative) - Leukocytoclastic vasculitis


 * 1) 1 cause of hematuria after URI: IgA nephropathy

ABI < 0.4 - sever vaso-occlusive disease

Mx: surgical revascularization.

Aster's Notes 67 of 111
Oliguria in hospitalized pt. -> assess pulmonary wedge pressure (to diff. hypovolemia

and ATN)

Fibrinogen is the most abundant acute phase reactant (responsible for increased ESR)

Age, Myeloma, Macroglobulinemia, Hypoalbuminemia increase ESR

Number-needed-to-screen is reciprocal of absolute risk reduction

Celiac Sprue: dermatitis herpetiformis Mx: Dapsone

Localization of extra-adrenal phaeo: MIBG scan

suspected phaeo

1.catecholamine levels

2.if levels elevated, Imaging

(imaging, done first, will lead to detection of incidental adrenal masses – high

prevalence)

Preop prep in Phaeo

full á blockade followed by â blockade (not vice versa)

Antidote for Mg toxicity is Calcium Gluconate

Mild pre-eclampsia: Bed Rest and Monitoring

Severe pre-eclampsia: Hospitalization,

Control of HTN, MgSO4 infusion

Dx of Hemachromatosis (Gold Standard):

Hepatic Iron Index (not HFE Gene analysis)


 * 1) 1 cause of TEN : Adverse Drug Reaction

Rapid Correction on HypoNa: CPM

Frozen shoulder = adhesive capsulitis

takes months to regain full function

(steroid injections can hasten recovery)

Orchiopexy in Cryptorchidism @ 1 year age

Orchiopexy deceases the proportion of seminomatous malignancies - but total risk of

malignancy stays the same.

Aster's Notes 68 of 111
Urine dipstick only detects albumin,

24 urinary protein assessment detecs all proteins

(Myeloma light chains will not be detected by dipstick)

Bone scan has no role in lytic lesions of myeloma

Hypotension in Meningococcemia:

Waterhouse-Frederrikson syndrome

Macrolide antibiotics prolong QT interval:

V.Tac.->Syncope

Kartagener's:

Sinusitis / Bronchiectasis / Infertility / Situs inversus

Disulfiram : slow excretion from the ody. Adverse reactions can occur even 1-2 weeks

after cessation of therapy. Disulfiram is not an option for long term alcohol abstinence

Statin therapy: monitor LFTs regularly

(CPK only if rhabdmyolysis is suspected)

Intravascular Catheter related infection :

Staph. epidermidis / S. aureus

(use Vancomycin, cultures pending)

Arterial Clots: Anti-PL antibody

Venous Clots: #1 inh. cause: Factor V Leyden

Postcoital contraception: is not 100% effective

(Progestin-only Pills are safer than OCPs)

HIRUDIN: is a direct thrombin inhibitor approved for use in pts. with Heparin-induced

Thrombocytopenia

Pulmonary Embolism: CXR is usally NORMAL


 * 1) 1 finding on EKG: Sinus Tachycardia

- Hampton's Hump: seen in Pulmonary Infarction

- Westermark's Sign: sign of Pulmonary Oligemia

Meningococcemia: seen in C5-C8 deficiency

Meningococcal vaccine: Polysaccharide vaccine (A,C,Y,W135).Aster's USMLE Step3 Notes

Aster's Notes 69 of 111
Neutropenia with Fever: (Neutropenia = < 500/mcL)

suspect Pseudomonas

Piperacillin/Tazobactam & Gentamycin

(or Ceftazidime)

if central line is present: Add Vancomycin

[Continue antibiotics even if cultures are negative]

Indomethacin: can decrease amniotic fluid production

Indications for CONIZATION

1. non-visualization of transformation zone

2. "pap" worse than bopsy

3. AdenoCa.

4. (+) endocervical cuerettage

5. Microinvasion on Bx

(+) F/H is not a risk factor for Ca. Cx

Neuroblastoma metastasis:

can cause periorbital ecchymosis / proptosis

- increased urinary VMA

- N-myc gene

PEPTO-BISMOL: affects platelet function

(can prolong bleeding time)

"popcorn" calcification in SPN : Hamartoma

Mx of SIADH: Fluid Restriction

Mx of malignant SIADH: Demeclocycline

"pop" or snap in knee : ACL tear

[Knee Immobilization / Crutches]

post-URI abdo pain / vomiting / RUQ mass in a child: ? Intussusception [Barium Enema

- Rx & Dx]

Legitimate Vanco. use :

â-Lactam resistant Staph. epidermidis.

Aster's Notes 70 of 111
Vit. A toxicity can cause Hypercalcemia

Gatsric ulcers: located on lesser curvature

within 1cm of gastric antrum

Adrenal Mass > 4cm & High Hounsfiled Values:

high chance of being malignant

Most ensitive test for Cushing's:

24 hour urinary cortisol

(levels are subject to diurnal variation)

Bilroth II:

Afferent Loop Syndrome (Pain after meal ingeston) Mx: Bilroth I conversion, roux-en-y

gastrojejunostomy

Blind Loop syndrome (bacerial overgrowth, malabs.) Mx: antibiotics

â-Thalassemia major: HbF increased

â-Thalassemia trait: HbA2 increased

Risk of Postop DVT


 * 1) 1 Elective Knee Arthroplasty


 * 1) 2 Elective Hip Arthroplasty


 * 1) 3 Hip # Repair

highest risk with ELECTIVE KNEE ARTHROPLASTY

Cocaine use assoc. MI:

combination of spasm and plaque rupture

(don't assume spasm is the cause, do angiography)

Pappenheimer's Bodies: Iron inclusions in RBCs

Rhabdomyolysis:

Hypocalcemia, Hyperkalemia, Hyperphosphatemia

Diverticulosis: #1 complication - BLEEDING

85% bleeds stop spontaneously

(#1 complication is not Diverticultis)

DIVERTICULITIS:

ŒPolymicrobial.

Aster's Notes 71 of 111
ŒBroad spectrum antibiotics

Œno barium enema / colonoscopy

h/o Malig. Hyperthermia with succinylcholine:

use NITROUS OXIDE in future anesthesia

Chronic Fatigue with normal physical exam: DEPRESSION INVENTORY -> Thyroid

studies

IE -> Mycotic Aneurysm -> Bleeding -> SAH

[embolization of bacteria to the brain)

IFN-â: decreases relapse frequency in MS

First Episode of DVT:

Heparinize -> Warfarin for 3-6m (INR 2.0-3.0)

Recurrent DVT:

Lifelong "Warfarin"

[if Warfarin is not tolerated : ENOXAPARIN]

Fever / Sore Throat / Atypical Lymphocytes

(without LN / Splenomegaly / MonoSpot) : CMV

Colles' #: splinting in NEUTRAL postion

(not in FLEXED position)

PSA levels in Prostatic Ca. correlate with lymphatic spread

Antibiotics in postpartum endometritis:

I/V Imipenem / Cilastatin

Vaginal Delivery in Breech

1. FRANK BREECH

2. Fetal Weight between 2000-3000g

3. Gynecoid Pelvis

Rx of Catatonia: Lorazepam

Incisions done for pre-existing infections and abscesses are considered INFECTED

WOUNDS

Severe Depression with Psychosis: Mx with ECT.

Aster's Notes 72 of 111
Hypertensive Heart Disease: S4 Gallup (LVH)

Depo-provera: - associated with Irregular bleeding

(use conjugated estrogen x 7 days to control bleeding)

Peak CPK levels:

give idea about size of an infarct

(no prognostic value)

Nephrolithiasis with increased Creatinine:

IVP can not be done

(No I/V CONTRAST in the setting of renal dysfn.)

Renal and Bladder Ultrasound Scan, instead

HTN in Graves' disease: Rx with â-blockers

Anti-Ro: associated with neonatal Lupus

(resolves in 6 months) and Congenital Heart Block

Lupus anticoagulant

Œanti-PL

Œrecrrent abortions

Œthrombotic state (arterial + venous)

Œ"in vitro" increased PTT

(doesn't correct with mixing)

ŒRussel Viper Venom Time

Doxepin (a TCA) is useful in chronic urticaria

suspected ADHD: get psychometric tests

Misleading Low Sodium is caused by Hyperglycemia

Mx of acute mountain sickness: acetazolamide

Dx of Sarcoidosis:

ŒBiopsy

ŒKveim test is obsolete

ŒACE levels are elevated in 50% pts.

Rx of Brown Recluse Spider Bite: DAPSONE

Middle Ear Effusion persisting for 4-6 months following an adequate course of.

Aster's Notes 73 of 111
antibiotics, with significant hearing loss (especially bilateral), is an indication for

myringotomy and insertion of tympanostomy tubes.

Chlamydial Ophthalmia:

Rx with SYSTEMIC ERYTHROMYCIN

(to prevent chlamydial pneumonia)

Appropriate Initial Test for suspected B12 def:

Serum B12 levels

(many patients have normal CBC and normal indices)

fruity breath odor: ketosis

prolonged latent phase of labor :

Œtherapeutic rest & sedation (usually morphine).

ŒNo Oxytocin / No Amniotomy

DtaP contra-indications:

1.previous febrile reaction: fever > 105 F

2.h/o seizures

(F/H of seizures is not a contra-indication)

Rx of choice for SVC syndrome:

Radiation

First HiB vaccine @ 2 months age

Female > 40y with abnormal vaginal bleeding Endometrial Bx to r/o Endo. malig.

Atrial Flutteris not a serious arrhythmia, but cardioversion should be attempted in the

presence of CHF.

Atrial Flutter due to Digitalis toxicity:

PACEMAKER

Anorexia nervosa:

BUN increase

Low Platelet Count

Leukopenia with relative lymphocytosis

elevated serum carotene levels

Legionaire's disease:.

Aster's Notes 74 of 111
Person-to-person spread has not been documented

Childhood obesity is not a predictor for adult obesity

long-term Rx of obesity in children : usually fails

Thoracic outlet syndrome:

appearance on numbness and paraesthesiae

with arm abducted to 90 degrees and externally rotated

(not defined by the disappearance of radial pulse)

Postmenopausal with stress incontinence:

Kegel exercizes, pessary, estrogen replacement

Retractile Testes:

Œexaggerated cremasteric reflex

Œtemporary

Œresolves in adolescence

Œno increased risk of malignancy

Flail Chest: Intubation & Assisted ventilation

(Strapping of Chest may lead to hypoxia & atelectasis)

Vaginismus is involuntary contraction

Behcet's: cutaneous hypersensitivity

60-70% will develop a sterile pustule within 48 hours of any aseptic injection

epidydimitis -> check age of pt.

< 35: Chlamydia, Gonococcus

> 35: E.coli

Gold stadard for diagnosis of melanoma:

BIOPSY

Treatment of alcoholism in wife-batterers does not treat battering behavior

Pt. with hemoptysis and normal chest film:

Fibre-optic bronchoscopy

(PPD is not indicated)

F/U COPD progression with FEV1.

Aster's Notes 75 of 111
Tick paralysis (neuro-toxin mediated): 10% mortality

prompt resolution if tick is identified and removed

Let children attend funerals, if they want to. They should be accompanied by adults who

can provide comfort and support

Hyperparathyroidism: inc. incidence of Pseudogout

NIACIN: can be associated with hepatotoxicity

rear-facing infant seats should be on the back seat.

< 12 y children: ride secured on car backseat

Headache onset with exertion, such as weight-lifting:

serios sign (look for CNS malformations & vascular malformations)

Minocycline: has anti-inflammatory action

(has been used in Rheumatoid Arthritis)

Gynecomastia in adolescence: Observation

Long standing Gynecomastia: SURGERY

HCM: EKG is abnormal (LVH, WPW, abnormal Q wves)

Ticlopidine: has been associated with neutropenia

Immediate gastric lavage is ot indicated in strychnine poisoning

Continuous gastric lavage: PCP overdose

Not all persons with anaphylaxis will have a repeat

reaction when exposed again to the agent. Repeat reactions are usually less severe.

Head, Neck, Face sutures:

leave in place for 3-5 days (rapid healing)

Eclampsia: MgSO4

(no role of anticonvulsants)

Clonidine withdrawl: Hypertensive Crisis.

Aster's Notes 76 of 111
The woman's need for physical intimacy often increases during pregnancy.

Abstention from intercourse in the last month of normal pregnancy is not necessary

Valsalva maneuver decreases the venous return to the heart, thereby decreasing

cardiac output. This decreases murmurs due to AS, MR, PS, but increases the

murmur due to HCM

FOBT testing does not decrease the mortality from colorectal carcinoma


 * 1) 1 symptom in vaulvar carcinoma: Pruritus

Of the anticonvulsant, VAPROATE has the least effect on hepatic enzymes and

therefore has the least impact on decreasing the efficacy of OCP's

Gilbert's syndrome: lower levels of unconjugated bilirubin cf. Crigler Najjar (6-45 mg/dL)

Menopause: Serum FSH increased

Estradiol decreases, and Estone becomes predominant estrogen.

Infiltration of local anesthetic agents (less pain):

Œwarm solution

Œsmall needles

Œslow infiltration

Œaddition of bicarbonate to the mixure

Mg-containing antacids in CRF:

can cause magnesium toxicity

Postherpetic neuralgia: higher incidence in older pts.

ANA titre < 1:160 is common in healthy older people

Orthostatic hypotension:

Drop in Systolic > 20 mmHg

Drop in Diastolic > 10 mmHg

Mx: discontinue any drugs that might be responsible

-> arise slowly -> elastic stockings -> Fludrocortisone

B pertussis is being recognized as a cause of

persistent cough in adults. (associated with dysnea, tingling sensation in throat)

d/o/c for Giardiasis in children: Furazolidone.

Aster's Notes 77 of 111
Tinea capitis: Oral Griseofulvin

poor response to topical medication

Males with impotence, decreased libido & decreased testosterone: order a prolactin

level

(r/o pituitary adenoma)

Pre-term infants: normal response to immunization

(although they have relative immunodeficiency)

Drug indiced LE: anti-histone antibodies

[ANA (+), Anti-dsDNA absent]

Œhydralazine, isoniazid, procainamide, penicillamine

ŒMx: discontinue medication + short-course of glucocorticoids

Œdisease lasts < 6 months

ŒANA may remain (+)

Œmost lupus inducing drugs can be safely used in SLE, if no alternative exists

HCM: sudden death in athletes

Dx: Echo Rx: â-BLOCKERS

Valsalva maneuver increases murmur

ITP: low platelet, BM aspiration shows numerous megakaryocytes

Risk of suicide: Female Physicians > general females

Physicians' risk of suicide

Psychiatrists > Ophthalmologist > Anesthesiologist

Anaphylaxis: Epinephrine

Juvenile Rheumatoid Arthritis:

very few patients are left with disabilty / deformity. At least 50% remit fully and majority

regain normal function

Urticaria > 48 h :

Skin Biopsy to r/o Urticarial Vasculitis

Mobitz Type II Heart Block: Mx is PACEMAKER.

Aster's Notes 78 of 111
Stage IA Hodgkin's: Radiotherapy alone is effective

Total Hip replaement:

Œimmediate relief

Œperioperative anticoagulation

Œsuccessful (no need for revision in 90%)

Œbone resorption is a major concern for long-term stability of implant

Pressure Ulcers:

Stage I: Nonblanching Erythema

Stage II: Broken Skin with partial thickness skin loss

Stage III: Full tickness skin loss (extension into subcutaneous fat)

Stage IV: Extension into Muscle or Bone

"kennel cough" is produced by a canine Bordetella

Risk factor for domestic abuse: female gender

Trochanteric bursitis

Œpresents with a deep, dull, aching pain

Œburning & tingling in lateral upper thigh

Œworse with activity

Œexcacerbated by sitting cross-legged with affected leg

The mortality rate for pneumococcal pneumonia is same for the past 50 years

SKIN SWELLING with Bee sting: local reaction

[not anaphylaxis]

Rx of Restless Leg Syndrome: Clonazepam

Alendronate: Pill-induced esophagitis

TCA withdrawl symptoms (cholinergic symptoms) : best managed with Benzotropine

(Anti-Ach)

Aspartame is c.i. in children with PKU.

Aster's Notes 79 of 111
Diaphragm & spermicidal jelly:

insert upto 2 hrs before intercourse

and leave in place for 6 hrs after intercourse

(for repeated intercourse, re-apply jelly)

Asthmatics who require â2-agonists > once/day; can be prescribed inhaled

glucocorticoids

Psoriasis in infancy: begins n diaper area (the area of greatest trauma)

Labia minora adhesions:

Œnot present @ birth

Œacquired condition

Œno urinary retention

Œnot assoc. with other anomalies

Œsurgical correction has a 100% recurrence rate

Œestrogen cream can lyse the adhesions

Carbidopa/Levodopa do not alter the progression of Parkinson's disease

Chronic Choleystitis with Cholelithiasis is frequently non-visualized on ultrasound.

Umbilical hernia in a child < 6m

Mx: Conservative [Strapping is ineffective]

(usually disappear by 1 year of age)

Surgery for strangulated hernia; persisting beyond 4y

Increased Postop Cardiac Death

ŒS3 Gallop

Œh/o MI in the past 6 months

ŒFrequent PVCs

ŒAortic Stenosis

Supression of lactation: breast inder & cold pack

[Bromocriptine is not approved for this purpose]

Cardiac Pacemaker: does not warrant IE prophylaxis

Pubertal development in an adolescent girl:

Thelarche, Pubic Hair, Growth spurt, Menarche

(Growth spurt precedes Menarche).

Aster's Notes 80 of 111
Most sensitive and specific means of diagnosing appendicitis is history and physical

exam.

(not CT or U/S)

In stroke, overzealous antihypertensive medications can reduce cerebral perfusion and

increase tissue damage.

Scabies in young children:

Permethrin

[Lindane not approved]

Wheezing in children may also be due to GERD

A single sexual encounter with a person with genital warts carries a 60% chance of

transmission. Transmission occurs in asymptomatic state too.

Hydrocephalic children:

Œincreased developmental disabilities

Œlower IQ

Œlearning deficits

Œdefective verbal abilities

Œmemory and visual problems

Chlamydial infections:

Azithromycine & Doxycycline have equal efficacy


 * 1) 1 cause of hematemesis in healthy newborn:

comiting of swallowed maternal blood

Clinical privileges to physicians are granted by the GOVERNING BODY of the hospital

New onset LBBB may be an indication for thrombolysis even in the absence of

characteristic ST elevation of MI

Dexfenfluramine: 1º Pulmonary Hypertension

Transdermal NTG Patches: Rapid Tolerance

Oropharyngeal dysphagia in elderly:

? early Parkinson's

====[[Aster's Notest's disease of bone:

ŒHead Enlargement.

Aster's Notes 81 of 111
ŒDeafness

ŒNerve compression

Œincreased urinary hydroxyproline

Œincreased alkaline phosphatase

HIDA scan: Cholecystitis (+)

Œnonvisualization of the GB

Œvisualization of CBD & Bowel

Leading cause fo mental retardation in US:

Fetal Alcohol Syndrome

Rotavirus G/E: decreased incidence in breast fed infants. None of the antibodies that

develop after the first attack are protective

Grade 1 Vesico ureteral reflux:

prophylactic antibiotics and double voiding of urine

Sodium Nitroprusside infusion:

may increase Thiocyanate levels to toxic range (delirium, tinnitus, blurred vision)

Allergic bronchopulmonary aspergillosis is treated by corticosteroids (not

ANTIFUNGALS)

Childhood autism:

Echolalia, minimal eye contact, repetitive behavior

serum digoxin levels elevation can be seen in pts. treated with oral verapamil

Recurrent Zoster is rare

Cocaine > Coronary Spasm

(free basing can lead to loss of eyebrows/eyelashes)

Measles vaccine significantly reduces the chances of developing SSPE

Influenza A is usually sensitive to Amantidine

(resistance occasionally seen in institutionalized pts.)

Synovial Fluid in OA : High Viscosity

Children with diarrhea who are not dehydrated should be give age appropriate diet.

Aster's Notes 82 of 111
Loperamide: contra-indicated in children

Secondary Amenorrhea: give Progestin Challenge

Rapidly Progressive Periodonitis (with good dental hygiene) might be suggestive of

HIV / AIDS

Hyperosmolar nonketotic coma:

Œrequire less insuin for correction (cf. DKA)

ŒFluid deficit is larger (cf. DKA) (10 L)

Œpatients are older

Œcan also occur in Type 1 DM

The hypochondriac believes that his fears about disease are totally realistic. He also

believes that physicians are not acting in his best interests by disputing the reality of

these fears.

Hypochondriacs:

poor response to antidepressants

Old age:

Vital Capacity decreases

Functional Residual Capacity increases

Arterial Oxygen Tension slowly declines with age

Pasturella multocida:

Rx Amox-Clav

(Pn allergy: Doxycycline) [NOT ERYTHROMYCIN]

Place PPD on all individuals being admitted to a nursing home. Persons with doubtful

reactions should be tested a second time within 1-2 weeks (boosted reaction). This

second reading should be taken as the baseline reading for that person.

Tennis Elbow : Lateral Epicondylitis

(usually acquired occupationally)

Obesity lowers aminoglycoside volume of distribution necessitating decrease in

dosage

Primary indication of joint replacement in OA:

Severe Pain.

Aster's Notes 83 of 111
Postcoital test : best done in midcycle

Adhesive bands are now the most common cause of intestinal obstruction for all age

groups

(strangulated hernias are the m/c cause in children)

Rx for ANUG (acute necrotizing ulcerative gingivitis) PENICILLIN

Vasoldilators of choice for CHF

ACEIs

Use of TCAs in patients with glaucoma can precipitate acute angle-closure attacks (ant-cholinergic

properties)

The only absolute contra-indication to breast feeding is

GALACTOSEMIA

Major abdominal trauma in 3 rd trimester pregnancy:

evaluate for placental abruption & preterm labor

[electronic fetal monitoring: obtain reactive NST]

Transient cortical blindness due to mild head traums usually recovers (benign outcome)

Pneumococcal vaccine: not before 2 years of age


 * 1) 1 cause of microscopic hematuria in elderly is BPH

Polychlorinated Biphenyls: skin rash called Chloracne

Ludwig's angina: infection of the deep fascial space of the submandibular space (early

airway compromise)

Mx: Intravenous steroid cover

Wilson's disease confirmed by inability to incorp. a copper isotope into Ceruloplasmin

Patients with procaine allergy usually tolerate Lidocaine (amide group) well

Always inject insulin in skin of non-exercized areas (to prevent exercize-induced

hypoglycemia). If the lefg is used as injection site, insulin absorption will be enhanced

with running leading to hypoglycemia..

Aster's Notes 84 of 111
Celecoxib: not to be used in patients with SULFA allergy

Passengers with stable medical conditions requiring low-flow oxygen cannot bring their

own oxygen on aircrafts according to Federal Air Regulations concerning hazardous

cargo. Most air carriers will provide O2 for a fee

Do not fly within 3 weeks of a MI

No air travel with term pregnancy

OCD

ŒSSRI

ŒResponse prevention & in vitro exposure

Don't give OPV to a child whose sibling is immunodeficient

Post MI Risk Stratification is done with an Exercize Stress Test (for patients who can

exercize). For patients who can not exercize, a Pharmacological stress testing or

Dobutamie Echo is indicated (both are less sensitive than Exercize Stress Testing)

Continue ASPIRIN in the post-MI period

Antiplatelet agent Post-stent placement:

Clopidogrel (ADP receptor inhibitor)

Abciximab (anti-IIb/IIIa)

(decrease restenosis rates)

The choice of agents in asthma therapy is determined by frequency of asthma

symptoms

The presentation & management of acute cholecystitis in pregnant patients is the same

as in non-pregnant population (Lap Cholecystectomy). Fetal otcome is the best in 2 nd

trimester

Hyperactive children: hypoperfusion in frontal lobes

NPH: order CT scan head to r/o ICSOL

(confirm NPH by documentation of improvement in symptoms with serial lumber

punctures)

Severe pre-eclampsia:.

Aster's Notes 85 of 111
Œdelivery @ term

ŒMgSO4 for seizure prophylaxis

Œantihypertensives for BP control

ŒMgSO4 is not an antihypertensive.

ŒControl of BP alone does not obviate the need for seizure prophylaxis

Suspected PCP in AIDS: Obtain a Chest X-Ray

Migraine prophylaxis: â-blockers

Migraine treatment: Sumatriptan

Somatization disorders: 1 st step in Mx

avoid un-necessary Ix & medical/surgical treatment

Community acquired pneumonia: S pneumoniae

Rx: Macrolide (Clarithromycin)

Patient presents to the office with unstable angina:

1 st step: Chew & Swallow Aspirin

Vaginal douching > 3-4 times / month:

associated with alteration of vaginal flora and increased incidence of PID

Prolonged survival in CHF: ACEI's

A fecal gram stain is always positive for bacteria and is not indicative of any pathology.

Inflammatory Bowel Disease: Fecal Leukocytes(+)

Gold standard for Dx of IBD: COLONOSCOPY

Critical Aortic Stenosis: Valve Repair Surgery

(Valvuloplasty in high risk due to other co-morbidity)

Spinal metastasis: Emergent Radiotherapy

COPD patient who still smokes:


 * 1) 1 step is smoking cessation

(immediate effect on declining lung function)

COPD patients should receive annual influenza vaccine (not HiB vaccine, it is only

given to children).

Aster's Notes 86 of 111
Dx of Adenomyosis: MRI (most accurate)

(U/S has lower sensitivity and specificity)

Abnormal Vaginal Bleeding:

Periodic, abnormal flow: Anatomic cause

Irregularly Irregular: Endocrine cause

Routine screening of asymptomatic population for dyslipidemia:

NONFASTING SPOT CHOLESTEROL

Screening of population with CAD/risk factors:

FASTING LIPID PROFILE

(non fasting random spot cholesterol not indicated)

Patient must have quite smoking 15 years ago

for it to not count as a risk factor for CAD

Digoxin with or without a nodal blocking agent (beta-blocker) is effective in

achieving rate control in Atrial Fibrillation

Chronic A.Fib.:

associated with enlarged Left atrium

Medical emergency in a physician's office:

1 st step is to initiate call to “911”

beta-blockers improve outcome in patients at cardiac risk undergoing non-cardiaovascular

surgery

Mx of HTN in patients with migraine: â-blockers

Renal Failure: is associated with calcium wasting & secondary

hyperparathyroidism (Calcium supplementation is beneficial)

Patient with syphilis & penicillin allergy:

Do a penicillin skin test to confirm & perform desensitization if necessary

uncomplicated UTI:

Œperform urinalysis

ŒOral TMP-SMX (3 days)

Œno need for urine cultures.

Aster's Notes 87 of 111
The occurrence of PVCs post-MI is associated with increased mortality &

morbidity. Treatment of asymptomatic PVC's with anti-arrhythmics is not

indicated. (Such treatment is itself associated with increased mortality)

No role of prophylactic anti-arrhythmics post-MI

Initiate Calcium supplementation even in cases of prolonged secondary

amenorrhea

Exercize-induced amenorrhea

Œlow adipose tissue

Œestrogen biosynthesis shifts to 2-hydroxylation with increased synthesis of catechol

estrogens

Œcatechol estrogens compete with catecholamines for COMT

Œresults in inreased dopamine

Œdopamine decreases GnRH release

Œresults in secondary amenorrhea

Œwhatever the age, OCPs (for HRT) & calcium supplementation are required to prevent

bone loss

Mx of psychotic depression: ECT

Post-void urinary volume estimation:

Straight Urinary Catheterization

(U/S is inaccurate in estimating bladder volumes)

All GDM patients should be tested @ 6w post-partum with 2-hr (75g Glucose) Oral

GTT

GDM is a risk for DM unrelated to pregnancy (regardless of glycemic control in

GDM)

Klebsiella penumonia

Œnecrotizing pnemonia

Œhospitalized patients / aspiration / post-stroke & alcoholics

Œcurrant-jelly sputum (bloody)

Staph aureus: causes cavitatory pneumonia

(associated with rapidly progressive effusions & empyema)

Colon Cancer screening:

ŒFOBT annually

ŒColonoscopy q10y.

Aster's Notes 88 of 111
ŒSigmoidoscopy q5y

PSA estimation is not recommended for Prostatic cancer screening (if at all one test has

to be done, it should be Digital Rectal Examination)

Chronic Uterine prolapse:

Œfirst fit a pessary

Œprescribe estrogen cream

Œlater proceed to surgery (surgical failure rate is high when performed in the presence

of dry atrophic mucosa)

In any patient with pain of cardiac origin: EKG

(to differentiate between Ischemia & Infarction)

Inhaled corticosteroids:

long-term stabilization of severe asthma

(beta-agonists provide only symptomatic relief)

Hypotensive response to NTG drip in patients with inferior ischemia: Right Ventricular

Failure

(Mx: Stop NTG, Start I/V crystalloids)

suspected anemia: 1 st Ix – CBC

suspected Fe deficiency anemia: Serum Ferritin levels

Normocytic anemia: 1 st Ix – Reticulocyte count

h/o GI bleeds with DVT: not a candidate for anticoagulation

Alcohol induced dilated cardiomyopathy:


 * 1) 1 step – stop alchol intake to halt progression

Polycythemia vera: increased risk of stroke

Valsalva maneuvre: decreases pre-load

Jedrassik maneuvre: decreases after-load

Valsalva decreases HCM murmur,

Jedrassik increases HCM murmur

Ankle – Brachial Index:

< 0.5 suggests severe ischemia

(surgical revascularization required).

Aster's Notes 89 of 111
MVP without MR: no IE prophylaxis required

[absence of MR to be documented by Echo]

Pilonidal Cyst: infection of hair follicles in sacrococcygeal area. Mx: removal of hair /

I&D

Elderly with Knee “locking”: Medial Meniscal Tear

“pop” in he knee: ACL tear

pain in lateral knee, athlete: Iliotibial Band Syndrome

COPD @ any stage, smoking cessation in beneficial

Painless Testicular Enlargement

Œ? Malignancy [Embryonal/Seminoma/Lymphoma]

ŒUltrasound, no Biopsy

Œspreads to retroperitoneal nodes, if inguinal nodes (+), suspect scrotal invasion

ŒSx: Inguinal approach, not Scrotal (Orchiectomy)

Evaluation of lung malignancy: CECT (IV contrast)

Dermatomyositis: search for occult malignancy

Most testicular varicoceles are on the left side

Neomycine allergy: 5% of population (Treat with Steroids). It is a Type IV

hypersensitivity reaction

SCC Lip Risk factor: Smoking > Sunlight exposure

Hydrocele: typically idiopathic (No Rx required).

Persistent hydrocele: Refer to Urology for Sx

Tuberous Sclerosis: Skull X-Ray to look for intracranial calcifications

AFP increase: NSGCT

b-hCG increase: Seminoma & NSGCT

Li-induced hypothyroidism: Mx – levothyroxine

(not discontinuation of Lithium)

Latest recommendation advise Influenza vaccination for >50y instead of >65y.

Aster's Notes 90 of 111
suspected Pseudotumor cerebri:

LP (inc. CSF pressure)

complex partial seizure:

aura, behavioral arrest, automatisms

Myesthenia gravis: CT Chest to r/o Thymoma

Propranolol is associated with depression

Fluoxetine takes 6-8 weeks to act !

Asplenia: PneumoVax / HiB / Influenza vaccine

Headache excacerbated by position & exertion:

increased ICT (? mass lesion)

Mitral Regurgitation

1.Transthoracic Echocardiography

2.If quantification reqd.: TEE

3.Gold Standard for any valvular disease:

Cardiac Catheterization

Suspected Anemia: next step – CBC

MICROCYTIC ANEMIA, to Dx Fe.-def anemia:

SERUM FERRITIN (Gold. Std.: Bone Marrow Bx)

NORMOCYTIC ANEMIA, next step:

RETICULOCYTE COUNT

GI side effects are common with oral FeSO4. They are not an indication for

discontinuing therapy. Always assess response (% Retics) after Iron Therapy.

OCPs can prevent anemia, they do not treat established Iron deficiency anemia. (Rx:

Iron)

ABI < 0.5: s/o significant PVD (Sx revascularization)

Steroid Rx in suspected GCA: start without waiting for ESR / Temporal Artery Bx results

Excessive Cow's Milk Intake: Fe. Def. Anemia

Pericarditis: Diffuse ST elevation.

(...continued in Part III of Aster's Notes)

AstersNotesIII

AstersNotesI