Aster's Notes for USMLE step 3 - part I

Aster's notes for USMLE step 3 is a collection of about 100 pages of useful information that has a lot of information. We made the whole notes available online for your benefit on residentscafe.com.

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 Step3

6.www.familypractice.com.

to be continued

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 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 32 of 111

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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

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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

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(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

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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 B cell marker

CD19: pan T 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

Cyclosporin:

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-â: Multiple Scerosis

IFN-ã: CGD.

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

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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

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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 p

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

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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. epidermidis[[Vancomycin + Aminoglycoside]]

Prosthetic Valve Endocarditis (Late) - S. viridans[[Vancomycin + 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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Continued in

Asters Notes II