My Step 2CK notes

Structure

1. Disease Topic- Sx
2. Pathophys
3. NBSIM
4. Treatment
5. Also RF, Microbes, Moa, side effects of drugs
Surgery-

1.
2. Patients with cervical spine injuries are at risk of respiratory compromise. Orotracheal intubation with manual
stabilization of the cervical spine is recommended for initial airway management.
3. Polyarteritis nodosa segmental, transmural inflammation of middle-sized arteries luminal narrowing and
microaneurysms, thrombosis, organ ischemia. Kidneys and GI are affected. Associated with Hep B and C. Lungs
are spared

4.
5. Psoas abscess commonly presents subacutely with fever and lower abdominal or flank pain radiating to the
groin. The "psoas sign," abdominal pain with hip extension, can often be detected on examination. CT
scans are required to confirm the diagnosis, and drainage with antibiotics is the mainstay of therapy.
6. Vascular rings encircle the trachea and/or esophagus. Compression of the trachea may present with stridor;
compression of the esophagus may present with dysphagia, vomiting, or recurrent food impactions. Dx CT
scan, bronchoscopy, laryngoscopy and echocardiogram Tx surgical division of the structure that forms the ring
7. Heart failure is the leading cause of death in patients with infective endocarditis. Surgical intervention needed
for those with heart failure, local progression, difficult to treat organisms, persistent bacteremia, and large
vegetations.
8. Angiodysplasias in the gastrointestinal (GI) tract are a common source of GI bleeding. Bleeding from
angiodysplasias may be triggered by underlying aortic stenosis, which is associated with low levels of von
Willebrand factor multimers; this glycoprotein is often destroyed when it passes through the damaged valve at
high velocity.
9. Von-Hippel lindau syndrome  AD mutation in VHL tumor suppressor gene chr 3  retinal and cerebellar
hemangioblastoma, pheochromocytoma, renal cell carcinoma ( clear cell carcinoma) surveillance for
associated malignancies  eye/retinal exam, plasma or urine metanephrines, MRI of brain and spine, MRI of
abdmomen and tumor resection
10. Gallstone ileus results from small bowel obstruction due to a gallstone that has passed through a biliary-
enteric fistula. As the stone advances it may cause "tumbling" obstruction before ultimately causing complete
obstruction. Treatment involves surgical removal of the stone and cholecystectomy. Diagnosis can be
confirmed by abdominal CT scan, which may reveal gallbladder wall thickening, pneumobilia, and an
obstructing stone. Treatment is surgical and involves removal of the stone and either simultaneous or
delayed cholecystectomy.

11. Gynecomastia is abnormal growth of breast tissue in males and is generally due to an increased ratio of
estrogens to androgens. Even with a normal testosterone level, hyperestrogenism can lead to gynecomastia;
therefore, if serum testosterone is normal, a serum estradiol level should also be measured.
12. Weight loss is recommended for pseudogynecomastia (ie, enlargement of fatty but not glandular breast
tissue), which presents with soft, nontender breast enlargement without a distinct margin of glandular tissue.
13. Neurofibromatosis 2  Bilateral vestibular schwannomas  Bilateral sensorineural hearing loss and loss of
balance, AD, merlin gene on chr 22, intracranial meningiomas, cataract and cutaneous tumor or skin plaques.
Tumor surveillance for audiometry, ophthalmologic eval and MRI of brain and spine.
14. Testicular torsion  Painful scrotum after exercise, fail to illuminate and does not resolve with elevation of
the scrotum (negative prehn’s sign), negative cremasteric reflex (stroking the inner thigh elevates the testis) Tx
surgical exploration; if not manual detorsion
15. Jervell Lange Nielson  congenital long Qt syndrome  present in childhood  profound bilateral deafness
and arrythmia induced syncope during period of stress
16. Age >60 + smoker+ atherosclerosis + lower back pain  AAA
Hemodynamically stable  CT scan of abdomen.
Pain is the most common manifestation of abdominal aortic aneurysm (AAA), and it can vary according to
aneurysm location. Proximal AAA tends to cause upper abdominal, flank, or back pain. In symptomatic,
hemodynamically stable patients, the diagnosis is best made by abdominal CT.

17. Duodenal Hematoma  Handle bar injury Sx Epigastric pain, bilious emesis Dx CT scan of abdomen Tx NPO,
bowel rest, nasogastric decompression and parenteral nutrition.
18. Liver laceration is one of the most common complications of BAT but typically results in abnormal vital signs
(eg, tachycardia), right upper quadrant tenderness, and intraperitoneal free fluid (blood). Spleen and
duodenal laceration cause intraluminal or subcapsular hematoma
19. Prolonged postoperative ileus, the delayed return of bowel function >72 hours after surgery, is typically self-
resolving; therefore, management is conservative with bowel rest and serial examinations.
20. Small bowel-follow through usually diagnose obstruction but needs not necessary in case of postoperative
ileus where there is generalized dysmotility
21. DeQueverian tendinopathy  Lateral hand and wrist pain; aggravated by resisted thumb abduction or
extension of forceful ulnar/ radial deviation. Tenderness at lateral wrist and reproduction of pain with
provocative maneuvers ie flexion at thumb with the wrist in ulnar deviation
22. Hypema (collection of blood in the anterior chamber of the eye)  Increased risk of intraocular hypertension
23. Fever+ lower abdominal pain radiating to groin + abdominal pain while hip extension “psoas sign”  CT scan
of abdomen and pelvis; drainage is critical, blood and abscess culture for antibiotic therapy
24. Slipped capital femoral epiphysis Fat kid  shearing at proximal femoral epiphysis chronic dull hip pain
for a month exacerbated by activity  Anterosuperior displacement of femoral neck and posterior
displacement of femoral head
25. Hyperextension injury, especially in elderly patients with cervical spine degenerative changes (ie, cervical
spondylosis), can cause central cord syndrome. This classically causes loss of pain and temperature sensation
in the upper extremities and disproportionate upper extremity weakness
26. The liver is the most common organ affected by metastatic colon adenocarcinoma. Surgical resection can be
curative when metastatic colon cancer is confined to the liver. Regardless of stage, resection of the primary
tumor is recommended for patients with obstruction or threatened obstruction of the colonic lumen.
27. Chronic radiation proctitis due to pelvic radiation therapy is characterized by obliterative endarteritis and
submucosal fibrosis, which leads to anorectal stricture formation, reduced rectal compliance, constipation,
and fecal incontinence. Chronic tissue hypoxia results in neovascularization and telangiectasia formation,
which can lead to hemorrhage.
28. Radiation proctitis (RP) is caused by mucosal damage associated with pelvic radiation therapy. Acute RP
presents ≤8 weeks post-radiation with diarrhea, tenesmus, and mucus discharge, whereas chronic RP occurs
months to years after radiation, resulting in hematochezia, anemia, and possibly strictures. Colonoscopy
demonstrates mucosal pallor, friability, and telangiectasias confined to the rectum.
29. CT scan is the preferred test to screen or evaluate for cervical spine injury. NEXUS Indications include high-
energy mechanism of injury or any of the following findings: neurologic deficit, spinal tenderness, altered
mental status, intoxication, or distracting injury.
30. The presence of a single vertebral fracture in a patient with blunt trauma is an indication to image the entire
spine. CT scan is the screening modality of choice because of its sensitivity and accuracy.
31. Coronary angiograph bypass grafting  risk of cardiac tamponade; Dx and Tx Echocardiography
32. Hypovolemic and distributive shock  Low CVP
33. Obstructive and cardiogenic shock  increased CVP
34. Complicated parapneumonic effusions and empyemas often present with continued symptoms (fever,
pleuritic pain) despite adequate antibiotic coverage for pneumonia. Chest x-ray usually shows loculation, and
thoracentesis reveals fluid that is exudative with low glucose (<60 mg/dL) and low pH (<7.2). Most
complicated parapneumonic effusions and all empyemas require drainage (eg, chest tube) in addition to
antibiotics
35. Roux- en gastric bypass  def of Vit C. Vitamin C deficiency is associated with ecchymosis, petechiae, poor
wound healing, perifollicular hemorrhage, coiled hairs, and gingivitis; platelet count, prothrombin time, and
partial thromboplastin time will be normal.
36. Anterior mediastinum  thymoma, lymphoma, seminomas, thyroid tissues (ectopic, substernal goiter)
37. Middle mediastinum  lymphadenopathy, lymphoma, benign cyst masses (bronchiogenic cyst), vascular
masses
38. Posterior mediastinum  lymphoma, spinal metastasis, neurogenic tumors and meningocele
39. Myositis ossificans  Intramuscular mass with pain and swelling, induration, formation of lamellar bone in
extraskeletal tissues, Xray shows periosteal bone reaction and calcification with radiolucent centers Tx ROM
exercise and NSAIDS, surgical excision
40. Crohns disease  intestinal fibrotic strictures
41. Gallstone pancreatitis should be suspected in patients who have acute pancreatitis with elevated alanine
aminotransferase levels >150 U/L and gallstones on ultrasonography. Urgent endoscopic retrograde
cholangiopancreatography (ERCP) is indicated if common bile duct obstruction or acute cholangitis is present.
Patients without these indications for ERCP are usually treated with supportive care followed by
early cholecystectomy.
42. Right sided colon tumors  lumen is wide and mostly liquidy+ cecum and ascending colon  occult bleeding
and iron deficiency anemia
43. Left sided colon tumors  obstruct the flow of stool  crampy or colicky pain  red/maroon hematochezia is
seen
44. Rectal tumors  mass in the rectum + hematochezia+ frank red blood + narrowed stools+ tenesmus
45. Open globe laceration (OGL) is typically caused by small, high-velocity particles sent airborne by power tools,
explosions, lawn mowers, or motor vehicle accidents. Large OGL may present with globe deformity, extrusion
of vitreous or iris, or a visible entry wound. Other manifestations include a peaked or teardrop pupil,
asymmetric anterior chamber depth, loss of visual acuity or afferent pupillary response, and reduced
intraocular pressure
46. Multiple vaginal deliveries  Rectal prolapse
47. LLQ abd pain + nausea+ vomiting+ alternating bowel movements + anorexia+ low grade fever  acute
diverticulitis Dx CT of the abdomen (oral and intravenous contrast) shows bowel wall thickening and
pericolonic fat; Mx bowel rest, antibiotics (metronidazole, ciprofloaxin), colonoscopy 6-8 weeks after
resolution; complication: abscess, fistula, obstruction, perforation. Risk factors for diverticulitis  chronic
constipation, low fiber- high fat diet
48. SBO due to postoperative adhesions related to previous abd/pelvic surgery  n/v/f+ paroxysms of
periumblical pain + cannot pass flatus. High pitched sounds present
49. Bladder cancer  urinary cystoscopy
50. Ischemic hepatitis from MI  inc LFTs
51. Patients undergoing clean surgery  PPx abs first line: 1 or 2 gen cephalosporin or vancomycin/ clindamycin if
pencillin allergy
52. Enlarged cardiac shilouttes with clear x-ray is malignant pericardial effusion with clear lungs  Dx Echo Tx
pericardiocentesis, Path: breast, lung, GI tumors, lymphoma and melanoma. C/F chest fullness, fatigue,
progressive dyspnea. ECG: dec QRS voltage+/- electrical alterans, CXR: enlarged cardiac shilouttes, with clear
lung fields. Echo: Large effusion with signs of tamponade. Acute management: pericardiocentesis, cytologic
analysis; prevention of recurrent: pericardial window, catheter. Malignant pericardial effusions are often large
and prone to recurrence. In addition to acute management with pericardiocentesis, they often require
prevention of reaccumulation, either via a pericardial window or prolonged catheter drainage.

53. Osteoarthritis causes chronic joint pain and is most common with advanced age, obesity, and prior joint
injury. Examination findings include bony enlargement and tenderness, crepitus with movement, and painful
or decreased range of motion.
54. Initial management of osteoarthritis of the knee includes weight loss, regular moderate activity, and topical or
oral nonsteroidal anti-inflammatory drugs. In addition, exercises to strengthen the quadriceps muscles can
reduce abnormal loading on the joint and protect the articular cartilage from further stress.
55. Acute mediastinitis presents with fever, chest pain, widened mediastinum, leukocystosis in due to
intraoperative wound contamination from cardiac surgery  IV abxs and surgery
56. BrightBloodPerRectum in male >60 angiodysplasias. Risk of bleeding from angiodysplasias is increased with
ESRD and aortic stenosis.
57. Colon ischemia  Due to hypovolemia, atherosclerotic state and watershed ischemia  hematochezia,
bloody diarrhea, moderate abdominal pain and tenderness; Dx CT scan and endoscopy Tx IV fluids, bowel rest,
IV antibiotics and colonic resection if necrosis develops
58. Chronic radiation protopathy often causes bloody stools, but usually presents for the first time within the first
year. Colonoscopy would show pale mucosa with ulcers, strictures, telangiectasias, and focal hemorrhage.
59. Traumatic injury to the eye can lead to the release of previously sequestered self-antigens that T
cells recognize as foreign. This can lead to inflammation and blindness in both the injured and uninjured eye.
60. Sudden bilateral flank pain + early onset hypertension+ family history of CKD  PKD
61. Mitral stenosis  increased PA diastolic and systolic pressure norm left ventricular diastolic pressure
62. If the TSH is low, as seen here, the patient should be evaluated with radionuclide thyroid scan using iodine-
123:

 A hypofunctioning ("cold") nodule (decreased isotope uptake compared to surrounding tissue) is

associated with a higher risk of cancer.
 A hyperfunctioning ("hot") nodule (increased isotope uptake in the nodule with decreased surrounding
uptake) is associated with a low cancer risk; therefore, FNA is not necessary

Certain sonographic features (eg, microcalcifications, irregular margins, internal vascularity) carry a much higher
risk of malignancy than others (eg, cystic or spongiform lesions). Thyroid nodules >1 cm with these high-risk
sonographic features—and all noncystic thyroid nodules >2 cm—should undergo fine-needle aspiration (FNA).

63. Pancreatic cancer  strongest risk factor is smoking

64. C.difficile  toxic megacolon  bacterial toxin induced colonic inflammation  abd pain, systemic toxicity,
leukocytosis, large bowel dilation
65. Foreign body aspiration should be suspected in a child with abrupt-onset cough and wheeze (with or without a
choking episode) that is unresponsive to albuterol. Supportive findings include a focal lung examination (eg,
wheeze, decreased breath sounds, hyperresonance) and/or unilateral lung hyperinflation with mediastinal
shift on x-ray.
66. Severe acute pancreatitis (SAP) occurs in 15%-25% of patients with acute pancreatitis and causes failure of ≥1
organ systems lasting >48 hours. Predictors of SAP include signs of the systemic inflammatory response
syndrome and evidence (eg, elevated blood urea nitrogen or hematocrit) of intravascular volume depletion.
Patients with SAP have increased risk of morbidity and mortality and usually require intensive monitoring.
67. Candida endophthalmitis occurs primarily in hospitalized patients with central venous catheters. It typically
presents with floaters and progressive vision loss; pain is absent until late in the disease course. Funduscopy
shows fluffy, yellow-white chorio-retinal lesions.
68. Atelectasis is a common postoperative complication that results from shallow breathing and weak cough due
to pain. It is most common on postoperative days 2 and 3 following abdominal or thoracoabdominal surgery.
Adequate pain control, deep-breathing exercises, directed coughing, early mobilization, and incentive
spirometry decrease the incidence of postoperative atelectasis.
69. Varicoceles typically present as a clustered scrotal mass above the testis. Men with a varicocele can have
reduced fertility, possibly due to increased scrotal temperatures that can cause a reduced sperm count and
decreased motility.
70. The first step in the treatment of acute upper gastrointestinal bleeding is to establish vascular access with 2
large-bore intravenous catheters to initiate resuscitation with intravenous fluids.
71. Ehlers-Danlos syndrome is a collection of genetic connective tissue disorders. It is usually characterized by
joint hypermobility/laxity, multiple joint dislocations, tissue fragility, poor wound healing, and cigarette,
paper-like scarring.
72. Anterior cruciate ligament injury rapid deceleration or direction changes; pivoting of lower foot when
planted; significant swelling Tx Rest, Ice, Compression, elevation
73. Estrogen deficiency osteoporosis
74. Complications of ankylosing spondylitis (impaired spinal mobility and limited chest expansion) 
osteoporosis/ vertebral fractures, aortic regurgitation and cauda equina syndrome. Relieved by exercise but
not with rest

75. Gout can cause acute bursal (eg, prepatellar, olecranon) inflammation, chronic bursal swelling, or tophus
deposition in the bursa. Tophus induces chronic inflammation in the surrounding soft tissue and bones, which
can result in erosions and overhanging edges of cortical bone on imaging.

76. Gout can affect superficial bursae (eg, olecranon, prepatellar) in multiple ways:

 Acute bursitis in a gout flare, presenting with erythema, warmth, and swelling

 Chronic bursitis, presenting with a large, rounded, fluctuant effusion

 Bursal tophus, manifesting as a slowly enlarging, hard mass (as in this patient), sometimes with
mild inflammatory changes

77. Adequate pain control is the mainstay of rib fracture management to prevent the associated complications of
atelectasis and pneumonia.

 Without adequate pain control, splinting and atelectasis increase the risk of pneumonia, a
frequent complication of rib fracture.

 Oral nonsteroidal anti-inflammatory drugs (eg, ibuprofen, ketorolac) and opioids are commonly
used.

 In addition to pain control, patients should be taught the importance of pulmonary toilet and
the use of incentive spirometry.

78. Ascariasis typically affects patients with recent travel from endemic regions (eg, Asia, Africa, South America).
It is often asymptomatic but may cause pulmonary (eg, cough, eosinophilic pneumonitis) or intestinal (eg,
abdominal pain, nausea/vomiting, malnutrition) manifestations. Complications include obstruction of the
small bowel or hepatobiliary tree (eg, cholangitis, pancreatitis). Treatment includes albendazole or
mebendazole.

79. In patients with severe burn injuries, early excision of necrotic tissue and wound closure (eg, skin grafting)
reduces the risk of burn wound infections

80. Epidermal inclusion cyst is a benign nodule containing squamous epithelium that produces keratin. It
presents as a dome-shaped, firm, freely movable cyst or nodule with a small central punctum. The lesion can
remain stable or gradually increase in size but may produce a cheesy white discharge; it usually resolves
spontaneously.
81. Dumping syndrome is a common post gastrectomy complication characterized by gastrointestinal (eg, nausea,
diarrhea, abdominal cramps) and vasomotor (eg, palpitations, diaphoresis) symptoms. The diagnosis is
primarily clinical. The symptoms can be controlled with dietary modification (eg, avoiding simple sugars) and
usually diminish over time

82. Copper deficiency typically occurs in patients with a history of gastric surgery (eg, bariatric), chronic
malabsorption (eg, inflammatory bowel disease), or excessive zinc ingestion. Symptoms include slowly
progressive myeloneuropathy similar to that of vitamin B12 deficiency (eg, distal extremity paresthesia,
numbness, sensory ataxia), anemia, hair fragility, skin depigmentation, hepatosplenomegaly, edema, and
osteoporosis

83. Selenium Deficiency causes cardiomyopathy, macrocytosis, immune and thyroid dysfunction.

84. Greater trochanteric pain syndrome is an overuse syndrome involving the tendons of the gluteus medius and
minimus at the greater trochanter. It presents with chronic lateral hip pain that is worsened with repetitive
hip flexion or lying on the affected side. Physical examination shows local tenderness over the greater
trochanter

85. Meralgia paresthetica is caused by compression of the lateral femoral cutaneous nerve where it passes under
the inguinal ligament. The pain and paresthesia typically occur in a variable region of the mid-lateral thigh.

86. Turner syndrome is associated with an increased risk for aortic dissection, which may present with migratory
chest pain. Extension of an aortic dissection into a mesenteric artery can cause mesenteric ischemia and
associated abdominal pain. The diagnosis is confirmed with CT angiography.

87. Patients with plantar puncture wounds through footwear are at risk for Pseudomonas
aeruginosa osteomyelitis. Pseudomonas infections are particularly prevalent after puncture wounds through
the sole of a shoe as the warm, moist environment is quite hospitable to this microorganism

88. Pelvic fractures, especially those with pelvic ring disruption, can cause life-threatening hemorrhage from
vascular (eg, venous plexus) injury. Pelvic binder application can decrease pelvic volume and promote
tamponade of bleeding.

89. Patients with trauma following rapid deceleration are at risk for blunt thoracic aortic injury. Signs may include
upper extremity hypertension with lower extremity hypotension (pseudocoarctation) and/or a hoarse voice
(left recurrent laryngeal nerve stretching).

90. Left ventricular free wall rupture can occur within 5 days or up to 2 weeks following transmural myocardial
infarction. Affected patients have sudden-onset chest pain and rapid development of cardiac tamponade that
quickly leads to obstructive shock and pulseless electrical activity cardiac arrest.
91. Acute pancreatitis is the most common complication after endoscopic retrograde cholangiopancreatography,
and typically presents with abdominal pain with radiation to the back, nausea, and
vomiting. Lipase and amylase levels will rise several hours after symptom onset whereas CT scans can be
normal for up to 48 hours.

92. Chronic neuropathic (Charcot) arthropathy of the foot and/or ankle typically occurs in patients with impaired
sensation and joint proprioception (ie, diabetic peripheral neuropathy) and can be diagnosed based on x-ray
findings. Common early x-ray findings include osseous resorption, architectural foot disorganization, and
midfoot arch collapse

93. In the absence of obvious open globe injury (OGI), suspected corneal injury should be assessed with
fluorescein staining. Localized fluorescein uptake is diagnostic of corneal abrasion, whereas fluorescein
uptake followed by clearing in a waterfall pattern (Seidel sign) is concerning for full-thickness corneal
laceration with OGI.

94. Lymphangiosarcoma  NBSM Lesion biopsy

95. Sialadenosis is a benign, noninflammatory enlargement of the salivary glands, often caused by chronic alcohol
use.

96. Parotid masses are typically benign. Cranial nerve dysfunction (facial droop, facial numbness) increases
concern for malignancy. Most tumors that originate in the parotid gland are benign (>80%) rather than
malignant. Neoplasms that originate in the submandibular gland or minor salivary glands have a higher
likelihood of malignancy.

97. A conductive hearing loss (CHL) may show improved speech understanding in background noise. CHL in a
young woman with a positive family history of hearing loss likely represents otosclerosis, which is
characterized by bony overgrowth of the stapes that causes stiffening of the ossicular chain

98. Postoperative pulmonary complications are common, particularly in patients with known risk factors. These
risk factors include smoking, preexisting pulmonary disease, age >50, thoracic or abdominal surgery, surgery
lasting >3 hours, and poor general health. Postoperative measures such as incentive spirometry and deep
breathing exercises are used to prevent such complications and improve outcomes by promoting lung
expansion.
99. Postoperative atelectasis is common and typically manifests 2-5 days following surgery. Hypoxemia results
from localized intrapulmonary shunting and ventilation-perfusion mismatch, and hyperventilation leads to
primary respiratory alkalosis with low PaCO2 and high pH.
100.Primary spontaneous pneumothorax (PSP) occurs in patients without a history of lung disease and is most
common in tall, thin men in their early 20s. Management of small PSP in clinically stable patients
includes observation and supplemental oxygen, which enhances the speed of resorption.
101.Mucus plugging can lead to large-volume atelectasis (lung collapse) due to airway obstruction. Chest x-ray
demonstrates opacification of the affected lung area and mediastinal shifting toward the side of atelectasis.
102.Ventilator-associated pneumonia should be suspected when an intubated patient develops new pulmonary
infiltrates on chest x-ray, worsened respiratory status (eg, increased oxygen requirement, increased
secretions), and clinical signs of infection (eg, fever, leukocytosis). Confirmation requires the identification of
an organism in a lower respiratory tract sample

103.Fat embolism syndrome can occur following fracture of large, marrow-containing bones (eg, femur, pelvis).
Patients classically have the triad of respiratory distress, neurologic dysfunction, and a petechial rash;
however, the rash is present in less than half of cases.
104.Delayed emergence from anesthesia is defined as the failure to return to consciousness within the expected
window of the last administration of an anesthetic or adjuvant agent (typically 30-60 minutes). The etiology is
often multifactorial, however; the presence of respiratory failure (eg, low pH, elevated pCO2, low pO2),
bradypnea, and bradycardia suggests prolonged medication effect resulting in hypoventilation.

105.FEV1 and diffusion capacity of the lung for carbon monoxide (DLCO) are the best predictors of postoperative
outcomes following lung resection surgery. Patients with an estimated postoperative FEV1 or DLCO of <40%
are at elevated risk of postoperative morbidity.

106.Venous air embolism results from the introduction of a large volume of air (eg, >50 mL) into the venous
circulation; it can occur in the setting of trauma, certain surgeries (eg, neurosurgical), central venous catheter
manipulation, or pulmonary barotrauma. The air can obstruct blood flow in the right ventricular outflow tract
or pulmonary arterioles, leading to hypoxemia, obstructive shock, and cardiac arrest.

107.Positive-pressure ventilation can rapidly exacerbate tension pneumothorax (TP) and cause cardiovascular
collapse. Therefore, decompression (eg, needle thoracostomy) to prevent cardiovascular collapse should be
performed prior to intubation for patients with TP who also need airway protection—an important exception
to the typical order.
108.Acute urinary retention (AUR) is common in elderly men, especially in the setting of underlying benign
prostatic hyperplasia. The risk of AUR is further increased during the postoperative period. Diagnosis is made
using bladder ultrasound. In a patient with suspected AUR who is unable to void, the diagnosis is confirmed
by bladder ultrasound demonstrating ≥300 mL of urine. Treatment is with insertion of a Foley catheter, and
urinalysis should be collected to rule out urinary tract infection, a potential cause of AUR.
109.Plantar fasciitis is a degenerative condition of the plantar aponeurosis at its insertion at the calcaneus caused
by overuse. Pain with dorsiflexion of toes and pain at insertion of plantar fascia. Pain is typically worsened by
prolonged standing and is located at the anteromedial heel. First-line treatments include activity modification,
physical therapy (stretching), and padded heel inserts. Calcaneal spurs are incidental and do not require
treatment
110.In cases of traumatic amputation, the amputated part should be transported by wrapping it in saline-
moistened gauze, sealing it in a plastic bag, and placing the bag in a bath of ice water. Cooling of the
amputated part prolongs the window for replantation.
111.Secondary angiosarcoma is a malignant endothelial tumor that develops 4-8 years after breast cancer
therapy. Risk factors include radiation therapy and chronic lymphedema. Typical lesions are red, bruise-like
plaques and purple papules and nodules. Timely biopsy is recommended for diagnosis because the cancer
readily metastasizes.
112.Necrotizing surgical infection is characterized by intense pain in the wound, decreased sensitivity at the edges
of the wound, cloudy-gray discharge, and sometimes crepitus. Early surgical exploration is essential. This
patient has the following signs and symptoms suggestive of necrotizing surgical site infection:
 Pain, edema, or erythema spreading beyond the surgical site
 Systemic signs such as fever, tachycardia, or hypotension
 Paresthesia or anesthesia at the edges of the wound
 Purulent, cloudy-gray discharge ("dishwater drainage")
 Subcutaneous gas or crepitus
113.Massive pulmonary embolism is likely in a postoperative patient with hypotension, jugular venous distension,
and new-onset right bundle branch block. In conjunction with respiratory and hemodynamic support,
fibrinolysis is indicated in the treatment of massive PE.
114.Hypovolemic shock in the setting of blunt chest trauma is concerning for intrathoracic hemorrhage. Rib
fractures (with intercostal vessel injury) are a common cause of hemothorax.
115.Venous air embolism (VAE) is suggested by sudden-onset respiratory distress following removal of a central
venous catheter. Patients with suspected VAE should immediately be placed in the left lateral
decubitus position to trap air on the lateral right ventricular wall and help prevent right ventricular outflow
 tract obstruction and embolization of air into the pulmonary circulation. High-flow oxygen is also important to
encourage absorption of the air embolus.
116.Patients with septic shock first require aggressive volume resuscitation with intravenous 0.9% saline prior to
the initiation of vasopressors to restore adequate tissue perfusion.
 Crystalloid solution (eg, normal saline, lactated Ringer) is the fluid of choice to restore
volume quickly as it is as effective as albumin in terms of survival but is less costly and easier to
acquire
 If the patient fails to respond or develops evidence of volume overload without improvement in
blood pressure, then vasopressors (eg, norepinephrine) should be started to improve perfusion
117.Ludwig angina is a rapidly progressive cellulitis of the submandibular and sublingual spaces. Airway
obstruction can occur due to displacement of the tongue posteriorly.

118.Hereditary hemorrhagic telangiectasia involves arteriovenous malformations (AVMs) in multiple organs.

Nasal telangiectasias lead to recurrent epistaxis, and pulmonary AVMs may cause hemoptysis. In patients with
symptomatic, bleeding pulmonary AVMs (hemoptysis), management involves pulmonary angiography
followed by embolization.
119.Penetrating trauma accompanied by shock (eg, severe hypotension) is attributed to hemorrhage until proven
otherwise. Intrathoracic hemorrhage can cause massive hemothorax (>1,500 mL), which requires emergent
thoracotomy to prevent exsanguination.
 Although tube thoracostomy is often sufficient to manage hemothorax, some patients (up to 15%)
require emergent thoracotomy for extreme bleeding, including those with:
 Initial bloody output >1,500 mL (as in this patient)
 Persistent hemorrhage: >200 mL/hr for >2 hours, or continuous need for blood transfusion to maintain
hemodynamic stability
120.Orbital compartment syndrome (OCS) causes eye pain and vision loss due to rapidly increased intra-orbital
pressure. Examination shows a tight orbit (eg, periorbital swelling, hard eyelid, proptosis) and a relative
afferent pupillary defect. OCS is a clinical diagnosis and requires immediate orbital decompression to prevent
permanent vision loss.
121.Patients with prosthetic heart valves, prosthetic cardiac grafts, and certain congenital heart abnormalities are
at high risk for infective endocarditis due to transient bacteremia. These patients should receive antibiotic
prophylaxis (eg, amoxicillin) 30-60 minutes prior to invasive procedures that involve the gingival surface,
respiratory mucosa, infected skin and soft tissue, and infected areas of the gastrointestinal/genitourinary
tract. No prophylaxis is required for most other asymptomatic genitourinary/gastrointestinal procedures (eg,
screening colonoscopy) ; 2nd line Clarithromycin
122.Squamous cell carcinoma in a cervical lymph node, especially in a smoker, likely has a mucosal head and neck
primary site and requires examination of the laryngopharyngeal mucosa.
123.Lateral ankle sprains are typically caused by forceful inversion of the foot. The anterior talofibular ligament is
most commonly injured. If there is tenderness only over the ligaments distal to the lateral malleoli and the
patient can bear weight, conservative management (eg, compression bandage or brace, ice packs, crutches to
reduce weightbearing) without imaging is appropriate.
124.Epidural spinal cord compression must be suspected in any patient with a history of malignancy who develops
back pain with motor and sensory abnormalities. Bowel and bladder dysfunction are late neurologic
findings. Intravenous glucocorticoids should be given without delay. MRI is then recommended.
125.Patients with bilateral, diffuse, and cyclic breast pain typically have physiologic mastalgia and do not require
imaging. In contrast, patients with unilateral, focal, and noncyclic breast pain require breast imaging to
evaluate for cancer.
126.Either mammography or ultrasound can be used for the first-line imaging study to assess a palpable breast
mass in women age 30-39. Breast biopsy is frequently required to confirm the diagnosis.
127.Enteral nutrition (EN) (ie, intestinal route) is preferred over parenteral (ie, intravenous) nutrition in patients
with burn injuries because EN is associated with multiple clinical benefits, including the following:

 Trophic effects on the intestinal mucosa and gut- and mucosa-associated lymphoid tissue, resulting
in maintenance of gut integrity and decreased bacterial translocation

 Reduced rates of sepsis and other infectious complications (eg, pneumonia)

 Decreased mortality

128.Management of frostbite starts with rapid rewarming of affected tissues in a warm water bath. For patients
with persistent signs of tissue ischemia (sensory loss, gray appearance, absent capillary refill), studies such
as angiography or technetium-99m scintigraphy can help identify those who would benefit from
thrombolysis.

129.High-voltage electrical injuries frequently cause more severe damage to internal structures (eg, muscle) than
external structures (eg, skin). Skeletal muscle necrosis is a frequent complication that can result in acute
compartment syndrome, rhabdomyolysis, and heme pigment–induced acute kidney injury.

130.Diverticular hemorrhage causes acute, self-limited hematochezia that generally lasts up to several days (not
months). It is usually painless and does not cause weight loss.
131.Cervical radiculopathy is due to nerve root compression and typically presents with neck or arm pain
associated with sensorimotor deficits; radiation of pain with neck movement may occur. The diagnosis is
usually made clinically, and most patients improve with symptomatic treatment, including nonsteroidal anti-
inflammatory drugs and avoidance of triggering activities.

132.Vertebral metastasis should be suspected in patients with back pain who have a history of cancer, pain worse
at night and unrelieved with rest, and focal vertebral tenderness. Other features may include neurologic
 deficits, unexpected weight loss, and hypercalcemia. The most common cancers associated with vertebral
metastasis include prostate, breast, kidney, thyroid, and non–small cell lung cancer, as well as non-Hodgkin
lymphoma

133.Ventilator-associated pneumonia occurs ≥48 hours after intubation and usually presents with fever, purulent
secretions, and abnormal chest x-ray. Patients should have lower respiratory tract sampling (Gram stain and
culture) and receive empiric antibiotics.

134.An enlarged, ulcerated tonsil with ipsilateral cervical adenopathy is likely oropharyngeal (head and neck)
squamous cell carcinoma. Human papillomavirus is the likely etiology in the absence of traditional risk factors
(smoking, alcohol).

135.Patellar dislocation usually occurs after quick, lateral movements on a flexed knee. Lateral dislocation is most
common. Risk factors include age <20, joint laxity, lower extremity malalignment, and patellar subluxation.
Examination shows reduced range of motion and lateral displacement of the patella out of the trochlea

136.A perilymphatic fistula can occur after head trauma and result in episodic vertigo triggered by sudden
pressure changes (eg, Valsalva maneuvers) or loud noises (Tullio phenomenon).

137.Splenic abscess usually presents with the classic triad of fever, leukocytosis, and left upper-quadrant
abdominal pain. Patients can also develop left-sided pleuritic chest pain, left pleural effusion, and
splenomegaly. Risk factors for splenic abscess include hematogenous spread, immunosuppression,
intravenous drug use, trauma, and hemoglobinopathies. Infective endocarditis is most commonly associated
with splenic abscess.

138.Large-volume crystalloid resuscitation increases coagulopathy, hypothermia, and mortality in trauma

patients. Balanced resuscitation, which restricts crystalloid use and uses blood products to maintain a blood
pressure just sufficient for tissue perfusion (ie, permissive hypotension) until hemorrhage is controlled, can
decrease these adverse effects.

139.Patients with chronic granulomatous disease (CGD) are susceptible to cavitary pneumonia caused
by Nocardia due to impaired respiratory burst and defective intracellular killing by neutrophils. Diagnosis of
CGD is established by measuring the phagocytic oxidative response via flow cytometry.

140.Femoral hernias (hernia located below inguinal ligament) protrude through the femoral ring and usually
present with a nontender, nonpulsatile bulge in the groin that grows in size with increased abdominal
pressure. Because the risk of incarceration with femoral hernias is high (due to narrow hernia orifice),
patients with asymptomatic femoral hernias are referred for early elective hernia repair. In contrast,
asymptomatic inguinal hernias (hernia located above inguinal ligament) can usually be managed with watchful
waiting because hernia contents pass through a wider orifice.

141.Adhesive capsulitis results from contracture of the glenohumeral joint capsule and presents with gradual
onset shoulder pain and reduced active and passive range of motion. Treatment includes gentle range of
motion exercises; adjunctive measures include nonsteroidal anti-inflammatory drugs and corticosteroid
injections.
142.Occlusion of an anal crypt gland can lead to a bacterial overgrowth and perianal abscess formation. Perianal
abscesses often present as tender, fluctuant, erythematous masses causing progressively worsening pain.
Prompt incision and drainage are necessary to prevent spread to deeper structures or systemic infection.

143.Patients with a complete small bowel obstruction (eg, obstipation, no air in the rectum on abdominal x-ray)
require nasogastric tube insertion for gastric decompression plus emergency laparotomy due to the high risk
of life-threatening complications (eg, bowel ischemia, perforation).

144.Approximately 25% of pancreatic cancer is heralded by a recent (<2 years) diagnosis of diabetes mellitus.
Although screening for pancreatic cancer is not recommended for patients with new-onset diabetes mellitus,
those who have symptoms (eg, constant abdominal pain, weight loss) of pancreatic cancer should
undergo abdominal CT scan.

145.Falls are a major source of injury in older patients. In addition to primary prevention strategies (eg, supervised
exercise, home safety assessment), patients at high risk for falls should be screened for osteoporosis (with
treatment as appropriate) to reduce the risk of fracture

146.Initial management of frostbite starts with rapid rewarming of affected tissues in a warm water bath. For
patients with persistent signs of tissue ischemia (sensory loss, gray appearance, absent capillary refill), studies
such as angiography or technetium-99m scintigraphy can help identify those who would benefit from
thrombolysis.

147.A conductive hearing loss (CHL) may show improved speech understanding in background noise. CHL in a
young woman with a positive family history of hearing loss likely represents otosclerosis, which is
characterized by bony overgrowth of the stapes that causes stiffening of the ossicular chain
148.Right quadrant ultrasound best detects gallstone pancreatitis

149.Patients with rheumatoid arthritis are at risk for atlantoaxial instability; neck extension during intubation can
result in subluxation with cord compression and cervical myelopathy. Symptoms of cervical myelopathy
include a slowly progressive, spastic paraparesis involving the upper and lower extremities, hyperreflexia,
sensory changes, and a positive Babinski sign. Hoffman sign may also be positive

IM- Allergy and immunology

1.

IM-ID

1.

2. Primary infection with varicella-zoster virus (chickenpox) is highly transmissible, primarily because viral
particles are microscopic (<5 microns) and remain suspended in the air for prolonged periods. Infection
control requires airborne isolation (eg, N95 respirator, negative-pressure isolation room) and contact
precautions (gowns, gloves).

3. Babesiosis is a tick-borne protozoal illness found primarily in the northeastern United States. Transmission
occurs via Ixodes scapularis, and coinfection with other microbes (eg, Borrelia burgdorferi, Anaplasma
phagocytophilum) is possible. Symptoms are often flu-like (fever, chills, malaise), and laboratory studies
usually show anemia with signs of intravascular hemolysis and thrombocytopenia. Diagnosis is made
primarily by identifying organisms on peripheral blood smear ("Maltese cross"). Tx
Atovaquone+azithromycin and quinine with clindamycin if severe
4. Patients with tinea corporis are at risk for developing additional foci of infection elsewhere on the body,
toes, groin, or nails due to autoinoculation. Patients with compromised immunity due to diabetes mellitus,
systemic glucocorticoid therapy, or HIV infection can develop extensive, widespread involvement.

5. Anthrax  painless necrotic ulcer

6. MAC suspected in patient with weight loss, fever, chills, hemoptysis in patient with bronchiectasis Dx Acid
fast staining

7. Chicken pox vs small pox

Small pox vaccina  severe prodromal sxs and different stages of vesicular eruptions Tx supportive

Chicken pox  no severe prodromal sxs but different stages of vesicular erupstions

8.

9.

10. Necrotizing (malignant) otitis externa represents osteomyelitis of the skull base and is most commonly
caused by Pseudomonas aeruginosa. The characteristic presentation consists of severe ear pain and ear
drainage; granulation tissue may be seen in the ear canal. Progression of the infection may lead to cranial
neuropathies.

11. Hospital acquired pneumonia CC  MRSA and pseudomonas aureginosa  Broad spectrum antibiotics eg
vancomycin+ ¾ gen cephalosporins

Community acquired pneumonia  Strep pneumonia and atypicals like M. pneumonia, legionella 
vancomycin and azithromycin

12. Herpetic whitlow is a viral infection of the hand caused by herpes simplex virus. Most adult infections are
acquired from contact with genital herpetic lesions or infected orotracheal secretions. Spontaneous
resolution is the norm but recurrences are common
13. Clinical manifestations of infectious mononucleosis include fatigue, sore throat, fever, lymphadenopathy,
and splenomegaly. Atypical lymphocytes on peripheral smear are characteristic; heterophile antibodies,
while specific for Epstein-Barr virus infection, may be negative early in the illness.

IM  mc ebv, fever+ tonsilitis+ exudative pharyngitis+ posterior or diffuse cervical lymphadenopathy+

hepatosplenomegaly+ fatigue+ rash after amoxicillin, Dx findings Positive heterophile Abs test, Atypical
lymphocytosis, transient hepatitis,Management : Avoid contact sports for more than 3 weeks to avoid
splenic rupture

Vs Acute lymphoblastic Leukemia  blasts are seen on smear and no exudative pharyngitis

14. Immunity to rubella is routinely evaluated at the initial prenatal visit. Patients without immunity are
vaccinated in the immediate postpartum period with the live-attenuated mumps-measles-rubella vaccine.
Postpartum vaccination prevents future infection but avoids the theoretical risk of congenital rubella.

15. Postherpetic neuralgia is characterized by burning pain and hyperesthesia lasting >4 months following acute
zoster. The risk is greatest in those with advanced age, severe initial pain, or severe rash. First-line
treatment includes anticonvulsants (eg, gabapentin) and tricyclic antidepressants (eg, amitriptyline)

16. Acute HIV infection frequently manifests 2-4 weeks after transmission with a persistent mononucleosis like
syndrome. Oral ulcerations and a generalized rash are often present. Laboratory studies frequently reveal
lymphopenia. Risk of infection is greatest with shared needle use and unprotected sexual intercourse.

17. Lymphangitis  Cutaneous injury  pathogen infiltration in deep dermis. MCC strep pyogenes, MSSA. Sx
Tender, erythematous streaks proximal to the wound, regional tender lymphadenopathy (lymphadenitis)
systemic signs (fever,tachycardia)

18. E.granulosis Tx albendazole, percutaneous therapy if >5cm or septation, surgery if rupture

2. E.histolytica  Metronidazole+/ paramomycin

3. Infective endocarditis usually presents with subacute nonspecific (eg, fever, fatigue, myalgia, arthralgia),
cardiac (eg, dyspnea), immunologic (eg, glomerulonephritis, Osler node), and/or embolic symptoms.
Diagnosis is typically confirmed with 3 sets of blood cultures and echocardiogram.

4. A single brain abscess usually results from direct extension of an adjacent infection (eg, otitis media,
sinusitis, dental infection). Viridans streptococcus and Staphylococcus aureus are the 2 most commonly
isolated organisms. Headache, fever, focal neurologic deficits, and seizure may be present. Brain imaging
(CT scan, MRI) typically reveals a single ring-enhancing lesion with central necrosis.

5. Nocardia brain abscess in an immune-compromised patients (CD4 count <100)

 6. Patients with febrile neutropenia should be started on empiric broad-spectrum antibiotics as soon as
possible after blood cultures are obtained. Empiric monotherapy with an antipseudomonal agent (eg,
cefepime, meropenem, piperacillin-tazobactam) is recommended for initial management.

7. Cryptosporidium can cause prolonged, watery (noninflammatory) diarrhea in immunosuppressed patients

(eg, AIDS, organ transplant recipients).

8. Tissue-invasive cytomegalovirus disease causing gastrointestinal manifestations is seen with kidney

transplant, but it would typically cause inflammatory diarrhea (eg, bloody stools, fecal leukocytes, occult
blood).

IM- MSK

1. Achilles tendinopathy  tenderness at insertion of achilles tendon Tx calf strengthening exercise

2. Mixed connective tissue disease is characterized by clinical features of systemic lupus erythematosus,
systemic sclerosis, and polymyositis, which appear sequentially. Important manifestations include Raynaud
phenomenon, swelling of the fingers and hands, inflammatory arthritis, and myositis. Autoantibodies for U1
ribonucleoprotein have high sensitivity and specificity.

3. Paget’s disease of the bone  Inc Alk phos and urine hydroxyproline  Tx: bisphosphonates 
suppresses bone turnover

4. Hand osteoarthritis typically involves the distal interphalangeal and first carpometacarpal joints in patients
age >40. Pain is provoked by activity and relieved by rest. In a patient with skin psoriasis, pain that involves
these joints and is unaccompanied by prolonged morning stiffness, synovitis, and nail psoriasis suggests
osteoarthritis.

5. Allopurinol  increase solubility of monosodium urate gout prophylaxis; colchicine for acute
exacerbation

IM- Environmental
1. High-voltage electrical injuries frequently cause more severe damage to internal structures (eg, muscle)
than external structures (eg, skin). Skeletal muscle necrosis is a frequent complication that can result in
acute compartment syndrome, rhabdomyolysis, and heme pigment–induced acute kidney injury.
2. Organophosphates inhibit cholinesterase in both the muscarinic and nicotinic cholinergic synapses,
leading to increased visceral smooth muscle tone and glandular secretions (mnemonic: DUMBELS) as well
as muscle fasciculations, weakness, and paralysis. Organophosphate poisoning can be confirmed with the
measurement of red blood cell acetylcholinesterase activity.
3. Cyanide poisoning  Exposure to cyanide containing meds, house fire, mining and burning of plastics
Path inhibits oxidative phosphorylation and forces anaerobic metabolism Sx Hypertension, tachypnea and
tachycardia circulatory collapse, and death, headache, confusion, anxiety seizures, coma and cherry
red skin and lactic acidosis. Tx decontamination, supportive care (100% oxygen, intravenous fluids,
vasopressors). Empiric treatment with hydroxy cobalamin+/- sodium thiosulfate
Vs methemoglobinemia poisoning –> cyanosis and lactic acidosis with exposure to dapsone, nitrates,
local/topical anesthetics
4. Salicylate poisoning  Characteristics of acute and chronic salicylate toxicity include vomiting, tinnitus,
pulmonary edema, hyperthermia, tachypnea, and an anion gap metabolic acidosis. Hemodialysis is
indicated in patients with altered mental status, pulmonary edema, renal failure, and persistent acidosis.
 5. High Altitude sickness decreased Pi02 at high altitude. Ams fatigue, nausea and headache HACE
dec Paco2 

6. Opioid medications in patients with

impaired kidney function

Recommended Avoid
 Fentanyl  Morphine
 Hydromorphone  Meperidine
 Methadone  Codeine
 Buprenorphine  Tramadol

7. Exertional heat stroke is characterized by temperature >40 C (104 F) and CNS dysfunction (eg, altered
mental status, seizure). First-line treatment is rapid cooling with ice water immersion

Surgery-Pulmonology

1. Deep breathing exercise and incentive spirometry to prevent postoperative pneumonia and atelectasis
Encourage high-tidal-volume respiration and help keep alveoli open.

2. Hypotension +tachypnea + flat neck veins+ decreased breath sounds+ hyperresonance Hemothorax

NBSIM: Tube thoracostomy >1500 ml emergent surgical thoracostomy

3. Postoperative atelectasis occurs 2-5 days after surgery. Intrapulmonary shunting and V/Q mismatch-
Hypoxemia-Hyperventilation- Resp alkalosis

4. Blunt thoracic aortic injury (BTAI) CXR: widened mediastinum, abnormal aortic contour, hemothorax.
Diagnosis of BTAI can be confirmed via CT angiography for hemodynamically stable patients or
transesophageal echocardiography (likely in the operating room) for unstable patients. Tx: Expediated
Emergency operative repair

5. Bronchial rupture causes rapid air leakage from the tracheobronchial tree, manifesting on chest x-ray as
pneumothorax, pneumomediastinum, and/or subcutaneous emphysema
6. Primary spontaneous pneumothorax Thin tall men with CF, COPD. Tx: Small: observation and oxygen. Large:
Needle aspiration and chest tube. Other risk factors include smoking, Marfan syndrome, and thoracic
endometriosis
7. Mucus plugging Air obstruction  Alveolar collapse Atelectasis
RF- Surgery under anesthesia and Smoking
CXR-Opacification of the affected lung and mediastinal shifting towards the affected lung
Tx- Chest physiotherapy for small atelectasis
Bronchoscopy for large complicated parapneumonic effusion
8. Flail chest Tx- PPV
9. Intubated pt+ new pulmonary infiltrates on CXR+ worsening respiratory status+ fever and leukocytosis+ after
>48 hours intubation Ventilator associated pneumonia Dx VAP: Noninvasive (eg, endotracheal aspiration) or
invasive (eg, bronchoalveolar lavage) sampling of the lower respiratory tract is required for confirmation;
moderate or heavy growth of ≥1 microorganism is generally diagnostic.
10. Respiratory distress+ neurologic dysfunction+ petechial rash  Fat Embolism Syndrome
11. Progressive dyspnea and cough accompanied by low-grade fever, hypoxemia, and chest x-ray revealing
perihilar opacities and interstitial edema within 6 months of transplant Acute lung transplant rejection.
12. Dx Acute Lung Transplant Rejection bronchoalveolar lavage and lung biopsy should be performed in the
diagnostic workup of ALTR
13. Tx Acute Lung Transplant Rejection high dose glucocorticoids
14. Subcutaneous emphysema+ chest pain+ SOB+ cough+ Hamman sign (Crunch sound over heart) 
Spontaneous pneumomediastinum; NBSIM CXR to rule out pneumothorax; Tx Analgesia, bed rest
15. Inhalational injury (oropharyngeal blisters) indication for endotracheal intubation in burn pts
16. Irregular, non-lobular infiltrates on chest x-ray or CT scan are classic for pulmonary contusion.
17. Thoracic trauma+ extrapulmonary air Tracheobronchial injury
Dx- Bronchoscopy; Tx- Operative repair
18. Antifibrotic drugs helps slow fibrosis by inhibiting fibroblasts in idiopathic pulmonary fibrosis
19. Acute dyspnea, febrile, and diffuse pneumonia, after the first year after lung transplant is CMV pneumonitis.
20. Foul smelling pleural fluid- empyema. MC- anaerobic bac, then staphylococcus aureus, strep. Pneumoniae
21. Venous air embolism- Large volume air during traumas, central catheter manipulation Tx left lateral decubitus
positioning

Neurology

1. Falls+ impaired gaze+ parkinsonism  progressive supranuclear palsy

2. Long term metformin therapy  B12 deficiency
3. Brain abscess  MCC Staph aureus Strep viri anaerobes CT/MRI Ring enhancing lesions
4. Intracerebral hemorrhage (ICH) typically presents with progressive headache, nausea/vomiting, and altered
mental status over a period of minutes to hours. ICH in young patients is commonly due to arteriovenous
malformation, which may also present with recurrent headache, seizure, or focal neurologic deficits.
5. Lambert-Eaton myasthenic syndrome is frequently associated with an underlying malignancy (eg,
small cell lung cancer). It is caused by autoantibodies directed against the voltage-gated calcium
channels in the presynaptic motor nerve terminal leading to symmetric proximal muscle weakness
with depressed deep tendon reflexes.
6. Deep tendon reflexes still be observed in brain death patients
7. craniopharyngioma  calcified tumor in suprasellar region compress pituitary stalk and optic chiasm 
bitemporal hemianopsia and panhypopituitarism

TSC  subependymal nodules in lateral ventricles (obstructive hydrocephalus), ash leaf spots and angiofibroma
8.

9. Parkinson disease dementia (PDD) is characterized by executive and visuospatial dysfunction with relatively
mild memory impairment at first. PDD may be distinguished from dementia with Lewy bodies by the timing of
symptom onset: If parkinsonism predates cognitive impairment by >1 year, PDD should be diagnosed. The
cognitive impairment of PDD may be treated symptomatically with cholinesterase inhibitors (eg, donepezil).
Psychotic symptoms of PDD may be treated by a dose reduction of antiparkinsonian agents and/or low-
potency antipsychotics (eg, pimavanserin, quetiapine).

10. Vitamin B12 Deficiency  Crohns disease, when test results are inconclusive order MMA or homocysteine
11. HIV associated neuropathy  only sensory symptoms are impaired
12. Dementia with Lewy bodies presents with dementia plus ≥2 of the following features: visual hallucinations,
parkinsonism, fluctuating cognition, and REM sleep behavior disorder. Cognitive impairment would develop
in this condition before or at the same time as parkinsonism, not years later, as seen in this patient.
13. Jaw claudication + fever+ large vessel vasculitis+ headache+temporal tenderness  ischemic optic neuropathy
 monocular blindness
14. Cluster headache  First line abortive 100% oxygen; prophylaxis  verapamil
15. First-line abortive therapy for refractory migraine headache is usually with triptans and antiemetics. However,
triptans and ergots are relatively contraindicated in patients with significant cardiovascular disease because
their associated vasoconstrictive properties can increase the risk for serious adverse effects (eg, stroke,
myocardial infarction)

16. Because HIV infection is being successfully managed with antiretroviral therapy and patients are living longer
\

with lower morbidity, common forms of dementia such as Alzheimer disease have become much more
common than HIV-associated dementia in these patients. HIV-associated dementia is a severe form of
subcortical dementia found almost exclusively in untreated HIV-infected patients. Although syphilis, primary
CNS lymphoma, and progressive multifocal leukoencephalopathy (PML) are more common in
immunosuppressed patients (eg, HIV-associated AIDS), this patient has no evidence of AIDS (ie, CD4 count
consistently >200/mm3). Furthermore, the patient's presentation is not consistent with any of these
conditions:

 Late neurosyphilis is characterized by general paresis, dementia, and tabes dorsalis and typically develops
10-25 years after infection.
  Primary CNS lymphoma in HIV-infected patients is strongly associated with Epstein-Barr virus and
presents with focal neurologic findings with lesions evident on neuroimaging.

 PML is associated with reactivation of the JC virus and presents with motor deficits, other neurologic
signs, and demyelination evident on neuroimaging.

17. Cervical myelopathy often causes both spinal cord and spinal nerve root compression, resulting in myelopathic
symptoms (eg, upper motor neuron signs below the lesion) and radicular symptoms (eg, lower motor neuron
signs, pain in a dermatomal/myotomal pattern). Lhermitte sign (electric shock–like pain with neck flexion)
may occur.
18. Fibromyalgia is a pain syndrome that occurs most commonly in young to middle-aged women and is
characterized by fatigue, widespread pain, and cognitive/mood disturbances. Advice sleep hygiene , patient
education and aerobic exercise. Amitriptyline is an effective initial therapy. Pregabalin, duloxetine, and
milnacipran are alternate therapies for patients not responding to tricyclic antidepressants.
19. Guillain-Barré syndrome is an acute or subacute ascending flaccid paralysis. Cerebrospinal fluid analysis shows
an elevated protein level with normal cell count (albuminocytologic dissociation).
20. Cholinesterase inhibitors such as donepezil, rivastigmine, and galantamine may provide moderate
symptomatic relief of cognitive symptoms and temporarily improve functioning in Alzheimer disease;
however, these medications have not been shown to alter the disease course.Donepezil, galantamine,
and rivastigmine are effective in patients with mild to moderate AD. Memantine, an NMDA receptor
antagonist, is approved for moderate to severe dementia.Selegiline is a monoamine oxidase inhibitor that is
sometimes used as a second-line treatment in AD for its antioxidant properties, although current evidence is
weak.
21. Myasthenia gravis  Fluctuating and fatigable weakness with sxs of oculobulbar and respiratory sxs. Triggers
lke medications abxs like fluoroquinolones, aminoglycosides, neuromuscular blocking agents, cardiac meds
like bbs , MgSO4 and pencillamine. Also pregnancy, stress, surgery,infection. Dx CTscan, icepack, AchR.-Ab
highly sensitive. Tx ACEI, immunotherapy, thymectomy
22. Autonomic dysfunction is common with Parkinson disease and can lead to neurogenic orthostatic
hypotension, with patients experiencing lightheadedness or syncope on standing. The disorder is typically
recognized by a ≥20 mm Hg drop in systolic blood pressure with standing and an absence of the expected
increase in heart rate.
23. The cardinal signs of Parkinson disease are rest tremor, rigidity, and bradykinesia. At least 2 of these on
physical examination are grounds for a clinical diagnosis.
24. Neurogenic thoracic outlet syndrome (TOS) occurs when the brachial plexus is compressed within the confined
space of the thoracic outlet. Symptoms of neurogenic TOS (the most common TOS subtype) include poorly
located numbness and dysesthesia (often in the C8 and T1 nerve root distribution), typically exacerbated by
sustained overhead arm use. The C5 and C6 nerve roots comprise the superior trunk of the brachial
plexus and provide sensory innervation to the lateral upper arm, forearm, and hand (eg, lateral palm and
thumb).
25. Tension-type headaches can occur due to stress and are usually bilateral, dull, and non-throbbing without
associated symptoms (eg, nausea, vomiting). When infrequent, they can be treated with analgesics (eg,
ibuprofen), but when more disabling, prophylactic medication (eg, amitriptyline) should be considered.
26. HIV neuropathy is a distal, symmetrical polyneuropathy that typically begins with numbness/tingling/pain in
the feet and progresses proximally. Older patients with long-standing, poorly controlled HIV are at greatest
risk. Antiretroviral treatment reduces the risk of progression. Gabapentin is first-line for symptomatic
management.

Cerebrospinal fluid analysis

Diagnosis Cell count Cell type Glucose Protein
Bacterial meningitis ↑↑ Neutrophils ↓ ↑↑
Viral meningitis ↑ Lymphocytes Normal Normal or ↑
Fungal or tuberculous meningitis ↑ Lymphocytes ↓ ↑
Herpes encephalitis ↑ Lymphocytes & erythrocytes Normal ↑
Guillain-Barré syndrome Normal Normal Normal ↑

27. Patients with severe immunosuppression (eg, AIDS, solid-organ transplantation, immunosuppressant
medications) are at increased risk for cryptococcal meningitis. Most cases are marked by subacute,
progressive headache, vomiting, fever, and nuchal rigidity. Cerebrospinal fluid typically shows lymphocytosis
with a mildly elevated white blood cell count, mild protein elevation, and low glucose. Diagnostic confirmation
requires identification of the encapsulated yeast in cerebrospinal fluid (eg, India ink stain) or
on polysaccharide antigen testing
28. Subarachnoid hemorrhage results in sudden-onset, severe headache with nausea and/or vomiting and other
signs of meningeal irritation. Patients should be evaluated with urgent noncontrast CT scan of the head; if
results are negative and a high suspicion for SAH remains, lumbar puncture should be performed.
29. Vasospasm is the major cause of delayed morbidity and mortality in subarachnoid hemorrhage and can result
in cerebral infarction. Vasospasm can best be prevented with initiation of nimodipine.
30. Multiple sclerosis Spasticity in legs. Tx: Baclofen or Tizanidine.
Mx Baclofen GABA-B agonist
Tizanidine  alpha 2 adrenergic  reduce alpha motor neuron excitability
Refractory cases: Botulism toxin A or intrathecal baclofen
31. Steppage gait (weak dorsiflexion) exaggerated hip and knee flexion while walking  L5 radiculopathy and
peroneal neuropathy
32. Epidural hematoma Lucid interval followed by uncal herniation and expanding hematoma
33. Narrowing of cervical canal with spinal cord compression  Spondylosis  gait dysfunction, extremity
weakness and vibratory/pain sensation
Dx: CT myelogram or MRI Tx; Surgical decompression
34. Lacunar stroke of posterior lateral thalamus  Pure contralateral sensory deficit Thalamic pain syndrome
(Severe pain over affected place with light touch; allodynia)
35. NBSM in ischemic stroke  Give thrombolytics (Alteplase) withing 4.5 hrs; if more than 4.5 hrs give aspirin).
For patients with ischemic stroke, eligibility for thrombolysis and mechanical thrombectomy is considered
independently. Depending on the time of presentation (<4.5 hr for thrombolysis, <24 hr for mechanical
thrombectomy) and the presence or absence of specific contraindications, patients may be eligible for one,
both, or neither of these therapies.
36. Alcoholic cerebellar degeneration Truncal ataxia+ Nystagmus+ Postural tremor
37. Central vertigo, Non- contrast CT should be obtained to rule out Stroke
38. Essential tremor bilateral tremor of the hands, head tremor without dystonia, no focal neurologic deficient,
improves with alcohol; Tx propranolol or primodine (anticonvulsant) in case of COPD or asthma
39. Prevent seizure recurrence in generalised convulsive status epilepticus Non benzodiazepine like
leviteracetam, fosphenotin, valproic acid
40. Phenytoin toxicity caused by CYP 450 inhibitors like TMP-SMX can cause symptoms like horizontal nystagmus,
ataxia, n/v, significant toxicity Coma, death
41. ALS degeneration of UMN (motor nuclei in precentral gyrus and their projections in corticospinal and
corticobulbar tracts) + LMN (spinal nerve and cranial nerve)+ bulbar sxs ( dysphagia, dysarthria); Dx clincal
evaluation, EMG and MRI of brain and spinal cord Tx riluzole ( decreased glutamate mediated excitotoxicity)
plus edavarone ( antioxidant) slows disease progression, respiratory support ( NIPPV), nutritional support(PEG
tube)
42. Rheumatoid arthritis patient At risk of atlantoaxial instability; Hoffman sign is positive
43. Imaging needed for high risk child with loss of consciousness, AMS, basilar skull fracture, vomiting, severe
headache, fall >5 ft
44. Presence of early onset postural instability can suggest other diagnosis than PD (bradykinesia + tremor or
rigidity) like progressive supranuclear palsy
45. Pronator drift UMN lesion or pyramidal or corticospinal tract defect
46. Brachial artery cannulation Median nerve injury Tingling in the little finger?????
47. Epidural hematoma Medial temporal lobe compression uncal herniation oculomotor nerve
compression ipsilateral fixed and dilated pupil and contralateral hemiparesis due to compression of ipsilateral
cerebral peduncle
48. Friedreich ataxia GAA trinucleotide repeat; limb and gait ataxia, loss of proprioception and vibration,
kyphoscoliosis and HCOM. Death from cardiac cause by 40
49. CVS complication of TSC (Ashleaf spots, angiomyolipomas and shagreen patches) is cardiac rhabdomyoma
50. Broca dominant frontal lobe; trouble with speaking fluently
51. Restless legs syndrome is a neurologic condition that can interfere with the quality and duration of sleep. It is
characterized by an urge to move the legs, with discomfort that is temporarily relieved by movement. Alpha-
2-delta calcium channel ligands (eg, gabapentin) are often effective. Measure ferritin level
52. Recent studies have suggested that a brain that has seized for >5 minutes (status epilepticus) is at increased
risk of developing permanent injury due to excitatory cytotoxicity. Cortical laminar necrosis is the hallmark of
prolonged seizures and can lead to persistent neurologic deficits and recurrent seizures.
  Magnetic resonance imaging of the brain will generally show evidence of cortical hyperintensity on
diffusion-weighted imaging suggesting infarction.

24. Tetanus is a presynaptic neuromuscular junction disorder caused by the Clostridium tetani toxin, which blocks
the release of the inhibitory neurotransmitters glycine and GABA across the synaptic cleft, leading to fever, painful
muscle spasms, and trismus (lockjaw). It is usually seen only in those who are unvaccinated or incompletely
immunized. Impairment of presynaptic Ach release. Sx Symmetric descending flaccid paralysis, blurred vision, and
areflexia and can include diaphragmatic paralysis.

25. Lacunar strokes occur due to micro-atheroma formation and lipohyalinosis in the small penetrating arteries of
the brain. They often affect the internal capsule and result in pure motor hemiparesis. Hypertension is the most
important risk factor.

22. Late neurosyphilis manifests years after untreated Treponema pallidum infection with general paresis
(progressive dementia) or tabes dorsalis (sensory ataxia, lancinating pains, reduced/absent deep tendon
reflexes). Patients often have Argyll Robertson pupils (normal pupillary constriction with accommodation but
not with light). Intravenous penicillin is the treatment of choice.
23. Patients with hemorrhagic stroke initially tend to have focal symptoms that rapidly progress to signs of
elevated intracranial pressure. Urgent noncontrast CT scan of the head is performed to confirm the
hemorrhage

IM- CVS
1. Congenital bicuspid aortic valve is the most common cause of aortic regurgitation (AR) in developed
countries, with patients typically diagnosed in their 30s or 40s. The AR is usually valvular but can also be
due to aortic root dilation.
2. Flailing of a tricuspid valve leaflet can occur due to chordae tendineae rupture in the setting of tricuspid
valve myxomatous degeneration. This is an example of primary TR, which is far less common than
secondary TR
3. Cardiac catheterization in patients with cardiac tamponade typically reveals elevated and equilibrated
intracardiac diastolic pressures. Urgent echocardiography should be performed in patients with
suspected cardiac tamponade for definitive diagnosis and management.
4. Pulmonic valve stenosis usually occurs as a congenital defect and can often remain asymptomatic until
adulthood. Cardiac auscultation reveals an ejection click, followed by a crescendo-decrescendo systolic
murmur over the left second intercostal space and widened splitting of S2.
5. Thickened ventricular walls with low-voltage QRS complexes on ECG should raise suspicion for infiltrative
myocardial disease. Cardiac amyloidosis due to age-related (wild-type) amyloid transthyretin (ATTR) is
typically seen in elderly men and is often associated with carpal tunnel syndrome.
6. Not taking dual antiplatelet therapy (DAPT) is the most common cause of intracoronary stent
thrombosis. Patients receiving an intracoronary stent should be counseled regarding the importance of
taking DAPT, both at the time of stent placement and in follow-up.
7. Acute cardiac tamponade is due to rapid accumulation of a small amount of fluid within a stiff
pericardium, causing a sudden rise in intrapericardial pressure. Unlike subacute tamponade, the cardiac
silhouette can be normal on chest x-ray.
8. SLE accelerated atherosclerosis  premature coronary artery diasease
9. OSA   Path: pharyngeal muscle relaxation; closure of airway; loud snoring with periods of apnea, Sx
nonrestorative sleep with frequent awakenings; daytime somnolence, morning headaches, affective and
cognitive symptoms; Complications: systemic PH, pulmonary hypertension with right heart failure
10. Statin and aspirin for PAD (ABI <0. 9) . Severe limb threatening complication like ulcer needs surgical
revascularization
11. Adenosine for PSVT and amiodarone and lidocaine for VT; amiodarone for Afib
12. Vasovagal syncope bradycardia and sinus arrest during attack on EKG
13. Paraxysomal afib is the most common arrythmias in most of the elderly patients (>65) with atrial
enlargement
14. S3 (Kentucky; normal in children and adolescents) but denote heart failure with reduced ejection fraction
in older patients more than 40
15. Preload reduction in acute decompensated HF with intravenous furosemide.
16. Furosemide reduced renal pressure and improves cardiac output to restore GFR gradient and increase
GFR (cardiorenal syndrome)
17. Long standing hypertension S4 (tenessee)
18. Exertional syncope+ ECG demonstrating T-wave inversions in lateral leads (V4-V6)  HCOM Dx:
Echocardiography
19. Propanalol for hyperthyroidism induced Afib
20. RVMI  Normal saline bolus; not work dopamine and dobutamine (inotropic agents)
21. Vasovagal syncope triggered by emotional stimuli or stress does not require further testing if other
testing for cardiac and orthostatic syncope are normal ; tilt table testing differentiated vasovagal and
orthostatic syncope
22. NBSM in Acute decompensated heart failure is nonivasive positive pressure ventilation
23. First degree block  Prolonged PR interval P followd by QRS, Pt asymptomatic. Tx: Observation
24. Mobitz type 1 ; PR prolongation with sudden drop in QRS; Tx; Observation
25. Infective endocarditis- septic or pulmonary emboli from TR; holosystolic murmur increase with
inspiration when additional blood is pulled to the right side of the heart
26. Bradycardia+ Av block+ diffuse wheezing  beta blocker toxicity Tx: Glucagon
27. Pulseless defibrillation; hemodynamically unstable cardioversion
28. Tokubetsu cardiomyopathy intermittent chest pain sxs after emotional stressor without CAD. Tx
supportive care
29. DASH diet lowers systolic BP by 11mg followed by weight loss then exercises 5days/week followed by salt
restriction followed by alcohol cessation
30. Cor pulmonale is RH failure without involvement of LH failure
31. Hypertension + osteoporosis  give thiazides (minimizes calcium wasting)
32. Positive hepatojugular reflex cardiac cause
33. PH due to HF needs left heart dysfunction drugs
34. OSA can cause systemic and pulmonary hypertension and right heart failure
35. Nitroprusside can cause acute cyanide toxicity Met acidosis, neurologic changes (agitation, seizure)
and cardiorespiratory stimulation (in early toxicity)
36. Coarctation of aorta Second most common cause of hypertension in young adults. Measure brachial
femoral delay (Bilateral arm and leg blood pressure measurements)
37. Tachycardia induced cardiomyopathy  Tx: rate or rhythm control; An elevation in ventricular
contraction rate (eg, >100/min) that is sustained for weeks or more can cause left ventricular dilation and
cardiomyocyte dysfunction known as tachycardia-induced cardiomyopathy. The cardiomyopathy is
usually reversible with slowing of the ventricular contraction rate; in atrial fibrillation this is accomplished
via improved rate control or reestablishment of sinus rhythm (ie, rhythm control).
38. Left ventricular diastolic pressure increased in acute mitral regurgitation
39. CHADSVASc Score >2 needs oral anticoagulant
40. Peripartum cardiomyopathy dilated cardiomyopathy during 38 weeks or 5 months, if presents with
dyspnea with exertion, S3 and lower extremity edema suggests decompensated heart failure; needs echo
for diagnosis; urgent delivery if hemodynamic instability or beta blockers and diuretics for Tx
41. Beta blocker is first line for chronic stable angina  dec myocardial contractility and heart rate

Alternatice : Nondihyropyridine calcium channel blockers ( verapamil, dilitiazem) same mech

42. Periinfarction pericarditis (4 days after MI) should undergo echocardiography to rule out pericardial
effusion Tx: ASA+ colchicine
43. Peaked T waves, loss of p waves, widened QRS, sine wave and asystole Hyperkalemic emergency Tx;
calcium gluconate

44. Epigastric pain+ Nausea and vomiting- Resting ECG

45. Acute limb ischemia (cold mottled leg without pedal pulses) after MI suggests embolization of left
ventricular thrombus Dx Echocardiography to find ventricular aneurysm
46. Ventricular aneurysm is a complication of MI presents with heart failure sxs(peripheral edema, bilateral
lung crackles ), key features : ST segment elevation with deep q waves in the areas where it was affected
by MI previously
47. Decompensated heart failure  no pulmonary edema due to increase lymphatic drainage. Therefore, the
absence of pulmonary edema in this patient does not exclude the diagnosis of DHF because patients with
slowly progressive decompensation may have minimal or no pulmonary edema. This is because the
pulmonary lymphatics can gradually increase fluid outflow rate up to 10 times the baseline when
needed, effectively offloading fluid from the pulmonary venous system to the central venous system and
allowing evidence of elevated central venous pressure (eg, JVD, peripheral edema) to be present despite
minimal or no pulmonary edema.
48. Unsynchronized cardioversion aka defibrillation for pulseless vent tachy and ven fib; using it in patients
with pulse can induce ven fib
49. Coronary artery thrombosis can occur after post stent placement with full occlusion causing severe chest
pain and ST segment elevation
50. Time to rhythm analysis and defibrillation has the most important survival factor in the patient
51. Obesity is most important risk factor for hypertension
52. WPW syndrome
 Shortened PR interval
 Delta wave
 Widened QRS complex
Tx definitive catheter ablation
Afib  procainamide class 1a
53. NSTEMI  Dual antiplatelet therapy to all patients, beta blockers, statins, ACEI/ARB, aldosterone
antagonists
54. Papillary muscle rupture--- acute within 3-5 days —RCA—harsh sys murmur with soft no palpable thrill
Sxs  pulmonary edema, hypotension and shock
55. Diffuse atherosclerosis and resistant hypertension renovascular hypertension; systolic diastolic bruit
has high specificity for renal artery stenosis
56. Cardiac tamponade  beck’s triad (Hypotension + muffled heart sounds +distended neck veins) ; pulsus
paradoxus ( >10mmHg decrease in systolic blood pressure)
57. Suspected acute coronary syndrome  administer aspirin immediately decreases mortality

Aspirin inhibits thromboxane A2 production to exert significant antiplatelet effects. It significantly

reduces the rate of myocardial infarction (MI), stroke, and overall mortality in ACS
58. Right sided precordial ecg for confirming RVMI; avoid nitrates
59. Acute pericarditis is the most common cardiac manifestation of SLE
60. Fibrinolytic therapy not indicated in NSTEMI
61. Chronic hypertension is one of the main risk factors for arrythmias
62. Non-sustained ventricular tachycardia is >3 consecutive ventricular beats at a rate >100/ min with
duration <30 secs. Predisposes to ventricular arrythmia and indicates an underlying electrolyte
abnormalities. Tx: beta blocker

63. Nonbacterial thrombotic endocarditis Non-infectious thrombin deposition on valves, seen in with
malignancy or SLE, which is associated with antiphospholipid syndrome check for APLA
64. Amiodarone induced interstitial pneumonitis (cough, fever, dyspnea, pulmonary infiltrates)
65. Nitrates systemic vasodilation decreased left vent preload decreased myocardial stress and oxygen
demand
66. Syncope without any trigger cardiogenic syncope Ambulatory ECG for monitoring arrythmias
67. Loop diuretics for decompensated heart failure and pulmonary edema in acute MI
68. Prompt restoration of blood flow with PCI or fibrinolysis improves long term mortality in patient with
STEMI
69. Alternate moderate intensity statin should be prescribed for those with high intensity statin toxicity, if
rhabdomyolysis discontinue immediately
70. Nonselective beta blockers N-Z (eg, propranolol, nadolol, sotalol, timolol) act on β1 and β2 receptors and
often trigger bronchoconstriction in patients with underlying asthma.
71. Cardioselective beta blockers A-M (eg, metoprolol, atenolol, bisoprolol, nebivolol) act predominantly on
β1 receptors and are generally considered safe in patients with mild-to-moderate asthma. However, all
beta blockers can trigger bronchoconstriction, especially when administered in large doses.
72. Atrioventricular dissociation Cannon A waves
73. Marfan syndrome (defect in fibrillin-1 gene) Aortic Regurgitation
74. Initial management of Afib includes rate control, beta blocker and CCB; hemodynamically unstable -
synchronized cardioversion
 75. Obstructive sleep apnea (OSA) likely encourages the development and persistence of atrial fibrillation,
possibly via nocturnal right atrial dilation and chronically elevated levels of sympathetic tone. The
diagnosis of OSA is important in patients with atrial fibrillation as treatment of OSA may assist in
management of the arrhythmia.
76. Low risk patient and those with increased risk with adequate functional capacity (> 4 Met equivalents) can
undergo surgery without any further testing
77. Chronic venous insufficiency, most common cause of LE edema is incompetence of valves causing venous
hypertension in the deep venous system. Accompanied by medial skin ulceration and skin discoloration,
varicose veins. Initial Tx; elevate leg, exercise, compression stockings. Worse in the evening; Risk factors
advancing age, obesity. Should undergo venous doppler U/S to confirm diagnosis
78. Initial EKG in STEMI is usually non- diagnostic or normal. Repeated EKG in ED every 15-30 mins required
79. Syncope with exertion and left ventricular hypertrophy in ECG consistent with aortic stenosis. Dx: Echo
80. A supervised exercise program should be recommended as a part of an initial treatment regimen in all
patients with intermittent claudication. Pharmacologic therapy with cilostazol and percutaneous or
surgical revascularization should be reserved for those with persistent symptoms despite adequate
supervised exercise therapy
81. Psittacosis transmitted by birds. Headache, dry cough and fever are common sxs
82. Tuberculosis pericarditis is the most common form of constrictive pericarditis in endemic region
83. Compensatory mechanisms in decompensated heart failure are activation of RAAS and SNS- sodium
retention and vasoconstriction and efferent renal arterioles decreased afterload and preload
84. Necrobiosis lipodica diabeticorum seen with diabetes in pretibial areas, presents as multifocal lesions
with brownish hue, dilated blood vessels and central epidermal atrophy
85. Stasis dermatitis scaling, weeping, superficial erosions, pitting edema. Dx: Duplex U/S
86. Aortic regurgitation due to biscupid aortic valve early- diastolic decrescendo murmur
87. STEMI presents with atypical sxs in elderly patients like nausea, vomiting and diaphoresis
88. Viral myocarditis presents decompensated heart failure with viral prodrome in younger patients
89. Mitral stenosis presents with dyspnea, orthopnea, PND and hemoptysis. Also causes afib and
thromboembolic complications.
90. Patients with severe mitral regurgitation develop left ventricular volume overload and LV dilation, with
an audible S3 gallop typically present.
91. Hyponatremia is a mortality predictor for decompensated heart failure
92. Smoking is a strongest risk factor for AAA
93. Do not use beta blocker in decompensated heart failure

IM-GI

1.
2. Patient with continuous hematemesis have decreased level of consciousness  Risk of aspiration—>
endotracheal intubation
3.
4. Infected pancreatic necrosis should be suspected in patients who develop worsening abdominal pain,
unstable vital signs, or signs (eg, fever, leukocytosis) of infection 7-10 days after onset of acute necrotizing
pancreatitis. CT scan of the abdomen demonstrating gas within the pancreatic necrotic collection is
diagnostic.
5. Ischemic colitis is a common complication of vascular surgery, as patients are often older and have extensive
underlying atherosclerosis. CT imaging can show thickening of the bowel wall. Colonoscopy shows cyanotic
mucosa and hemorrhagic ulcerations. Contributing factors may include loss of collateral circulation,
manipulation of vessels with surgical instruments, prolonged aortic clamping, and impaired blood
flow through the inferior mesenteric artery.
Ischemic colitis  underlying atherosclerosis, watershed ischemia, hypovolemia, Sx hematochezia, abd
tenderness, diarrhea, metabolic acidosis and leucocytosis Dx CT scan colonic wall thickening, fat stranding,
Endoscopy: Edematous and friable mucosa Tx IV fluids and bowel rest, abxs with enteric coverage and
colectomy if necrosis develops.
6.
7. Down syndrome constipation find underlying met condition (Hypothyroidism, DM, hypercalcemia )
8. Recently hospitalized fever+ leukocystosis + voluminous watery diarrhea C.diff colitis. Dx: PCR stool
antigen TX: oral vancomycin
9. HBsAg and IgM anti-HBc are the most appropriate diagnostic tests for acute hepatitis B infection as they are
both elevated during initial infection and IgM anti-HBc will remain elevated during the window period.
10. Most common cause of cirrhosis in US is viral hepatitis, chronic alcohol abuse, NAFLD, hematochromatosis
11. Gonoccocal proctitis Sx: mucopurulent anal discharge, tenesmus, occasional rectal bleeding, constipation; Dx
NAAT, Tx doxycycline+ ceftriaxone
12. Patient with FDR with CRC or high-risk adenomatous polyps Colonoscopy at age 40 (or 10 years prior to age
of diagnosis in FDR, whichever comes first); Repeat every 5 years (every 10 years if FDR diagnosed at age >60)
13. Isoniazid therapy Niacin deficiency (vit D3)  Pellagra diarrhea, dementia, dermatitis Tx : Vit B6
14. Acute intermitted porphyriared tinged urine + no photosensitivity+ psychosis+ abdominal pain+ diarrhea+
vomiting+ neurologic sxs (parasthesia, confusion and agitation). Usually chronic and increase in LFT’S, no rash
15. History of radiation abdominal therapy  colorectal adenocarcinoma
16. Patients with familial adenomatous polyposis have a significantly increased risk of colorectal cancer. Frequent
screening with colonoscopy is started in childhood, and elective total proctocolectomy is considered in the
late teens or early twenties
17. Severe acute pancreatitis local release of pancreatic enzymes  systemic vascular endothelial injury 
increased vascular permeabiltity Hypotension Tx : several liter of IV fluids
18. PBC  autoimmune destruction of intrahepatic bile ducts, antimitochondral Abs present in middle aged
women with fatigue, pruritis, hepatomegaly and increasd alk phos, associated with xathelesma, osteomalacia
due to Vit D malabsorption and hepatocellular carcinoma
19. Ascites 80% from chronic liver disease most commonly cirrhosis due to chronic alcohol misuse, nonalcoholic
steatohepatitis, hep C
20. Atrophic glossitis+ microcytic anemia + GI sxs (bloating, diarrhea), microcytic anemia, Vit D deficiency  Celiac
disease
21. Celiac disease autoimmune response to gliadin in gluten atrophy of villi  malabsorption Sx abd
distention, diarrhea, foul stool; Dx IgA anti-tissue transglutaminase and IgA anti-endomysial antibodies.
Selective IgA deficiency patients may have neg Abs. Tx gluten free diet and dapsone for dermatitis
herpertiformis
22. Patient with cirrhosis need upper GI endoscopy to rule out esophageal variceal hemorrhage
23. Main stay for esophageal varices are nonselective betablockers (nadolol) and endoscopic variceal ligation
24. A transjugular intrahepatic portosystemic shunt is often used as salvage therapy in patients with refractory
ascites or esophageal varices who have failed endoscopic or medical management.
25. Drug induced pancreatitis thiazides, furosemide, Ace inhibitors, isoniazid and TMP-SMX
26. Collagenous colitis Chronic watery diarrhea in women aged >60 during fasting and in night, colonoscopy
shows normal mucosa; Bx; mucosal subepithelial collagen deposition
27. Gilbert syndromedec UDP glucuronyl transferase activity dec conjugation intermittent jaundice and
indirect hyperbilirubinemia. Triggered by period of stress like infection, prolonged starving, menses and
surgery
28. Chronic pancreatitis Dx: Pancreatic calcification on CT scan
29. Acute liver failure Acute onset of liver injury with encephalopathy + impaired synthetic function (INR>1.5).
Drug toxicity and acute viral hepatitis are common causes
30. Hepatitis A causes fever, vomiting, jaundice, hepatomegaly, and severe elevations in hepatic transaminases
(eg, aminotransferase levels >1,000 U/L). Unvaccinated individuals are at increased risk, as are day care
workers, homeless shelter residents, international travelers, and men who have sex with men.
31. Crohns disease Involve anywhere from oral mucosa to the anus, rectal sparing, chronic abd pain+
nonbloody diarrhea+ weight loss+ evidence of inflammation (anemia and inflammatory markers)
Tx: corticosteroids, azathioprine, anti-TNF therapies (infliximab)
32. Postprandial GI bloating+ abdominal pain with normal physical examination Dx Lactose hydrogen breath test
Tx dietary restriction of lactose and lactase supplementation
33. Tuberculosis hepatitis from miliary TB; Dx: granulomas on liver biopsy
34. Oropharyngeal dysphagia (stroke, malignancy); difficulty initiating swallowing, cough, choking and nasal
regurgitation Dx; Video fluoroscopic modified barium swallow
35. Esophageal dysphagia Difficulty swallowing seconds after initial swallow; sensation of food in the
esophagus, solids/liquids Motility Solids alone  structural Dx upper GI endoscopy and barium swallow
36. Constipation can be one of the secondary causes of behavioral change in down syndrome patients
37. Acetaminophen toxicity Tx: N-acetylcysteine
38. Whipple disease arthralgias +weight loss +fever +diarrhea+ abdominal pain Bx PAS positive material in the
lamina propria of small intestine
39. Tropical sprue  chronic watery diarrhea, considered in the patient in the tropical region for more than a
month
40. Gilbert syndrome and criggle-najar are because of decreased conjugation; increased indirect bilirubin; rotor
and dubin johnson syndrome are defective excretion; increased direct bilirubin ; Dubin johnson has the black
liver on the biopsy
41. Secretory diarrhea is a watery diarrhea that occurs during fasting or sleep. A low stool osmotic gap
(<50mOsm/kg). Toxins (V.cholera), hormones (VIPoma), CF, bile acids ( postsurgery patients)
42. Upper GI bleed increased urea production and urea reabsorption  Inc BUN/ creatinine ratio
43. Proctalgia fugax spastic contraction of anal sphincter and pudendal nerve compression. Recurrent brief
episodes of rectal pain unrelated to defecation. Normal PE. Diagnosis of exclusion. Reassurance, nitroglycerin
cream and biofeedback therapy for refractory sxs. Vs coccydynia causes pain while sitting
44. Sarcoidosis can have asymptomatic liver involvement (Inc LFT)
45. Gastroparesis can be from post viral gastroparesis; Tx low fat and low fiber diet; refractory case
metochlorpromide and percutaneous jejenual feeding tube, implantable gastric stimulator
46. PSC Asymptomatic mostly. Fatigue& pruritis associated with ulcerative colitis. Elevated alkaline
phosphatase. Multifocal structuring/dilation of intrahepatic and extrahepatic biliary duct. Periductal onion skin
pattern. Dx:MRCP. Tx: ursodeoxycholic acid; liver transplantation
47. SAAG >1.1 indicated portal HTN (cirrhosis, buddchiari ,CHF)
48. SAAG<1.1 indicated non-portal HTN (malignancy, nephrotic syndrome, pancreatitis, TB)
49. Burning intermittent epigastric pain (also nocturnal pain) + postprandial discomfort +nausea+ GI bleeding 
PUD
50. H.pylori induced production of gastric acid by parietal cells  duodenal ulcer formation Dx Endoscopy Tx
clarithromycin+ omeprazole+ amoxicillin
51. Autoimmune hepatitis causes hepatocellular pattern liver injury with anorexia, nausea, abd pain, fatigue,
pruritis and jaundice or completely asymptomatic. Dx: Anti smooth muscle abs, ANA,anti liver, kidney
microsomal -1 Abs, antinuclear Abs. Hypergammaglobulinemia with elevated protien gap, Hx portal and
periportal lymphoplasmacytic infiltrate Tx is prednisone with or without azathioprine
52. Diffuse esophageal spasm Uncoordinated simultaneous contraction of esophagus; Sx dysphagia for liquids
and solids, chest pain Dx: cockscrew pattern Tx CCb; nitrates or tricyclics
53. Long standing hx of DM1 is most common cause of gastroparesis. Dx: Gastric emptying scan Tx: low fat, small
and frequent meals; gastric prokinetic agents eg metacholpromide, erythromycin
54. Fever+jaundice+ increased bilirubin and Alk phos Acute cholangitis (Charcot’s triad); altered mental status
and hypotension (Reynolds pentad ) U/S dilation of intrahepatic and common bile duct Tx: Enteric Ab coverage
and biliary ERCP drainage within 24-48 hrs.
55. Intermitent Epigastic pain+ melena  Duodenal ulcer;Dx endoscopy or urea breath test Tx: PPI, amoxicillin /
clarithromycin. 2nd line Metronidazole/ PPI, bismuth, Tetracycline; test of cure needed
56. NSAIDS and Aspirin gastritis  GI bleeding loss of iron stores Iron def anemia
Dx Upper endoscopy
57. Anemia of chronic disease RBC production suppression by inflammatory cytokines Inflammatory
arthropathies eg RA, lupus
58. In acute liver failure due to acetaminophen toxicity, liver transplantation is firmly indicated in patients with
grade III or IV hepatic encephalopathy, PT >100 seconds, and serum creatinine >3.4 mg/dL (as in this patient).
One-year survival following liver transplantation for ALF is approximately 80%.
59. Most common site of colon mets is liver, presents with RUQ pain, inc LFT’s and firm hepatomegaly. Dx CT scan
60. Autoimmune hepatitis Young to middle aged women with acute or chronic hepatitis, > 1000 U/L
transaminases, anti-smooth muscle abs
61. Roux- en- Y engastric bypass (minimizes food intake and induces malabsorption), gastrojejenal anastomosis
usually within first year, nausea, vomiting, postprandial vomiting, GE reflux, dysphagia to the levl of not
tolerating liquids  GJ anastomosis Dx and Tx Esophagogastroduodenoscopy
62. Rapid emptying of food, especially highly osmotically active simple carbohydrates (eg, corn syrup), from the
gastric pouch can cause dumping syndrome due to abrupt transfer of fluid from the circulatory system into the
intestines. In addition to abdominal pain, nausea, and diarrhea, patients typically have hypotension and
tachycardia accompanied by diaphoresis, lightheadedness, or syncope.
63. Initial work up of ascites abd U/S and then paracentesis. Tx includes sodium retention, spironolactone,
furosemide and alcohol abstinence. Refractory cases large volume paracentesis and TIPS
64. Hep A transmitted fecal oral, poor sanitation, contamination of water and food. Fever+ nausea+RUQ pain+
jaundice and hepatomegaly. Dx: Anti hep A antibodies, elevated transaminases (>1000) Tx supportive
65. Patient with ulcerative colitis have increased risk of colorectal cancer. Screening colonoscopy should begin 8
years after diagnosis and every 1-3 years thereafter
66. Acute erosive gastroenteropathy causes several hemorrhagic lesions after exposure of gastric mucosa to
various injurious agents and reduction in blood flow
67. Mallory Weiss syndrome is partial tear to the distal esophagus at gastroesophageal junction after bouts of
retching and vomiting
68. Crohns disease involve anywhere from mouth to anus with rectal sparing. Apthous ulcer and perianal
manifestation are more common Tx: Corticosteroids and Infliximab
69. Patient with chronic pancreatitis with weight loss and abd pain pancreatic adenocarcinoma Dx CT abdomen
with contrast (w/o jaundice) or abd U/S (with jaundice)
70. Patient with iron def anemia should be evaluated with colonoscopy and endoscopy even if FOBT is negative
71. Clostridium septicum is closely associated with colon cancer
72. Albumin, total protein level, cell count and differential are ordered for diagnostic paracentesis.
73. Patient with brush border enzyme deficiency will have normal absorption of D-xylose
74. Patient with small intestine mucosal disease have low absorption of D-xylose
75. False positive D xylose test (low urine D-xylose with normal mucosal absorption.)
Delayed gastric emptying
 SIBO
 Impaired GFR
76. Any patient with cirrhosis or ascites with fever and mental status change spontaneous bacterial peritonitis
Tx third gen cephalosporin PPX fluoroquinolones
77. Autoimmune metaplastic atrophic gastritis antibodies towards parietal cells (hypochlorhydria and
unchecked gastrin production) and intrinsic factor (vit B12 def) postprandial abd pain+ bloating+ elevated
serum gastrin +macrocytic anemia
78. Stool studies (eg, multiplex PCR, culture) should be performed for suspected bacterial gastroenteritis.
Indications include bloody stools, high-grade fever, severe disease, and co-existing high-risk conditions (eg,
elderly, immunocompromised).
79. Dilated submucosal veins and AV malformations + painless GI bleeding (maroon coloured stool) mostly from
the right side of the colon, age >60 angiodysplasia; Dx endoscopy or colonoscopy; Tx asymptomatic no tx;
cautery for symptomatic
80. Diverticulosis  Bright red blood; arterial, unlikely to be missed on a colonoscopy
81. Chronic diarrhea in a day care setting, mainly nocturnal diarrhea needs further testing through stool antigen
testing.
82. Tumor must be ruled out by endoscopy to rule out pseudoachalasia before diagnosing achalasia with
manometry
83. Stress ulceration is common in patients in the intensive care unit and can cause occult or gross
gastrointestinal bleeding. Risk factors include shock, sepsis, coagulopathy, mechanical ventilation traumatic
spinal cord/brain injury, burns, and high-dose corticosteroids
84. Hepatic hydrothorax  Sx dyspnea, cough, pleuritic chest pain and hypoxemia. Transudative pleural effusion
due to small defects in the hemidiaphragm most commonly on the right side due to less muscular; Dx
documents through c-Xray and exclude other causes. Tx salt restriction and diuretic administration.
Therapeutic thoracocentesis in prominent sxs and chest tube placement avoided
85. Splenic infarction presents with acute pain+ tenderness. MCC is thromboembolic syndrome eg SLE,
malignancy
86. Alcoholic hepatitis AST 2X> ALT, increased ferritin and increased GGT
87. If marked elevations (>25 times the upper limit) of AST and ALT are present, toxin-induced (eg,
acetaminophen), ischemic, or viral hepatitis should be suspected.
88. Herpes zoster (shingles)  pain may precede vesicular rash by several days. Tx acyclovir
89. Folate deficiency commonly occurs in alcohol abuse, and methylmalonic acid level is normal
90. Cobalamin deficiency SIBO or pernicious anemia, MMA is high
91. Ischemic hepatic injury after incidence of shock (CHF, septic shock). LFT’s come back to normal in 1-2 weeks
92. Pancreatic hyperstimulation in exocrine pancreatic insufficiency abdominal pain. Pancreatic enzyme
supplementation can help with pancreatic exocrine insufficiency and pain.
93. Acalculous cholecystitis occurs in critical illness with fever, RUQ tenderness due to gall bladder stasis.
Increased alkaline phosphatase and total bilirubin.
94. Minimal rectal bleeding due to hemorrhoids or other benign causes. If no weight loss, change in stool caliber
or fever may denote serious issues, need colonoscopy (age >45), anoscopy is appropriate
95. Alpha 1 antitrypsin deficiency causes emphysema (cough, dyspnea) and hepatitis.
96. Major risk factors for C.difficle are recent antibiotic use, age >65 and gastric acid suppression .
97. Cirrhosis patient should have Hep A and Hep B vaccine if not immune
98. Peptic ulcer  perforation peritonitis Dx Upright Xray of chest and abdomen (supra-diaphragmatic free
air  Immediate surgical intervention
99. Pill induced esophagitis; Tetracyclines, potassium chloride, alendronate, Iron, aspirin and NSAID Sx
odynophagia (pain on swallowing) and retrosternal pain Dx clinical but confirmed by endoscopy showing
ulcers and Tx is to stop offending medication
100.Microscopic colitis  chronic watery diarrhea+ colonoscopy shows normal mucosa; Biopsy: mucosal collagen
subepithelial deposition
101.Patients with Sjögren syndrome are at high risk for chronic atrophic candidiasis, which is marked by
erythematous patches on the hard palate, buccal mucosa, and/or gums. Patients typically develop mouth pain
and sensitivity to acidic and spicy foods. Potassium hydroxide scrapings of the lesions are diagnostic
102.Most common complication of Roux-en-Y bypass surgery is stomal stenosis. Sx: nausea, postprandial vomiting,
gastroesophageal reflux and dysphagia to the point of not tolerating liquids Dx and Tx
Esophagogastroduodenoscopy
103.Partial SBO  bowel rest and serial bowel examinations; Complete SBO with no flatus and no air in rectum
exploratory laparotomy

Respiratory

1. Primary pulmonary tuberculosis is suspected in high risk setting like homeless shelter and health care facility.
Pleurisy, chronic cough and prolonged fever. Unilateral effusion, hilar lymphadenopathy and cavitation,
consolidation. Positive AFB and mycobacterial culture. Tx RIPE
2. Asbestosis  lower portion of the lung
3. Pneumonia down increased perfusion of poorly ventilated areas worsens hypoxemia
Pneumonia up decreased perfusion of poorly ventilated areas improved hypoxemia
4. Patient with exacerbated COPD should be treated with systemic glucocorticoids and IV abxs (fluoroquinolones
and azithromycin) to inhibit cascade of airway inflammation to lessen bronchial wall edema and secretions
and to improve expiratory airflow

5. COPD treatment
 Group A low symptoms low exacerbation  SAMA/SABA
 Group B Higher sxs and low exacerbation  LAMA+LABA
 Group E High exacerbation  LAMA+LABA+ ICS

2. Malignancy induced exudative effusion localized vascular inflammation and metastatic obstruction of
pleural fluid drainage  lymphocyte predominant and erythrocyte count >10000/mm3.
3. Effusions that meet ≥1 of the 3 Light criteria are considered exudative; this patient's effusion meets all 3
Light criteria (fluid/serum protein ratio >0.5, fluid/serum lactate dehydrogenase [LDH] ratio >0.6, and
fluid LDH more than two-thirds the upper limit of normal for serum LDH), consistent with exudate.
4. Aspirin exacerbated respiratory disease  Samter triad: Asthma + chronic rhinosinusitis with nasal
polyps+ NSAID’s induced respiratory reactions. Production of proinflammatory than anti-inflammatory
leukotriences. Tx avoid NSAID, do sensitization, leukotriene blockers (zileuton, monteleukast) can help
5. Mitral stenosis due to rheumatic heart disease  dyspnea, cough, orthopnea, enlarged heart and left
main stem bronchus elevation
6. Rheumatic heart disease only rarely causes isolated aortic valve involvement; there is almost always
concomitant mitral valve disease, usually from mitral stenosis (eg, opening snap, middiastolic murmur).
7. ILD cough, dyspnea, reticular or nodular interstitial markings on CXR
8. Ventilation = RR*TV. TV= pts weight*6ml/kg.
9. Patient with history of Hodgkin’s disease with treatment related sequele Increased risk of cardiac
disease, radiation induced hypothyroidism and secondary malignancy lung cancer in smoker, breast
cancer and GI cancer (colorectal, esophageal and gastric)
10. Capnography measures C02 in exhaled breath
11. Hypertrophic osteoarthropathy  sudden onset clubbing and sudden onset joint arthropathy in chronic
smoker. Mostly associated with lung cancer and need CXR to rule out malignancy
12. AAT1 deficiency should be considered in patient with COPD <45 years, minimal or no smoking hx, basilar
predominant COPD and unexplained liver disease, family history of liver disease Dx AAT levels and PFT Tx
human pool AAT
13. Multifocal atrial tachycardia  Distinct p waves with 3 different morphologies, atrial rate >100/min and
an irregular rhythm. Precipitated by acute respiratory illness with patients with underlying lung disease.
Tx; correct underlying inciting disturbance
14. Long term supplement oxygen therapy has been proven to prolong survival in patients with COPD and
significant hypoxemia
15. Orthostatic hypotension  dec renal perfusion  activations RAAS  decreased urine sodium
16. Cor pulmonale is due to right heart failure from pulmonary hypertension most commonly from COPD. Cor
pulmonale is impaired function of the right ventricle due to pulmonary hypertension that usually occurs
due to chronic lung disease. Signs of right ventricular failure include:

 Elevated jugular venous pressure

 Right ventricular 3rd heart sound
 Tricuspid regurgitation murmur
 Hepatomegaly with pulsatile liver
 Lower-extremity edema, ascites, and/or pleural effusions

Echocardiogram will show signs of increased right heart pressures, and right heart catheterization will show
pulmonary systolic pressure >25 mm Hg.
17. Positive Pressure Ventilation decreased LV preload, decreased RV preload, increased RV afterload
18. Pleural mesothelioma  Large pleural effusion on CXR
19. Theophylline toxicity  GI distress, diffuse tremor, hypotension and tachyarrhythmias
20. Granulomatosis with polyangiitis Upper resp (chronic rhinosinusitis) + Lower resp (tracheal ulceration
and lung nodules with cavitation) +rapidly progressing GN+ livedo reticularis and nonhealing ulcer. Dx:
ANCA and biopsy Tx corticosteroids and immunomodulators
21. Criteria for extubation readiness include:pH >7.25, Adequate oxygenation (eg, PaO2 ≥60 mm Hg) on
minimal support (ie, fraction of inspired oxygen [FiO2] ≤40% and positive end-expiratory pressure [PEEP]
≤5 cm H2O), Intact inspiratory effort and sufficient mental alertness to protect the airway.

22. Unfractioned heparin is preferred over LMWH, fondapaurinx, rivaroxaban  Renal insufficiency
increased risk of bleeding

23. Chronic pulmonary aspergillosis-> Risk: underlying lung disease (cavitatory TB) Sxs; chronic: cough,
hematemesis, weight loss, dyspnea, night sweats, fever Dx Aspergillosis IgG+, aspergilloma fungal ball on
CT Tx resection+ voriconazole

24. Noninvasive positive pressure ventilation in patients with acute exacerbation of chronic obstructive
pulmonary disease helps to unload the work of breathing and decreases mortality and need for intubation
Do not exceed more than 93 as it can cause intrapulmonary shunting

25. Right lower lobe crackles CXR r/o pneumonia

26. O2 = PEEP= FiO2

27. Co2= RR=Tidal volume

28. Fever+ dry cough+ SOB + erythematous rash Acute nitrofurantoin induced lung injury; Bilateral basilar
opacities and pleural effusion are common. Labs eosinophilia

29. Nirofurantoin short term use lung disease; long term use ILD; Tx symptomatic improvement after
stopping the drug in 1-2 days

30. Right position of endotracheal tube is 2-6 cm above the carina. Most common complication is right
mainstem bronchus intubation. Pull it back.

31. High doses of b2 agonist/ insulin  hypokalemia muscle weakness, hyporeflexia and cardiac arrythmias

32. Restrictive lung disease dec TLC, normal/inc FEV1/FVC ratio and dec DLCO

33. Bronchodilator-responsive airflow obstruction (≥12% increase in FEV1 or FVC) suggests asthma, regardless
of age. Because late adult-onset asthma features greater airway remodeling, the FEV1/FVC ratio may not
fully normalize

34. Bronchiectasis  bronchial dilation and thickening dyspnea, fever, tenacious sputum production,
hemoptysis, crackles, and digital clubbing

35. CF is the etiology for bronchiectasis in upper lobes of the lungs

36. Pulmonary Arterial Hypertension is a very common manifestation of scleroderma. Presents with
progressive dyspnea right ventricular enlargement  right heart failure

37. Peripartum cardiomyopathy seen after 36 weeks postpartum, sxs of heart failure dyspnea, orthopnea
and peripheral edema Tx beta blockers, diuretics; if unstable delivery

38. Recurrent pneumonia CT scan of chest  R/o malignancy obstruction causes impaired bacterial
clearance

39. Worsening CHF Bibasilar crackles, hypocapnia, resp alkalosis

40. Worsening COPD  occasional wheezing, respiratory acidosis

41. Persistent asthma treated with step up strategy

 Less than daily  ICS-formeterol PRN

 Most days waking up with asthma  ICS-formeterol daily (low dose ICS)

 Daily sxs, waking up with asthma, dec FEV1  ICS formeterol daily (med to high ICS)

 Uncontrolled after step 4: ICS formeterol daily(high dose ICS)+LAMA; consider biologic therapy Anti-IgE or
Anti- IL5/5R Mab

42. Myasthenic crisis Triggered by acute infection  rapidly worsening respiratory failure elective
intubation for impending respiratory failure (respiratory acidosis, falling vital capacity)

43. MCC of primary adrenal insufficiency  autoimmune adrenalitis; tuberculosis adrenalitis is most common
worldwide

44. Hyperkalemia and hypovolemia are present in primary adrenal insufficiency

45. Patient with acute or severe exacerbations of COPD should be treated with respiratory fluoroquinoles.
Inhaled mucolytic agents (NAC) has no effect

46. Alcohol, opiods, benzoz central resp depression  hypoventilation  hypercapnic respiratory failure
 increase RR or tidal volume for correction

47. Fluid restriction in asymptomatic or mildy symptomatic SIADH (headache, vomiting) patients; hypertonic
fluid for severe hyponatremia (coma, seizures)

48. ARDS  direct / indirect insult from pancreatitis, pneumonia, sepsis  activation of inflammatory cells
and increased permeability  fluid leakage into alveoli. Sx respiratory distress, hypoxemia Dx bilateral
lung opacities, Pao2/ Fio2<300 hypoxemia, edema not explained by cardiac failure or volume overload
49. ARDS pathophysiology  dec lung compliance  increased WOB
V/Q shunting  Hypoxemia
Increased hypoxic vasoconstriction  increased RV afterload and acute PHTN
50. Normal pleural fluid pH is 7.60. Transudative fluid usually has Ph 7.4-7.55
51. Early septic shock  peripheral vasodilation  leakage of fluids  increased heart rate, stroke volume
and PP  bounding peripheral pulses
52. Progesterone induced hyperventilation during pregnancy  increased respiratory drive in medulla 
increased oxygenation and decreased carbon dioxide due to increased minute ventilation dec residual
volume and FRC

53. Acute bronchitis  preceded by viral illness, cough for 5 days +- sputum production. No fever, chills. CXR
only if suspicious of pneumonia Tx symptomatic NSAID, bronchodilator
54. Severe exacerbation of COPD  hypercapnic encephalopathy  somnolescense and astrexis  ABG gas
analysis if suspected
55.

56. Pulmonary tuberculosis is common in older individuals with comorbidities (eg, renal failure) due to
waning cell-mediated immunity. Older patients often have fatigue, weight loss, and anorexia; cavitation is
seen less often on chest Xray
 57.

IM-Endocrine

1.
2. Primary hyperaldosteronism (Conn syndrome) causes hypertension, hypokalemia, and metabolic alkalosis.
The diagnosis is confirmed by low plasma renin activity with an elevated serum aldosterone level.
3. BAM CUSHINGOID (cushing disease)
 Buffalo hump
 Amenorrhea
 Moon facies
 Crazy
 Ulcer
 Striae
 Hypotension
 Infection
 Necrosis of the femoral head
 Glaucoma
 Osteoporosis
 Immunosuppression
 Diabetes

4. Hyperthyroidism  osteoclast activation  hypercalcemia  dec PTH dec Vit D activation  hypercalciuria
and net calcium loss  bone loss
5. Diabetic nephropathy  persistent albuminuria more (>30mg/g) and dec GFR  proliferative diabetic
retinopathy or long standing hx of DM
6. Crohn’s disease  chronic vit D deficiency  decreased calcium, decreased phosphorus and increased PTH
7. Patient with DM with adequate blood sugar control protects microvascular complications (retinopathy,
nephropathy) than the macrovascular complications (stroke, MI)
8. Stricter glucose control  cardiovascular mortality and risk of hypoglycemia. Recommended target HBA1c in
non-elderly patient is 7%
9. Humoral hypercalcemia of malignancy  dependent PTH  calcium level >14mg/dl Tx bisphosphanates
10. Carbemazapine  induces CYP24A1 induces catabolism of Vit d Vit D deficiency. Other drugs that
induces Vit D deficiency are include phenytoin, isoniazid and rifampin
11. Decreased bone mineral density in anorexia nervosa due to hypercortisolism, growth hormone resistance and
endocrine abnormalities
12. If albumin is low, corrected calcium = measured calcium + 0.8 [4g/dl – serum albumin in g/dl]
13. Hypothyroidism can elevate lipid level. Tx with levothyroxine
14. Glucagonoma  weight loss+ migratory erythema migrans + DM/hyperglycemia + GI symptoms
Dx glucagon level; abdominal (MRI or CT scan)
15. Euthyroid syndrome is a common pattern of thyroid function seen in hospitalized and acutely ill patients.
16. Combined OCP contains progesterone to stimulate endometrial differentiation and estrogen to stabilize
uterine lining which restores normal cycles
17. Acidosis  increased ionized calcium
18. Alkalosis  decreased ionized calcium
19. Primary adrenal deficiency  loss of salt, sweet and sex  loss of mineralocorticosteroids and
glucocorticosteriods. Hydrocortisone has lot of glucocorticoid activity and less mineralocorticoid activity;
fludrocortisone has mineral corticosteroid is added with that
20. Cirrhosis can cause hypogonadism due to primary gonadal injury or hypothalamic-pituitary dysfunction.
Cirrhosis is also associated with elevated circulating levels of estradiol due to increased conversion from
androgens.?
21. Chronic pancreatitis  Loss of insulin and glucagon secreting cells
22. Postprandial hyperglycemia  basal insulin to cover fasting phase and fast acting bolus (lispro, aspart) insulin
before meals
23. Rapidly progressing hirsutism due to increased androgen production by neoplasm Inc DHEAS in adrenal
neoplasm

24.
25. Cushing syndrome  Hypertension with hypokalemic met. Alkalosis
26. Secondary adrenal insufficiency  less ACTH less glucocorticoid and mineralocorticoid. MCC chronic
glucocorticoid use and infiltrative disease
27. PCOS androgenic alopecia, irregular menses and obesity  increased risk of DM2  Oral glucose tolerance
test
28. Sensorimotor polyneuropathy in diabetes is characterized by length-dependent axonopathy. Small fiber
involvement causes pain, paresthesia, and allodynia, whereas large fiber injury causes numbness, loss of
proprioception and vibration sense, and diminished ankle reflexes
29. Symptomatic or macro prolactinoma (>1 cm) should be treated with dopaminergic agonist (carbergoline,
bromocriptine), if not resolved or large tumor (>3cm) needs transsphenoidal resection
30. Alcohol decreases gluconeogenesis in the liver causes hypoglycemia in diabetic patients
31. Hypocalcemia in the presence of normal renal function caused by hypoparathyroidism
32. The causes of primary hypoparathyroidism include:

 Post-surgical (most common cause)

 Autoimmune
 Congenital absence or maldevelopment of the parathyroid glands (eg, DiGeorge syndrome)
 Defective calcium-sensing receptor on the parathyroid glands
 Non-autoimmune destruction of the parathyroid gland due to infiltrative diseases such as
hemochromatosis, Wilson disease, and neck irradiation

32. Painless thryroiditis / silent thyroiditis  chronic autoimmune thyroiditis nontender goiter, spontaneous
recovery. Positive TPO antibody and low radioiodine uptake

33. Subacute thyroiditis postviral inflammatory  fever and hyperthyroid sxs  painful/tender goiter.
Elevated ESR/CRP, low radioiodine uptake.

34. HHS or DKA have normal or midly elevated postassium level due to absence of insulin and
hyperosmolarity push K+ extracellulary. Insulin  Intracellular potassium movement  Hypokalemia

35.
36. Insulinoma  high insulin, high c-peptide and high pro-insulin

Exogenous insulin use  high insulin, low c-pep

37. Primary adrenal insufficiency  8 AM cortisol and plasma ACTH test; ACTH cosyntropin test can
distinguish between PAI and 2/3 AI

38. Low dose and high dose dexamethasone test; 24 hr urine free cortisol for cushing’s disease

39. Increased T4  thyrotoxicosis from graves’ disease causes hypertension from increased myocardial
contractility

40. Milk-alkali syndrome is characterized by hypercalcemia, acute kidney injury, and metabolic alkalosis.
It is caused by excessive intake of calcium and absorbable alkali, usually in the form of calcium carbonate
taken for heartburn or osteoporosis. Tx Discontinuation of causative agent and isotonic saline followed by
furosemide

41. glucocorticoid induced myopathy  progressive painless muscles weakness, proximal muscles
muscle atrophy due to catabolic effects of cortisol. CK and ESR normal

42. Treatment of diabetic gastroparesis includes:

Optimization of glycemic control

Dietary modification (eg, smaller, more frequent meals; decreased fat and insoluble fiber intake)

Medications that improve gastric emptying like metoclopramide

43. Cardiovascular related mortality+ weight loss+ minimize hypoglycemia  GLP-1 agonist and SGLT-2
inhibitor

44. Radioiodine therapy for Graves disease leads to resolution of hyperthyroidism in 6-18 weeks, but the
dose needed for treatment gradually leads to permanent hypothyroidism in most patients. This therapy
can also acutely worsen Graves ophthalmopathy due to increased titers of thyroid-stimulating
autoantibodies.

45. Opioid suppresses GnRH and LH secretion  decreased testosterone production

46. Hypothyroidism  feedback  increased TRH to increased TSH and prolactin  increased GnRH 
dec FSH and LH

47. Pan-hypopituitarism  Central Adrenal Insufficiency + hypogonadotropic hypogonadism+ central

hypothyroidism

48. Hashimoto thyroiditis  anti-TPO abs  increased risk of miscarriage in euthyroid and hypothyroid
women

49. MEN 1 Pituitary tumors + pancreatic tumors + Hyperparathyroidism most common presents with
peptic ulcer and kidney stones

50. Postpartum thyroiditis  Hyperthyroidism  Hypothyroidism  Euthyroidism

51. Postpartum thyroiditis is an autoimmune disorder characterized by lymphocytic inflammation of the

thyroid and disruption of thyroid follicles occurring <12 months after parturition. It can cause a self-
limited hyperthyroid phase due to release of preformed thyroid hormone. Management includes a beta
blocker to attenuate adrenergic symptoms, but specific antithyroid therapy is not usually needed.

IM- Dermatology
1. Allergic contact dermatitis  Type 4 hypersensitivity reaction; common triggers: poison ivy/oak, nikel, dyes,
topical medications, skin care products acute : red indurated plaques with vesicles/ bullae, chronic:
lichenification/ fissuring; Dx clinical diagnosis, patch testing for persistent cases, Tx Avoidance of suspected
allergen, topical or systemic corticosteoid
2. Plaque psoriasis is an inflammatory skin condition that typically presents with discrete erythematous plaques
with silvery scales; common locations include extensor surfaces of the extremities (eg, elbows, knees), scalp,
and retro-auricular areas. The diagnosis is made clinically.

3. Tinea pedis most commonly presents with a pruritic rash between the toes. The diagnosis is usually made
clinically but can be confirmed with a potassium hydroxide preparation of skin scrapings. A variety of topical
antifungal agents (eg, miconazole, terbinafine, tolnaftate) is effective for treatment, but nystatin is not
effective.

4. Bullous Phemphigoid Age> 60, pruritic, tense bullae, rare mucosal involvement, prodrome of
urticaria/eczematous like rash, associated with dementia, Parkinson’s disease, depression, bipolar disorder,
Histology: subepidermal cleavage, IM IgG/C3 deposition along the basement membrane. Abs to
hemidesmosomes. Topical therapy: high potency corticosteroids, systemic therapies: corticosteroids and
doxycline.
5. MCV- Affect children than adult, umblicated and smooth rather than scaly more likely a skin coloured papules
6. Tinea cruris  scaly, pruritic rash in the groin area sparing scrotum. Recurrent infection due to exposure from
external source or autoinfection from concurrent infection from other parts of the body ( tinea pedis, tinea
corporis, onchyomycosis) . Other body parts must be checked. Corticosteroids make it worse
7. Actinic keratosis  topical medication 5-FU or imiquimod
8. Seborrheic keratosis is a benign epidermal tumor that presents in middle-aged or elderly individuals as a tan
or brown, round lesion with a well-demarcated border and "stuck-on" appearance. Diagnosis is based
primarily on clinical appearance, and treatment is usually not required. Risk factor Age; Sudden appearance
of numerous keratosis in the upper back  Leser- trelat sign  gastrointestinal malignancy
IM-Renal

1.
2. Renal colic in pregnancy is associated with abdominal pain, flank tenderness, hematuria, and, often, irregular
uterine contractions. Ultrasonography is the diagnostic imaging modality of choice for evaluating abdominal
pain in pregnancy because it avoids radiation to the fetus.In pregnancy, nephrolithiasis often occurs in the
second and third trimesters due to progesterone-induced ureteral dilation and decreased peristalsis, which
lead to urinary stasis. In addition, pregnancy is associated with increased urinary calcium excretion. These
combined effects predispose pregnant women to stone formation.
Right lower abdominal cramps+ flank tenderness + hematuria during pregnancy  nephrolithiasis Dx
Renal and pelvic U/S
3. Hematuria in the setting of direct penile trauma is concerning for urethral injury and should prompt
retrograde urethrography. Retrograde urethrography involves x-ray of the urethral tract following injection
of radiopaque contrast through the urethral meatus. Extravasation of contrast from the urethra is diagnostic
of urethral injury. Urethrography should precede any attempts at urethral (eg, Foley) catheterization because
catheterization can worsen the injury, potentially converting a partial urethral tear into a complete urethral
laceration
4. Patients with chronic obstructive pulmonary disease often have chronic CO2 retention, resulting in respiratory
acidosis and compensatory metabolic alkalosis. Diuretics are often administered to treat cor pulmonale
symptoms but must be used cautiously as they can lead to a reduction in cardiac output and subsequent
development of prerenal acute renal injury.
5. Initial hematuria suggests urethral damage, terminal hematuria indicates bladder or prostatic damage, and
total hematuria reflects damage anywhere in the urinary tract. Clots are not usually seen with renal causes of
hematuria (eg, glomerular diseases).
6. Chronic constipation is a risk factor for recurrent cystitis in young children. The impacted stool can
cause rectal distension, which compresses the bladder and urethra, prevents complete voiding, and
leads to urinary stasis and bladder infection.
7. Calcineurin inhibitors (eg, tacrolimus, cyclosporine) have vasoconstrictive properties that are responsible for
much of their toxicity. Acute calcineurin inhibitor toxicity is often triggered by impaired hepatic clearance of
the drug and presents with hypertension and prerenal acute kidney injury.
8. Chronic vomiting leads to volume depletion and metabolic alkalosis, which is initiated by a loss of hydrogen
and perpetuated by chloridedepletion. Treatment with normal saline restores intravascular volume and
replenishes chloride, thereby allowing renal elimination of bicarbonate.
9. Chronic lithium therapy is commonly associated with nephrogenic diabetes insipidus (DI), presenting with
polyuria and persistently dilute urine. Lithium-induced nephrogenic DI results from lithium accumulation in
the renal collecting ducts, which leads to antidiuretic hormone resistance and impaired renal water
reabsorption
10. Autosomal dominant polycystic kidney disease commonly presents with hypertension, hematuria, and
recurrent flank pain in patients in their 30s or 40s. Treatment is mostly supportive, although vasopressin-2
receptor antagonists (eg, tolvaptan) may slow disease progression in some patients.
11. Glomerulonephritis with hypocomplementemia is typical of immune complex-mediated glomerulonephritis
(except IgA nephropathy). Poststreptococcal glomerulonephritis causes renal-limited disease, so
hypocomplementemic glomerulonephritis associated with systemic vasculitis is usually due to
membranoproliferative glomerulonephritis (positive serum cryoglobulins) or lupus nephritis (positive
antinuclear antibodies).
12. Trimethoprim  Hyperkalemia

The primary causes of hypocomplementemic, IC-mediated forms of GN and their corresponding laboratory findings
include the following:

 Poststreptococcal GN (PSGN): Antistreptolysin O antibodies

 Membranoproliferative GN (MPGN): Serum cryoglobulins
 Lupus nephritis: Antinuclear antibodies (ANAs), anti-double-stranded DNA (anti-dsDNA)
 Endocarditis-associated GN: Positive blood cultures

13. Posterior urethral valves present in newborn boys with bladder distension, decreased urine output, and
respiratory distress (due to oligohydramnios and subsequent lung hypoplasia). Initial evaluation includes renal
and bladder ultrasound and voiding cystourethrogram. Management involves bladder drainage and
electrolyte correction followed by cystoscopy to confirm the diagnosis and ablate the PUV.
14. Uric acid stones should be suspected in patients with acidic urine (especially when urine pH is <5.5) and
conditions that increase uric acid levels (eg, gout). Excess urinary excretion of uric acid and low urine pH can
cause supersaturation with uric acid that promotes stone formation.
15. Loop diuretics are frequently administered to cirrhotic patients with volume overload and ascites. Potential
side effects include hypokalemia, metabolic alkalosis, and prerenal kidney injury.
16. However, acute kidney injury tends to cause an anion gap metabolic acidosis and hyperkalemia.
17. Hepatorenal syndrome is characterized by a decrease in glomerular filtration in the absence of other causes of
renal dysfunction, minimal hematuria, and lack of improvement with volume resuscitation. It occurs due to
splanchnic arterial dilation, decreased vascular resistance, and local renal vasoconstriction with decreased
perfusion.
 HRS occurs as cirrhosis progresses and patients develop splanchnic arterial dilation and an
overall decrease in vascular resistance. This, in turn, activates the renin-angiotensin system and
results in local renal vasoconstriction with decreased perfusion and glomerular filtration. The
most common inciting factors of HRS include spontaneous bacterial peritonitis and
gastrointestinal bleeding.
 Definitive therapy involves return of liver function through either hepatic recovery (eg,
abstinence from alcohol) or transplantation. For patients who are unlikely to have a quick
recovery and are not candidates for liver transplantation, other temporizing options to increase
renal perfusion include splanchnic vasoconstrictors (eg, midodrine, octreotide, norepinephrine)
and albumin. Dialysis is of limited benefit but may be attempted to help bridge to liver
transplantation.
18. Glomerulonephritis can cause glomerular hypercellularity and capillary wall thickening (ie,
membranoproliferative glomerulonephritis) due to deposits of immunoglobulin and/or complement factors.
Immunofluorescence microscopy helps identify the underlying cause. Deposition of C3 without
immunoglobulin deposition indicates a disease with alternative complement activation.
19. Alcohol bingeing can lead to acute alcohol myopathy and rhabdomyolysis, especially when combined with
cocaine abuse. Patients with rhabdomyolysis are at risk of developing acute kidney injury due to both
intravascular volume depletion and pigment-induced nephropathy.
20. Hypertensive nephrosclerosis develops in patients with chronically uncontrolled hypertension and is
characterized by hyaline arteriolosclerosis and ischemic glomerulosclerosis. Clinical features include
progressive, irreversible renal insufficiency with mild proteinuria and small, atrophic kidneys.

These changes explain the characteristic findings:

 Elevated creatinine (decreased glomerular filtration rate)

 Ultrasonographically small, atrophic kidneys
 Bland (ie, no white/red blood cells) urinalysis with mild proteinuria (<1 g/day).

In response to chronic hypertension, renal arterioles undergo medial hypertrophy and intimal fibrosis, and
subsequent endothelial damage leads to plasma protein and basement membrane material deposition into
arteriolar walls (hyaline arteriolosclerosis).

21. Complement-mediated MPGN is characterized by deposition of C3 but minimal or absent immunoglobulin

deposition (as seen in this patient). It is seen with C3 and C4 glomerulopathies. In particular, dense deposit
disease (DDD), a unique and uncommon form of MPGN, is due to IgG antibodies directed against C3
convertase of the alternative complement pathway, which leads to persistent activation of the pathway and
resultant kidney damage. DDD is associated with malignancy and has a poor prognosis.
22. Immune complex–/immunoglobulin-mediated MPGN is seen with certain chronic infections (eg, viral
hepatitis B and C) and autoimmune conditions associated with chronic circulating antibodies or antigenemia.
This leads to deposition of both circulating immune complexes (eg, antigen-antibody complex) and
complement factors (due to acute injury triggering the classic complement cascade)
23. Because of reduced renal clearance, the dosage of medications eliminated by the kidneys (eg, gabapentin)
should be decreased or ceased in patients with acute kidney injury and/or chronic kidney disease. Gabapentin
toxicity can cause encephalopathy and myoclonus, which typically resolve on discontinuation.
24. Exercise-associated hyponatremia occurs due to a combination of excessive fluid intake and non-osmotically
mediated release of inappropriately high levels of antidiuretic hormone. In severe cases, patients may
experience seizures, profound confusion, and even death.

Stimuli for secretion of antidiuretic hormone

 Serum osmolality > ~285 mOsm/kg H2O
Osmotic

 Nausea
 Pain
 Physical or emotional stress
 Hypotension
Nonosmotic
 Hypovolemia
 Hypoxia
 Hypoglycemia

25. Ace inhibitors/ Arbs are indicated in bilateral renal stenosis until and unless creatinine >30
26. SSRI use, carbamazepines, NSAIDS  SIADH  hyponatremia  confusion, seizure,coma
27. Hyperkalemic emergency Tx calcium gluconoate ; insulin and glucose to push in K
28. Renal tubular acidosis (RTA) involves a net loss of HCO3− and is a common cause of nonanion gap metabolic
acidosis. Type 1 RTA results from impaired H+ excretion in the distal tubule and can be recognized by
inappropriately high urine pH (>5.5) in the setting of acidosis.
29. Hypokalemia is a common adverse effect of loop diuretic use. It can cause generalized muscle weakness and
ECG changes, including ST-segment depression, T-wave flattening, U waves, and prolongation of the QT
interval.
30. Calciphylaxis (calcific uremic arteriolopathy) is characterized by systemic arteriolar calcification and soft-
tissue calcium deposition with local ischemia and necrosis. It is primarily seen in patients with
longstanding end-stage renal disease. Risk factors include hyperparathyroidism, hyperphosphatemia, and
hypercalcemia, although serum calcium is often normal. Pathogenesis is likely multifactorial; proposed
mechanisms include high calcium × phosphorus product with mineral deposition in vascular walls, deficiencies
in inhibitors of vascular calcification (Fetuin-A), and chronic inflammation.
31. High-dose intravenous acyclovir can cause crystalluria with renal tubular obstruction.
Administering intravenous fluids concurrently with the drug can help reduce the risk of acute kidney injury.
32. Sepsis leads to hypotension and intravascular volume depletion and is a common cause of prerenal acute
kidney injury (AKI). Prerenal AKI is characterized by low urinary sodium (<20 mEq/L), low fractional excretion
of sodium (<1%), and elevated blood urea nitrogen/creatine ratio (>20:1). Urine sediment is bland. In addition
to the treatment of the underlying disorder (eg, antibiotics for pneumonia), patients with prerenal AKI require
volume resuscitation with intravenous crystalloids as soon as possible to restore adequate renal perfusion.
33. Acute renal vein thrombosis presents with hematuria, renovascular congestion, and flank pain. The most
common causes are nephrotic syndrome, malignancy, and trauma. Diagnosis can be confirmed by CT or MR
angiography or renal venography.
34. Diuretic abuse leads to increased excretion of water and electrolytes by the kidneys, resulting in dehydration,
weight loss, orthostatic hypotension, hyponatremia, and hypokalemia. Urinary sodium and potassium will be
elevated. Patients sometimes abuse diuretics to induce weight loss.
35. Mixed cryoglobulinemia syndrome is a small-vessel vasculitis that commonly presents with palpable purpura,
glomerulonephritis, peripheral neuropathy, and arthralgias. Chronic hepatitis C infection is the most common
cause, and characteristic laboratory abnormalities include hepatitis C antibodies, rheumatoid factor, and
hypocomplementemia.
36. Dialysis-related amyloidosis results from inadequate clearance of beta2-microglobulin despite dialysis, and
the prevalence increases with age and dialysis duration. It has a predilection for osteoarticular structures
 presenting as scapulohumeral periarthritis (shoulder pain/hypertrophy), carpal tunnel syndrome, and bone
cysts.
37. Renal vein thrombosis is an important complication of all causes of nephrotic syndrome. However, it is most
commonly associated with membranous glomerulopathy. Loss of antithrombin III (an inhibitor of multiple
coagulation factors) in the urine increases the risk of venous and arterial thrombosis
38. Loop diuretics are frequently administered to cirrhotic patients with volume overload and ascites. Potential
side effects include hypokalemia, metabolic alkalosis, and prerenal kidney injury.
39. Loop diuretics function by inhibiting the Na-K-2Cl carrier in the loop of Henle, which results in increased loss
of sodium in the urine. The increased sodium delivery to the distal tubule subsequently results in elevated
hydrogen and potassium ion secretion in the urine. Loop diuretics also result in volume contraction and
increased aldosterone levels, further promoting the secretion of hydrogen ions in the urine.
40. Patients with diuretic abuse and Bartter/Gitelman's syndrome may also present with hypokalemia, alkalosis
and normotension, but their urine chloride concentrations are high. Patients with diuretic abuse may give a
history of diuretic abuse and have a positive urine assay for diuretics.
41. Initial hematuria suggests urethral damage, terminal hematuria indicates bladder or prostatic damage, and
total hematuria reflects damage anywhere in the urinary tract. Clots are not usually seen with renal causes of
hematuria (eg, glomerular diseases).

42. Eosinophilic esophagitis is characterized by food impaction, dysphagia, or heartburn that does not respond
to standard medications. Endoscopy usually reveals esophageal rings or strictures.
43. Membranous nephropathy (MN) is a common cause of nephrotic syndrome and is most often primary. When
primary MN is excluded (eg, negative phospholipase A2 receptor staining), causes of secondary MN should be
sought, including malignancy screening.
Negative test results for primary MN—as in this patient with negative tissue stain for PLA2R—warrant
evaluation for secondary causes of MN. These include the following:

 Malignancy: Solid tumors (eg, lung, colon, breast)

 Autoimmune disease: Systemic lupus erythematosus (SLE) (most common)
 Infection: Hepatitis B (most common), hepatitis C, HIV, syphilis
 Medication: Nonsteroidal anti-inflammatory drug, penicillamine

44. HIV-associated nephropathy is thought to be caused by direct infection of the renal epithelial cells by HIV and
typically presents with heavy proteinuria, rapidly progressive renal failure, and edema. It is most common in
patients of sub-Saharan African descent with advanced HIV infection.It is especially prevalent in patients of
 sub-Saharan African descent, possibly due to the presence of an apolipoprotein L1 (APOL1) gene variant that
is thought to confer resistance to trypanosomiasis but may increase susceptibility to HIVAN.

IM-Hemato and oncology

1. Patients with aggressive hematologic malignancies are at risk of tumor lysis syndrome when initiated on
cytotoxic chemotherapy or immunotherapy. Intracellular contents are released into the serum, leading to
hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia (due to calcium phosphate binding
in the renal tubules). Major complications include acute renal injury (uric acid/calcium phosphate tubular
injury) and cardiac arrhythmia. Prophylaxis with intravenous fluids and uric acid inhibitors reduces the
risk of kidney injury.
2. Acute lymphangitis is a common complication of injection drug use due to inoculation of skin flora into
subcutaneous tissue. However, this condition is generally marked by tender red streaks up the lymphatic
channels with painful, swollen, erythematous regional lymphadenitis
3. Thalassemia minor typically presents with microcytic anemia and a normal red cell distribution width. An
elevated reticulocyte count reflects a compensatory bone marrow response to the anemia
4. A mechanical or severely calcified aortic valve can cause hemolytic anemia due to erythrocyte shearing.
Patients also frequently have mildly low platelets due to concurrent mechanical platelet injury. An
echocardiogram should be performed to assess the valvular function.
5. Precipitation of Rrna Lead poisonin; Single round blue inclusions  Howell- Jolley bodies  Functional
hyposplenia
6. Urticarial transfusion reactions are common and caused by preformed recipient IgE antibodies reacting
against a soluble allergen in the donated plasma (or vice versa). Patients have isolated urticaria that
improves with transfusion cessation and diphenhydramine administration. If no signs of anaphylaxis are
present (eg, wheeze, angioedema, hypotension), the transfusion can be resumed without additional
evaluation
7. Acquired methemoglobinemia results from the oxidization of iron in hemoglobin, which is most
commonly due to topical anesthetic agents or dapsone. It presents with hypoxia, a characteristic pulse
oximetry reading of ~85%, and a large oxygen saturation gap.

Some medications - most commonly topical anesthetics (eg, benzocaine), dapsone, and nitrates (in
infants) - cause the iron component of hemoglobin to be oxidized, thereby forming methemoglobin,
which cannot bind oxygen.

Cyanosis can occur when methemoglobin comprises ~10% of total hemoglobin, but hypoxia symptoms
(eg, headache, lethargy) occur only when levels surpass 20%. At levels >50%, there is risk of severe
symptoms (eg, altered mental status, seizures, respiratory depression) and death. Treatment involves
discontinuing the causative agent and administering methylene blue, which helps reduce iron to its
normal state.

8. Pancytopenia (decreased red blood cells, white blood cells, and platelets) is common in patients with
systemic lupus erythematosus. It usually indicates concurrent peripheral, immune-mediated destruction
of all 3 cell lines
9. Excessive cow's milk consumption (>24 oz/day) commonly causes microcytic, iron deficiency anemia with
a low erythrocyte count and elevated red blood cell distribution width.
10. Heavy alcohol use is a common cause of nutritional folate deficiency in the United States and would cause
megaloblastic anemia.
11. Lower extremity motor weakness+ hyperreflexia+bladder dysfunction epidural spinal cord compression;
Tx intravenous glucocorticoids. Glucocorticoids decrease vasogenic edema (caused by obstructed epidural
 venous plexus), help alleviate pain, and may restore neurologic function. Once imaging confirms ESCC,
neurosurgery and/or radiation oncology consultation is typically required.
12. Osler-weber rendu syndrome  epistaxis+ pulmonary AVM+ diffuse telengectacias ( ruby colored papules
on the lips that blanch with pressure)
13. Acute lymphoblastic leukemia should be considered in an adolescent patient with an anterior mediastinal
mass in addition to pancytopenia, hepatosplenomegaly, and testicular enlargement. Presentation often
relates to compression of mediastinal structures, such as superior vena cava syndrome causing jugular
venous distension and difficulty breathing/cough.
14. Anemia with reticulocytosis suggests that the bone marrow is responding appropriately to the anemia by
generating new erythrocytes and that sufficient levels of folate, vitamin B12, and iron are available for
erythrocytosis. Anemia with reticulocytotis is commonly seen in acute bleeding conditions and
hemolysis. Chronic lymphocytic leukemia is associated with warm autoimmune hemolytic anemia.
15. Glucose-6-phosphate dehydrogenase deficiency causes hemolytic anemia due to oxidative injury to red
blood cells. Hemolytic episodes can be precipitated by infection or medications, especially dapsone,
antimalarials, and nitrofurantoin.
16. Antibody-mediated hemolysis is seen with warm or cold agglutinin disease. Certain
medications can also cause immune-mediated hemolysis, but most cases are linked
to cephalosporins, penicillins, and nonsteroidal antiinflammatory drugs
17. Heparin-induced thrombocytopenia should be suspected in patients receiving heparin anticoagulation
who have thrombocytopenia, thrombosis (arterial or venous), or a >50% drop in the platelet count from
baseline 5-10 days after the initiation of treatment.

Type 1 HIT occurs due to a nonimmune direct effect of heparin on platelet activation and usually
presents within the first 2 days of heparin exposure. The platelet count then normalizes with continued
heparin therapy and there are no clinical consequences.

Type 2 HIT is a more serious immune-mediated disorder due to antibodies to platelet factor 4 (PF4)
complexed with heparin. This leads to platelet aggregation, thrombocytopenia, and thrombosis (both arterial and
venous). Platelet counts usually drop >50% from baseline, with a nadir of 30,000-60,000/µL. Type 2 HIT usually
presents 5-10 days after the initiation of heparin therapy and may lead to life-threatening consequences (eg, limb
ischemia, stroke).

18. Anemia of chronic disease is a disorder of iron utilization that most commonly occurs in the setting of
chronic inflammation. It is characterized by a normocytic anemia with decreased serum iron, decreased
total iron-binding capacity, decreased iron saturation, and normal/elevated serum ferritin. Treating the
underlying inflammatory disorder will often improve the anemia.
19. A mechanical or severely calcified aortic valve can cause hemolytic anemia due to erythrocyte shearing.
Patients also frequently have mildly low platelets due to concurrent mechanical platelet injury.
An echocardiogram should be performed to assess the valvular function.
20. Sickle cell disease patients are at high risk of delayed hemolytic transfusion reactions due to
alloimmunization from frequent transfusions. Reactions develop >24 hours after transfusion and can
cause hemolytic anemia. Diagnosis is confirmed with a newly positive Coombs test.
21. Infections are a common complication of chronic lymphocytic leukemia (CLL). CLL is diagnosed by flow
cytometry (clonality of mature B cells)
22. Acute hemolytic transfusion reaction is an uncommon, life-threatening reaction due to transfusion of
mismatched blood (eg, ABO incompatibility), which causes fever, flank pain, and hemoglobinuria within 1
hour of transfusion initiation. Continued hemolysis can lead to acute renal failure, disseminated
intravascular coagulation, and shock. Management includes immediate cessation of transfusion,
aggressive intravenous fluid administration, and supportive care.
 23. Budd-chiari syndrome  Hepatic venous outflow obstruction often with subacute manifestations acute
sxs jaundice, hepatic encephalopathy, variceal bleeding, with vague, progressive abdominal pain, ascites
and hepatosplenomegaly. Dx Abd doppler U/S, investigation for underlying disorders JAK2 testing for PV
24. Prostate cancer may initially present with symptoms related to metastatic disease. Spread to the axial
skeleton is common, and manifestations typically include slowly progressive lower back pain or functional
impairment (eg, motor weakness, incontinence). Prostate cancer usually causes osteoblastic bone lesions
with normal or low calcium, elevated alkaline phosphatase, and radiographic evidence of focal, sclerotic
lesions.
25. Oral direct factor Xa inhibitors (eg, rivaroxaban, apixaban) have similar efficacy to warfarin in the
treatment of acute venous thromboembolism and do not increase the risk of bleeding complications.
These drugs do not require laboratory monitoring or overlap therapy with heparin and are becoming
preferred agents for the treatment of acute venous thromboembolism.
26. Physiologic anemia of infancy is an asymptomatic condition characterized by a normal decrease in
hemoglobin with a nadir at age 2-3 months. Pathophysiology involves a transient down-regulation of
erythropoietin due to increased tissue oxygenation after birth. Tx reassurance; anemia will resolve after 3
months
27. Splenic sequestration is a potentially life-threatening complication of sickle cell disease, an inherited red
blood cell (RBC) disorder characterized by the presence of hemoglobin S on electrophoresis. RBCs
become entrapped within the spleen, causing acute anemia and tender splenomegaly.
28. The 2 most common causes of microcytic anemia, iron deficiency and thalassemia, are differentiated by
iron studies. Thalassemia is a hemoglobin defect caused by alterations to ≥1 of the hemoglobin globin
subunits. Thalassemia minor is minimally symptomatic.
29. Patients with chronic immune thrombocytopenia have platelets <100,000/mm3 for >1 year. Splenectomy
is an option for those with persistent bleeding and thrombocytopenia despite repeated pharmacologic
interventions (eg, glucocorticoids, anti-D, intravenous immunoglobulin).
30. Burkitt lymphoma is a neoplasm of mature B cells associated with Epstein-Barr virus infection and typically
affects children. Although pancytopenia and hepatosplenomegaly can occur, patients typically have a
mass involving the mandible or abdominal viscera; mediastinal involvement is rare.
31. Hairy cell leukemia is a chronic B-cell neoplasm that infiltrates the bone marrow, spleen, and peripheral
blood, resulting in cytopenias, splenomegaly, and peripheral smear evidence of atypical lymphocytes with
"hairy" cytoplasmic projections. Hepatomegaly, lymphadenopathy, and B symptoms are uncommon.
Diagnosis is made with bone marrow biopsy.

29. Hemolytic uremic syndrome (HUS) is characterized by the triad of hemolytic anemia, thrombocytopenia, and
acute kidney injury (typically following a prodromal diarrheal illness caused by Escherichia coli O157:H7). The
mechanism of intrinsic renal injury in HUS is renal vascular occlusion caused by capillary microthrombi. Treatment
of HUS is supportive (eg, fluid management, transfusions) because most children (60%-70%) recover completely.

Vs HSP  abdominal pain+ AKI+ purpura and joint pain

32. The differential diagnosis for anterior mediastinal mass includes the 4 Ts: thymoma, teratoma (and other
germ cell tumors), "terrible" lymphoma, and thyroid neoplasm. Seminomas may cause elevated β-hCG,
but alpha fetoprotein (AFP) is essentially always normal. In contrast, most nonseminomatous germ cell
tumors cause elevated AFP and/or β-hCG.
 33. Immune thrombocytopenia is an autoimmune disorder with increased platelet destruction and inhibition
of platelet production due to IgG autoantibodies against platelet membrane glycoproteins. Patients may
have mucocutaneous bleeding with isolated thrombocytopenia and no hepatosplenomegaly.
34. Epidural spinal cord compression must be suspected in any patient with a history of malignancy who
develops back pain with motor and sensory abnormalities. Bowel and bladder dysfunction are late
neurologic findings. Intravenous glucocorticoids should be given without delay. MRI is then
recommended.

IM-ENT

1. Central retinal artery occlusion is a monocular painless acute vision loss most commonly caused
by an embolized atherosclerotic plaque from the ipsilateral carotid artery.
2. Blood and thunder  Central retinal vein occlusion
3. If a patient develops a whistling noise during respiration following rhinoplasty, one should
suspect nasal septal perforation likely resulting from a septal hematoma.Additional conditions
that can cause septal perforation are self-inflicted trauma (nose picking), syphilis, tuberculosis,
intranasal cocaine use, sarcoidosis and granulomatosis with polyangiitis (Wegener's).
 4. Ménière disease  SNHL, vertigo lasting 20 mins to hours, tinnitus and feeling of fullness in the
ear
5. BPPV  Brief episode of vertigo triggered by headmovement, Dix-Halllpike maneuver triggers vertigo
6. Vestibular neuritis  single episode of vertigo that can last for many days, preceeded by viral
infection, abnormal head thrust test. Vestibular neuritis is a self-limited inflammatory disorder
affecting the vestibular branch of the eighth cranial nerve that sometimes follows a viral
infection. Vestibular neuritis with unilateral hearing loss is termed labyrinthitis. Vestibular
suppressants (eg, meclizine) and antiemetics. Corticosteroids may improve short-term recovery,
and vestibular rehabilitation can improve residual imbalance.
7. Migraine  Vertigo associated with headache or other phenomenon; completely symptom free
between episodes
8. Brainstem/cerebellar stroke sudden onset, persistent vertigo along with other neurological sxs
9. Hearing loss+ tinnutis + aural fullness  Meniere’s disease; increased endolymphatic volume and
pressure (endolymphatic hydrops)
Subconjunctival hemorrhage is a benign condition in which blood collects in the space between
the conjunctiva and the sclera. Patients are typically asymptomatic. The diagnosis is clinical, and
no treatment is necessary.

OB/GYN

1. Chemical pneumonitis is typically a self-limited inflammatory response caused by direct pulmonary injury
from aspirated acidic gastric contents. Patients typically develop dyspnea, hypoxemia, and alveolar infiltrates
in the dependent lung segments within hours of aspiration.
 Pregnancy increases the risk for aspiration due to elevated progesterone, which delays gastric emptying
and decreases esophageal sphincter tone. In addition, the gravid uterus increases intraabdominal
pressure and promotes reflux. These obstetric factors, in combination with surgical risk factors (eg,
sedation, recumbent positioning, emergency intubation), likely led this patient to aspirate.
2. Ovarian masses in postmenopausal patients are initially evaluated with a pelvic ultrasound. In
postmenopausal women with a benign-appearing mass, a CA-125 level can further risk stratify the mass as
either likely benign or malignant to further guide management (eg, observation, surgical exploration).
1. Endometriosis is the ectopic implantation of endometrial glands and stroma in the abdominopelvic cavity that
can cause pain symptoms based on implant location. Patients with bladder implants typically have cyclic
hematuria, dysuria, suprapubic tenderness, and negative urine culture
2. Toxic shock syndrome, caused by Staphylococcus aureus bacteremia and associated exotoxin release, typically
presents with fever, hypotension, tachycardia, and a diffuse, red, macular rash. Treatment includes fluid
replacement and antibiotic therapy with clindamycin plus vancomycin.
3. The risk of intimate partner violence (IPV) increases during the postpartum period due to increased
emotional, physical, and financial stressors. Therefore, routine postpartum screening for IPV is required to
decrease the risk of maternal and infant morbidity.
4. Congenital cytomegalovirus occurs due to transplacental (vertical) transmission. Ultrasound findings
consistent with include bilateral periventricular intracranial calcifications, intrahepatic calcifications, and fetal
growth restriction
5. Granulosa cells are the primary component of the ovarian stroma and convert testosterone to estradiol via
aromatase. Malignant proliferation of these cells (ie, granulosa cell tumor) results in high estradiol levels that
affect breast tissue (eg, tenderness, fibrocytic changes) and the uterine lining (eg, postmenopausal thickened
endometrium).

6.
7. Incisional hernias develop due to fascial closure breakdown and may have a delayed presentation (months-
years). Patients typically have a slowly enlarging abdominal mass (ie, protruding abdominal contents) that is
palpable while supine and enlarges with the Valsalva maneuver.
8. During pregnancy, patients with sickle cell disease are more likely to have acute vasoocclusive pain episodes
(eg, abdominal pain) due to increased metabolic demands and a hypercoagulable state.
9. Amphetamine use in pregnancy increases the risk for spontaneous abortion, preeclampsia, abruptio
placentae, fetal growth restriction, preterm delivery, and intrauterine fetal demise.
10. Hypotension, a common adverse effect of epidural anesthesia, is caused by blood redistribution to the lower
extremities because of venous pooling from sympathetic blockade. Treatment of postepidural hypotension
includes left uterine displacement (ie, positioning patient on the left side) to improve venous return,
intravenous fluid bolus, and vasopressor administration (eg, phenylephrine, ephedrine)
11. Those who are positive for GBS during pregnancy should be treated with pencillin during delivery
12. Breast cancer metastasis to liver, lung, bone and brain
13. Initial step of management of eclampsia is magnesium sulfate
14. Tx DIC FFP (clotting factors, fibrinogen, antithrombin 3, plasma proteins), cryoprecipitate (concentrated
fibrinogen) , prothrombin complex concentrate
15. Bacterial vaginosis can be treated orally and vaginally with metronidazole. Treatment of partner is not
necessary because it is not sexually transmitted
16. Patient with high risk of preterm delivery  give progesterone from 16 weeks until delivery , inhibits
contractility and supports uterus
17. Parvovirus B19 infection in pregnancy can cause nonimmune fetal hydrops, or excessive fluid accumulation in
the interstitium (eg, pericardial or pleural effusions, ascites). Parvovirus B19 infection may be asymptomatic in
adults but is commonly acquired by respiratory transmission from young children, who typically have a
slapped-cheek facial rash that follows nonspecific prodromal symptoms.
18. The increased adipose tissue associated with obesity increases the peripheral conversion of androgens to
estrone, a type of estrogen. Chronically elevated estrone levels disrupt the hypothalamic-pituitary-ovarian
axis and result in anovulation and abnormal uterine bleeding.
19. Urinary tract infections typically cause dysuria, urinary urgency, and frequency but may also present with
more subtle symptoms, including acute-onset urinary incontinence due to bladder irritation and spasm.
Positive leukocyte esterase on urine dipstick or urinalysis supports the diagnosis.
20. Hyperemesis gravidarum is a severe form of nausea and vomiting in pregnancy that typically occurs during the
first trimester. A common risk factor is a twin gestation due to elevated hCG and progesterone levels.
21. Primary dysmenorrhea commonly occurs in adolescents after the establishment of ovulatory menstrual
cycles. Excessive endometrial prostaglandin production results in lower abdominal cramping and other
associated symptoms (eg, fatigue) during menses. Symptoms typically decrease with age. Tx OCP and NSAIDS.
22. Initial prevention of recurrent urinary tract infection (ie, ≥2 infections in 6 months or ≥3 infections in 1 year) is
with behavioral modifications, which includes contraception alteration. Diaphragm with spermicide use
increases risk of cystitis due to alterations in vaginal flora, increased colonization of pathogens, and urinary
stasis
23. Asymptomatic leiomyomata(fibroids) observation and reassurance only
24. Atypical glandular cells on Pap testing may indicate endometrial hyperplasia/cancer, which is confirmed via
endometrial biopsy. Endometrial hyperplasia/cancer is typically due to unopposed estrogen exposure (eg,
obesity, chronic anovulation) and subsequent uncontrolled endometrial proliferation
25. Pagets disease of the breast  pruritis, bloody discharge, eczema of breast, nipple retraction  Dx Tissue
biopsy, suspicious underlying DCIS or invasive carcinoma of the breast
26. Excess vit A toxicity  Acute  nausea, vomiting, changes in vision. Chronic  ataxia, hepatotoxicity and
alopecia. In pregnant women  microcephaly and cardiac defects as well as spontaneous abortion.
27. Corpus luteal cyst is more common in pregnancy presents with acute pelvic pain and complex cystic masses or
free fluid in the pelvis. Tx observation and supportive care.
28. Vulvar hematoma can happen after delivery due to damage to pudendal artery Tx ice pack and analgesia; I and
D if needed
29. Infertility is the inability to conceive after 12 months of regular, unprotected intercourse in women age <35.
Male factor infertility is a common cause, and the initial evaluation for infertility includes semen analysis.
30. Interstitial cystitis (painful bladder syndrome) is an idiopathic, chronic condition characterized by pain that is
exacerbated by bladder filling and relieved by voiding. Additional clinical features may include dyspareunia
 and urinary frequency and urgency. Management includes bladder training, fluid management, analgesics,
and avoidance of any precipitating agents (eg, caffeine, alcohol, artificial sweeteners).
31. Vesicovaginal fistulas may occur after pelvic surgery (eg, hysterectomy) and present as a continuous, painless,
watery discharge from urine leaking (ie, pooling of clear fluid) into the vagina. Risk factors: pelvic surgery,
pelvic radiation, genitourinary malignancy, prolonged labour/child birth. Dx Physical Examination, dye testing,
cystourethroscopy. Obstructed labor in resource-limited areas is the most common cause of vesicovaginal
fistula worldwide. Vesicovaginal fistula presents with a continuous, watery vaginal discharge and an area of
raised, red granulation tissue on the anterior vaginal wall. Diagnosis is with pelvic examination and bladder
dye test.
32. Vaginal cuff dehiscence, or vaginal wound separation, is a rare but serious postoperative complication after
hysterectomy. Although peritoneal leakage through the vagina may be seen, the apex would appear
inflamed, indurated, or open. This patient's vaginal apex appears normal
33. Partial ovarian torsion typically presents with intermittent, self-resolving episodes of unilateral pelvic pain due
to temporary ovarian vessel occlusion. Patients with intermittent partial torsion can suddenly develop
complete torsion, which requires diagnostic laparoscopy. Management is with diagnostic laparoscopy for
manual detorsion of the adnexa and removal of any contributory cysts or masses; oophorectomy may be
required if the ovary is necrotic.
34. The combination of dysuria and sterile pyuria is a common presentation for Chlamydia trachomatis urethritis
in sexually active women. Patients with this clinical presentation require nucleic acid amplification testing for
chlamydia and gonorrhea.
35. Infertility is failure to conceive after 12 months of unprotected sexual intercourse in women age <35.
A hysterosalpingogram is used to diagnose an anatomic cause of infertility such as tubal obstruction from
prior pelvic infection
36. Candida vulvovaginitis is caused by overgrowth of Candida albicans and typically presents with vulvovaginal
erythema, vaginal pruritus, and discharge with a normal vaginal pH (3.8-4.5). Treatment options include oral
(eg, fluconazole) and intravaginal (eg, clotrimazole) antifungals.
37. Herpes simplex virus (HSV) infection typically resolves spontaneously within a week of lesion development.
However, HSV is associated with recurrent disease, which can become less frequent over time. Antivirals (eg,
acyclovir, valacyclovir) are used to decrease symptom duration and the number of recurrences
38. Congenital aromatase deficiency is a rare enzyme deficiency that prevents the conversion of androgens to
estrogens. It causes virilization of female fetuses, resulting in normal internal genitalia with ambiguous
external genitalia. This rare enzyme deficiency first manifests in utero with the inability of the placenta to
convert androgens into estrogens, leading to a transient masculinization of the mother that resolves after
delivery. At birth, female infants have normal internal genitalia and ambiguous external genitalia due to high
levels of gestational androgens. In adolescence, patients have delayed puberty, osteoporosis, undetectable
estrogen levels (eg, no breast development), and high concentrations of gonadotropins that result in
polycystic ovaries.
39. Choriocarcinoma is a metastatic form of gestational trophoblastic neoplasia that may occur after a
hydatidiform mole, normal pregnancy, or spontaneous abortion. The lungs are the most frequent site of
metastasis. Choriocarcinoma should be suspected in postpartum women with an enlarged uterus, irregular
vaginal bleeding, pulmonary symptoms, and multiple infiltrates on chest x-ray. Diagnosis is confirmed by
an elevated β-hCG level.
40. Vaginal squamous cell carcinoma is due to persistent infection with human papillomavirus (HPV) infection
high-risk types 16 and 18. Chronic tobacco use decreases the normal immune response, which allows for
persistent HPV infection and squamous cell metaplastic changes.
41. Diethylstilbestrol was previously used for spontaneous abortion prevention but was discontinued due to
multiple adverse effects (eg, infertility due to anatomic defects). Women who were exposed to this
medication in utero are at increased risk of vaginal clear cell adenocarcinoma, not squamous cell carcinoma.
42. HIV testing is recommended atleast once during pregnancy and during third trimester for high risk patients.
43. VEAL=CHOP
44. Absent fetal heart rate U/S fetal
45. Trisomy and heritable fetal disorders like tay sachs, CF and SMA in first trimester screening
46. Immature ovarian and hypothalamic axis along with anemia  give OCP to normalize the menstural cycle and
decrease the amount of bleeding by stabilizing endometrium

47. Spinal epidural abscess MC organism is Stap Aureus; Immunosuppression (HIV, diabetes, alcohol use,
infection) lumbar back pain+ fever+ low extremity neurological symptoms (weakness, tingling numbness) +
increased ESR Dx MRI of the spine with contrast, blood and aspirate cultures Mx broad spectrum antibiotics
(ceftriaxone+ vancomycin), surgical decompression/ urgent aspiration after spinal anesthesia or direct
inoculation spread from vertebral osteomyelitis.
48. Tamoxifen is used for adjuvant therapy in hormone-positive breast cancer and has mixed agonist and
antagonist activity on estrogen receptors. Hot flashes are the most common adverse effect. Tamoxifen use
also increases the risk for endometrial cancer, uterine sarcoma, and venous thromboembolism.
49. Wernicke’s encephalopathy Associated conditions; Chronic alcoholism, hyperemesis gravidarum and
malnutrition (anorexia nervosa) Path: Thiamine deficiency Sx: gait and postural ataxia, oculomotor
dysfunction, encephalopathy. Tx Intravenous thiamine followed by glucose infusion
50. Vertical transmission of group B Streptococcus (GBS) during vaginal delivery causes early-onset neonatal GBS
infection (eg, sepsis, pneumonia). Patients with GBS bacteriuria in their current pregnancy or those who
delivered a prior infant with early-onset GBS infection are at high risk for transmission; therefore, these
patients require intrapartum antibiotic prophylaxis.
51. In menopausal patients with moderate to severe vasomotor symptoms (ie, hot flashes), first-line treatment is
with menopausal hormone therapy. Patients with a uterus require estrogen-plus-progesterone therapy. In
contrast, patients without a uterus require estrogen-only therapy (eg, transdermal estrogen patch).

52. Recurrent pregnancy loss (≥3 consecutive pregnancy losses) may be caused by submucosal fibroids due to
impaired embryo implantation or growth. It is managed with hysteroscopic myomectomy, which restores
normal intrauterine anatomy and reduces the risk for future pregnancy loss.
53. Patients with von Willebrand disease may present with a postpartum hemorrhage and prolonged bleeding
time. Activated PTT may be normal or prolonged, and platelet count and PT are normal. Treatment of acute
bleeding includes desmopressin.
54. Uterine atony and retained products of conception can cause heavy postpartum bleeding but examination
shows an enlarged, boggy uterus
55. Postpartum endometritis  fever+ uterine tenderness+ purulent vaginal discharge
56. Painful  HSV: Papules, pustules or ulcers that’s painful, presents with painful lymphadenopathy;
H.Ducrey  large, deep ulcers with yellow/gray exudate, well demarcated borders, soft and friable
bases, severe lymphadenopathy that may suppurate
 Painless  syphilis: Single ulcer (chancre), indurated borders with hard, nonpurulent base, bilateral nontender
LN
Chlamydia trachomatis: initial small painful ulcers followed by painful, fluctuant adenitis (buboes)
Klebsiella donovanosis : Subtropical climate, india, Guyana; painless genital ulcers with no
associated LN

57. Vasa previa is a rare condition in which the fetal vessels overlie the cervix, making them prone to tear and
bleed with rupture of membranes or contractions. Management of a ruptured fetal vessel is with emergency
cesarean delivery because of the high risk of fetal exsanguination and demise.
58. Physiologic hydronephrosis of pregnancy  ureteral compression from uterine enlargement and decreased
ureteral peristalsis due to decreased progesterone  U/S shows bilateral renal enlargement with dilated
pelvis and proximal ureter no management required
59. Ureteral stents and nephrostomy tubes for nephrolithiasis that causes hydronephrosis
60. Pregnant women are at increased risk for gallstone formation and subsequent acute cholangitis, which
typically presents with fever, right upper quadrant pain, and jaundice (ie, direct hyperbilirubinemia) (Charcot
triad). Patients with severe cases may also develop hypotension and altered mental status
61. Fibroadenoma benign, estrogen sensitive fibroepithelial tumor, adolescent female and female <30,
unilateral, firm, well circumscribed mass in upper outer quadrant, cyclic changes with menses ( increased
breast size and tenderness), observation and reexamination in adolescent and U/S in adult women.
62. Acute postpartum urinary retention causes an inability to void as well as overflow incontinence due
to pudendal nerve injury and bladder atony. Risk factors include prolonged labor, perineal trauma, and
regional neuraxial anesthesia.
63. Vaginal burning, itching, dyspareunia after a dose of antibiotics  candida vaginosis
64. Patients with cytology results that show bacterial vaginosis on Pap testing should be asked about symptoms
(eg, malodorous vaginal discharge). Symptomatic patients are screened (eg, wet mount microscopy,
potassium hydroxide whiff testing) and treated if the diagnosis is confirmed. Asymptomatic patients do not
require treatment.
65. Bartholin cyst duct  Asymptomatic: observation and management; symptomatic cysts incision and
drainage
66. Skene gland cyst  next to urethral meatus; Gartner cyst is lateral sides of anterior vaginal wall, incomplete
regression of wolffian duct during development
67. Gardnella vaginalis  thin, grey malodourous discharge, no burning or itching, clue cells on wet mount
68. Ovarian failure may occur secondary to chemotherapy and presents with amenorrhea and signs of estrogen
deficiency (eg, vaginal dryness). Ovarian failure is characterized by increased FSH and LH due to lack of
feedback inhibition from estrogen
69. Twin pregnancy  increased risk of preterm delivery
70. Fetal dysmaturity syndrome after 42 weeks gestation  uteroplacental insufficiency and age-related placental
changes  meconium stained amniotic fluid, SGA, thin body with loose skin
71. NAFLD  obesity, T2 DM, increased AST/ALT <1; Tx weight loss and bariatric surgery if BMI>35 Prognosis:
Hepatic fibrosis associated with increased risk of cirrhosis and liver related death
72. Intrahepatic cholestasis of pregnancy  pruritis on palms+ elevated LFT’s and total bilirubin
73. Preeclampsia  Hypertension+ RUQ pain + proteinuria + end organ damage
74. Emergency contraception  Copper T 99% efficacy
75. Performed at initial prenatal visit & 3rd trimester:

 HIV, Syphilis, Hepatitis B & C viruses, Gonorrhea, Chlamydia

76. During early pregnancy, the corpus luteum produces progesterone, which prepares the endometrium for
implantation, promotes implantation, and maintains the pregnancy through 10 weeks gestation. Patients who
have the corpus luteum removed (eg, oophorectomy) prior to 10 weeks gestation
require progesterone supplementation to prevent pregnancy loss.
77. Cocaine use, trauma abruptio placentae
78. Prior caesarian delivery  uterine rupture, irregular mass, sudden onset abdominal pain, rapid fetal
decompressions Tx Laparotomy for delivery and uterine rupture
79. Viral myocarditis  Viral prodrome with signs of HF (respiratory distress, murmur, cardiomegaly,
hepatomegaly)
80. Acute pyelonephritis (fever, maternal and fetal tachycardia, costovertebral tenderness) in pregnancy 
inpatient admission with IV abxs KEE organisms and GBS
81. PID  Inpatient tx with cephalosporin and doxycylin, metronidazole if tubo-ovarian abscess is suspected
82. Abruptio placentae is the premature separation of the placenta from the uterine wall prior to fetal delivery.
Patients typically have acute abdominal pain; a rigid, tender uterus; and high-frequency contractions. Risk
factors include cocaine and tobacco use, which cause placental vasoconstriction, ischemia, and hemorrhage.
83. Asherman syndrome vs sheehan syndrome  Low FSH and LH in sheehan and normal FSH and LH in asherman
syndrome vs primary ovarian insuffiency high FSH and LH
84. Patient with high fever and resistance to antibiotics  Septic pelvic thrombophlebitis Tx anticoagulation and
broad spectrum abxs
85. A secondary varicocele should be suspected in a prepubertal boy with a soft, coiled ("bag of worms"), right-
sided scrotal mass that fails to decompress when supine. Abdominal ultrasound is indicated to evaluate for
anatomical causes leading to venous compression (such as a venous thrombus or abdominal mass).
86. Patients at high risk for preeclampsia (eg, multiple gestations) are prescribed low-dose aspirin prophylaxis at
12-28 weeks gestation (but optimally before 16 weeks) for prevention
87. Postpartum urinary retention  inability to void after >6 hr of vaginal delivery or >6 hrs after urinary catheter
removal following cesarean delivery  overflow incontinence causes pudendal nerve injury or impaired motor
or sensory sacral spinal cord impulses from regional neuraxial anesthesia
88. PCOS  irregular menses and signs of hyperandrogenism. Anovulation from failed follicular
maturation
89. OCP should not be used in those with hypertension

24.

Thyrotoxicosis with normal or ↑ RAIU Thyrotoxicosis with ↓ RAIU

 Painless (silent) thyroiditis
 Subacute (de Quervain) thyroiditis
 Graves disease  Amiodarone-induced thyroiditis
 Toxic multinodular goiter  Excessive dose (or surreptitious intake) of levothyroxine
 Toxic nodule  Struma ovarii
 Iodine-induced
 Extensive thyroid cancer metastasis

90. Ovarian torsion causes acute-onset, severe pelvic pain due to ovarian rotation impeding circulation and
causing ischemia. Mature cystic teratomas (dermoid cysts) are common causes of premenopausal adnexal
masses and have an elevated risk of torsion due to their heterogeneous composition.U/S shows partially
calcified, multiple thin and echogenic bands.
91. Most common unilateral, bloody nipple discharge is benign intraductal papilloma. No associated mass or
lymphadenopathy. Mammogram and ultrasound. Tx biopsy+/- excision
92. Pregnant women should be evaluated for tuberculosis using the same diagnostic approach as nonpregnant
patients. A positive tuberculin skin test or interferon gamma release assay should be followed with chest x-
ray to differentiate latent infection versus active disease.
93. Maternal sickle cell disease causes vasoocclusion that can result in placental infarction, ischemia, and
subsequent uteroplacental insufficiency. Uteroplacental insufficiency may present with decreased fetal
movement and oligohydramnios (ie, amniotic fluid index ≤5 cm) due to decreased fetal perfusion.
94. Generalized pruritis + pruritis worse on hands and feet + RUQ+ 3rd trimester  Intrahepatic cholestasis of
pregnancy Tx Ursodeoxycholic acid, antihistamines, delivery in 3rd trimester
95. Acute fatty liver of pregnancy  occurs in 3rd trimester with multiple gestation, microvesicular fatty infiltration
of hepatocytes due to abnormal maternal- fetal fatty acid metabolism, Hepatic inflammation  RUQ+ inc LFT+
jaundice+ sxs of fulminant hepatic failure (scleral icterus, coagulopathy + leukocytosis), platelet count
<1,00,000 , DIC and AKI Tx maternal stabilization and immediate delivery
96. HELLP  RUQ pain+ low platelets, hemolysis, elevated lactate
97. Universal screening for syphilis is required at the first prenatal visit to identify patients at risk for
transplacental transmission and associated obstetric and fetal complications. Syphilis is treated with
intramuscular benzathine penicillin G.
98. Patients with an underweight prepregnancy BMI and inadequate gestational weight gain are at increased risk
of pregnancy-related complications (eg, low birth weight, preterm delivery).
99. Exclusive breastfeeding for the first 6 months of life is recommended unless contraindications are present.
Although active substance use disorder is not compatible with breastfeeding, mothers on
a methadone treatment program can breastfeed

100. Uterine surgical history & vaginal birth

Surgery Trial of labor

Low transverse cesarean delivery (horizontal incision)

Classical cesarean delivery (vertical incision)

Abdominal myomectomy with uterine cavity entry

Abdominal myomectomy without uterine cavity entry

101.Sjogren syndrome  keratoconjuctivitis sicca+ dry mouth+ autoimmune sialoadenitis. Dyspareunia is women
102.Pregnancy weight loss  fetal growth restriction, preterm delivery
103.Renal colic in pregnancy is associated with abdominal pain, flank tenderness, hematuria, and, often, irregular
uterine contractions. Ultrasonography is the diagnostic imaging modality of choice for evaluating abdominal
pain in pregnancy because it avoids radiation to the fetus. In pregnancy, nephrolithiasis often occurs in the
second and third trimesters due to progesterone-induced ureteral dilation and decreased peristalsis, which
lead to urinary stasis. In addition, pregnancy is associated with increased urinary calcium excretion. These
combined effects predispose pregnant women to stone formation.
104.Pelvic inflammatory disease (PID) can spread to the intraperitoneal cavity and cause perihepatitis (ie, Fitz-
Hugh–Curtis syndrome). PID complicated by perihepatitis typically causes fever, vomiting, and pain in the
right upper quadrant and lower abdomen. Inpatient tx when pregnant, severe vomiting, failed outpatient tx
and complications ( perihepatitis and tuboovarian abscess) Tx Inpatient cephalosporin with doxycycline.
105.Placenta previa occurs when the placenta covers the cervix and typically presents with painless vaginal
bleeding after 20 weeks gestation. Blood loss is primarily maternal in origin; therefore, fetal heart rate
tracings are typically reactive early in the disease process.
106.Cesarean delivery is reserved for standard obstetric indications (eg, nonreassuring fetal tracing, breech
presentation, prior uterine surgeries)
107.Breech presentation occurs when the fetal buttocks or feet are the closest fetal part to the cervix. A risk
factor for breech presentation is uterine leiomyomas, which can distort the uterine cavity, thereby limiting
fetal mobility and preventing fetal cephalic engaged
108.Patients who undergo cervical conization for cervical intraepithelial neoplasia 3 and have surgical margins free
of disease remain at risk for recurrent dysplasia and cancer. Therefore, these patients require more frequent
cervical cancer screenings with repeat Pap and HPV cotesting at 1- and 2-years post-procedure.

109.Ovarian torsion occurs due to rotation of the ovary around the infundibulopelvic ligament, causing ovarian
vessel occlusion and ischemia. It classically presents with acute-onset, unilateral lower abdominal pain and a
tender, palpable adnexal mass. Diagnosis is clinical, and management is with emergency laparoscopy.
110.Intraamniotic infection (chorioamnionitis) is a complication of preterm prelabor rupture of membranes. Due
to the increased risk of maternal morbidity and mortality, patients with intraamniotic infection require
therapeutic antibiotics and immediate delivery, regardless of gestational age.
111.Early decelerations are uniform, shallow decelerations with gradual onset that occur symmetrically with
contractions. They nadir at the peak of the contraction and return to baseline at the end of the contraction.
Early decelerations are a benign finding caused by fetal head compression, which leads to a physiologic vagal
response
112.Labial adhesions, or fused labia minora, typically affect prepubertal girls due to low estrogen production.
Topical estrogen cream is first-line therapy for symptomatic lesions.
113.A biophysical profile (BPP) is performed in patients at risk for uteroplacental insufficiency (eg, ≥41 weeks
gestation). Chronic hypoxemia causes an abnormal BPP score and suggests imminent risk of fetal demise;
delivery is typically indicated.
114.Lower uterine mass that extends laterally  cervical cancer
115.Rectus abdominis diastasis is a weakening of the linea alba between the rectus abdominis muscles that can
present as a nontender abdominal bulge in pregnant or postpartum patients. Management is conservative
with observation and reassurance
116.Endometriosis  unilocular hypoechoic mass on the ovary (endometriosis) + infertility + pain with
dyspareunia and exercise Tx OCP to suppress ovulation and NSAID to reduce inflammation
117.Epithelial ovarian cancer  septate mass with solid and cystic components
118.Mature teratoma calcifications and hyperechoic nodules on ultrasound
119.Tubooarian abscess  multicystic adnexal mass with enhancing rims
120.Pelvic congestion syndrome  Pelvic pain associated with intercourse due to pelvic pain dilation. Visible
dilation on observation
121.Patients with gestational diabetes mellitus with suboptimal glycemic control and/or need for
pharmacotherapy (eg, insulin) are at increased risk for stillbirth. These patients require third-trimester
antenatal fetal surveillance (eg, nonstress testing at regular intervals).
122.Metabolic complications of infants of diabetic mothers include hypoglycemia, hypocalcemia, and
hypomagnesemia. Serum calcium level should be obtained for symptomatic neonates (eg, jitteriness),
particularly if serum glucose is normal
123.Ectopic pregnancy (ie, pregnancy implanted in an extrauterine location) can be diagnosed by a persistent rise
in β-hCG level following diagnostic dilation and curettage. Medical therapy is with methotrexate, a folate
antagonist that inhibits DNA synthesis in rapidly dividing cells (eg, trophoblasts).
124.Breast pain is typically benign when it is cyclic (ie, associated with menses), bilateral, and diffuse with no
associated examination abnormalities (eg, breast mass). Patients benefit from reassurance and symptom
management (eg, supportive bra, nonsteroidal anti-inflammatory drugs).

125.Acute urinary incontinence should prompt investigation for reversible causes. Because urinary tract
infection is a common reversible cause, urinalysis with urine culture is appropriate for most patients. This is
particularly true in older patients who may lack typical signs/symptoms or cannot provide a reliable history
(eg, dementia).
126.Postmenopausal women with endometrial cells on Pap testing require an endometrial biopsy to evaluate
for endometrial hyperplasia/cancer.
127.Women age ≥45 with abnormal uterine bleeding and classic menopausal symptoms (eg, night sweats,
insomnia, difficulty concentrating) are likely in menopause and require no additional testing. In contrast,
women age <45 with these symptoms require FSH, TSH, and prolactin levels to exclude an underlying
endocrine disorder (eg, hyperthyroidism).
128.Vertical transmission of maternal infection with Toxoplasma gondii can result in fetal infection with
characteristic fetal ultrasound findings of hydrocephalus and intracranial calcifications, particularly in the basal
ganglia. Nonspecific findings of hepatosplenomegaly and fetal growth restriction are also common.
129.Internal podalic version facilitates vaginal delivery of the second twin by grasping the feet and performing
a breech extraction. It is not indicated in the management of singleton gestations.
130.Positional headache that is worse when upright and improves when supine, with nausea, vomiting and neck
stiffness  postdural puncture headache, Tx self-limited, epidural blood patch
131.Urethral diverticulum  anterior mass to vaginal, dyspareunia, purulent discharge, dysuria or postvoidal
drainage Dx Pelvic MRI; Tx surgery
132.Pregnant patients positive for group B Streptococcus (GBS) receive intrapartum antibiotic prophylaxis to
prevent early-onset neonatal GBS disease. Patients with a penicillin allergy that is low risk for anaphylaxis
receive cefazolin.
133.Initial evaluation of mixed urinary incontinence includes a voiding diary to classify predominant type of
urinary incontinence (eg, stress, urgency) and to determine optimal treatment (eg, bladder training).
134.Severe Nodulocystic acne PCOD; sign of hyperandrogenism
135.Granulosa cell tumor  sex cord stromal tumor  increased estrogen  endometrial biopsy and surgery
136.Patients with high-grade squamous intraepithelial lesions on Pap testing are at high risk for cervical
intraepithelial neoplasia and cervical cancer. Because these lesions typically arise from the transformation
zone, patients with an unsatisfactory colposcopy (ie, entire squamocolumnar junction cannot be visualized)
require endocervical sampling (eg, endocervical curettage).
137.In the immediate postpartum period, physiologic changes include uterine contraction, lochia, breast milk
excretion and milk letdown, and chills and shivering causing hyperthermia or low-grade fever. These changes
are hormone-mediated (eg, increased oxytocin/prolactin levels, decreased estrogen/progesterone levels).
Patients with these normal findings are managed with routine postpartum care.
138. Pulmonary edema is a life-threatening complication of preeclampsia with severe features. It is caused by
increased systemic vascular resistance, capillary permeability, and pulmonary capillary hydrostatic pressure in
addition to decreased serum albumin level.
72. Preeclampsia increased risk of acute ischemic stroke due to formation of vascular microthrombi cerebral
vessel occlusion; dysregulation cerebral blood flow  cerebral vasospasm  elevated perfusion pressure 
ruptured intracerebral vessels (Hemorrhagic stroke)
73. Pelvic organ prolapses (POP) may present with pelvic pressure or urinary dysfunction (eg, retention, stress
urinary incontinence). However, many patients with POP are asymptomatic and are managed with
reassurance and observation only.
74. Amniotic fluid embolus syndrome is a rare, catastrophic complication that results from amniotic fluid entering
the maternal circulation. Common signs include hypoxia, hypotension, and disseminated intravascular
coagulation. Urgent coagulation studies can be used to diagnose early coagulopathy. Complications are DIC,
cardiovascular collapse, and maternal and fetal death

75. Preterm prelabor rupture of membranes, rupture of membranes <37 weeks gestation before the onset of
labor, requires inpatient management due to the risk of placental abruption, intraamniotic infection, umbilical
cord prolapse, and preterm labor.

76.

77. Condyloma acuminata = HPV

Condyloma Lata = secondary syphilis
 78. Müllerian agenesis causes primary amenorrhea due to failed development of the uterus, cervix, and upper
third of the vagina. Urogenital structures develop from a common embryologic source; therefore, renal
malformations are common, so patients require evaluation with renal ultrasonography.

Pediatrics

1.
2. 1. Acute bacterial gastroenteritis + seizure  shigella sonnei
3. Enterobius vermicularis (pinworm) infection is highly contagious and manifests as nocturnal perianal pruritus.
First-line treatment is with pyrantel pamoate or albendazole.
4. Young children may have an atypical presentation of nephrolithiasis with isolated gross hematuria in the absence
of abdominal or flank pain. Because of radiation exposure associated with CT scans, renal and bladder
ultrasonography is the preferred imaging study for detecting stones in children.
5. Hypospadias is characterized by a ventrally displaced urethral opening and dorsal hooded foreskin. Urologic
evaluation is required prior to circumcision because the foreskin may be needed for hypospadias repair, and
conventional circumcision techniques may be unsafe.
6. Acute, unilateral cervical lymphadenitis is an infection in children age <5 characterized by an enlarged, markedly
tender, warm, erythematous cervical node. Empiric antibiotic therapy (eg, clindamycin) should target the most
common bacteria, including Staphylococcus aureus, Streptococcus pyogenes, and anaerobes.
7. Neisseria meningitidis reproduces primarily in the nasopharynx, and infectious particles are readily
aerosolized through coughing and respiratory procedures. Droplet precautions should be ordered for all
potentially infected patients until they have been treated with antibiotics for 24 hours.
8. By age 12 months, an infant's weight triples and height increases by 50%. Developmental milestones
include pulling to a standing position and walking while holding onto furniture (cruising), using a 2-finger
pincer grasp, and saying "mama" or "dada" specifically.
9. Bilious emesis in a neonate with hemodynamic instability or peritoneal signs (eg, rigid abdomen) warrants
emergency exploratory laparotomy. Malrotation with midgut volvulus, which can cause intestinal perforation and
necrosis, should be considered in patients who also have a normal rectal examination and air-fluid levels on x-ray.
10. Iron studies are performed prior to hemoglobin electrophoresis in patients with microcytic anemia suspicious for
iron deficiency (eg, heavy menses, low erythrocyte count, reactive thrombocytosis) and concomitant thalassemia
(eg, Greek origin, family history).
11. Urinary tract infections are most commonly caused by gram-negative bacteria (eg, Escherichia coli) and can
present with fever and fussiness in an infant. The presence of nitrites and leukocyte esterase on urinalysis is
characteristic. Empiric therapy with a third-generation cephalosporin is recommended.
12. Postictal lactic acidosis commonly occurs following a tonic-clonic seizure. It is a transient anion gap metabolic
acidosis that resolves without treatment within 90 minutes following resolution of seizure activity.
13. Beta thalassemia (decreased beta globin chain production) can cause hemolysis and unconjugated
hyperbilirubinemia. However, newborns are asymptomatic because they have mostly fetal hemoglobin (α2, γ2).
After age 6 months, symptoms of hemolytic anemia emerge as adult hemoglobin (α2, β2) is produced.
14. Glomerular sources of gross hematuria should be considered in a patient with brown urine, red blood cell casts,
proteinuria, hypertension, and/or edema. Initial evaluation includes serum complement (C3, C4) levels.

15. Legg-Calvé-Perthes disease, or avascular osteonecrosis of the femoral head, typically presents in boys age 3-12
with insidious-onset hip or (referred) knee pain and an antalgic gait. X-rays may be normal in early disease but
demonstrate abnormalities (eg, femoral head flattening, fragmentation, sclerosis) with chronic symptoms.
Treatment is aimed at maintaining the femoral head within the acetabulum by avoiding weight-bearing activities
and by splinting or surgery.
16. Patients with congenital long QT syndrome are at risk for polymorphic ventricular tachycardia that leads to
syncope or sudden cardiac death, especially during periods of rapid heart rate and high sympathetic activity. Beta
blockers (eg, propranolol, nadolol) dampen sympathetic activity and shorten the QT interval at high heart rates to
reduce the risk of these complications
17. Complete atrioventricular septal defect is the most common heart defect in Down syndrome. Clinical features
can include heart failure in early infancy, a fixed split S2, and a systolic ejection murmur due to
increased pulmonary flow from the atrial septal defect.
18. 4. Persistent pulmonary hypertension of the newborn (PPHN) can be caused by conditions that injure the lungs (eg,
meconium aspiration syndrome). Treatment of PPHN includes oxygenation, ventilation, and administration
of pulmonary vasodilators (eg, inhaled nitric oxide)
19. Leukocoria, or white pupillary reflex, in an infant or young child should prompt immediate referral to an
ophthalmologist to evaluate for retinoblastoma. Strabismus and nystagmus are other red flags. Dx MRI of brain
and orbit Tx immediate ophthalmologic referral to prevent the spread
2. Retinitis pigmentosa is a genetic disorder characterized by progressive retinal degeneration. Typical
presentation includes night blindness, decreased visual acuity, and visual field loss
3. Eosinophilic esophagitis should be considered in toddlers who have feeding dysfunction (eg, solid food
refusal) and poor weight gain. Endoscopy with eosinophils on esophageal biopsy is diagnostic, and first-line
treatment is dietary modification.
4. Physiologic jaundice of the newborn is a common, benign cause of indirect hyperbilirubinemia on days 2-4 of
life. Mechanisms include increased bilirubin production, decreased bilirubin clearance, and increased
enterohepatic recycling

5. Posterior urethral valves are the most common cause of urinary tract obstruction in newborn boys.
Oligohydramnios from urinary obstruction can lead to Potter sequence, which is characterized by pulmonary
hypoplasia, flat facies, and limb deformities.
1. Primary nocturnal enuresis is defined as nighttime urinary incontinence in a child age ≥5 who has not achieved a
prolonged period of nighttime dryness. A family history of bed wetting is the greatest risk factor for developing
this condition. Def: bedtime urinary incontinence >5, no prior dry episodes Path: dec bladder control maturation,
dec bladder capacity, increased nocturnal urinary output Dx urinalysis, voiding dairy Risk factors famil hx, age 5-8;
Management tx of comorbid condition, behavioural modification like limiting fluids enuresis alarm, desmopressin
therapy
2. Transient hypertrophic cardiomyopathy may be seen in infants of diabetic mothers due to myocardial fat and
glycogen deposition. Left ventricular outflow tract obstruction causes a systolic ejection murmur with or without
hypotension and respiratory distress. Characteristic echocardiographic findings of a thickened interventricular
septum spontaneously regress by age 1 due to normalization of insulin levels.
3. Kawasaki disease presents with fever ≥5 days, in addition to 4 of 5 mucocutaneous findings: conjunctivitis,
mucositis, perineal rash, distal extremity changes, and cervical lymphadenopathy. Echocardiogram is indicated for
all patients to assess for coronary artery aneurysms. Tx IVIG and aspirin
Vs streptococcal pharyngitsis  fever, exudative pharyngitis, sandpaper rash

4. Psychogenic pseudosyncope is a type of conversion disorder characterized by an apparent loss of consciousness

without impaired cerebral perfusion. Prolonged duration of unconsciousness, absence of objective physical
findings, and high frequency of episodes are common.
5. Pericardial effusion can occur after cardiac surgery and typically presents with distant, "muffled" heart sounds and
signs of decreased cardiac output (eg, tachycardia, tachypnea). An enlarged cardiac silhouette on chest x-ray is
characteristic. Dx Echocardiogram

6. Immune thrombocytopenia typically presents with isolated thrombocytopenia after a viral infection. Children with
isolated cutaneous symptoms (eg, petechiae) usually recover spontaneously and require observation alone,
regardless of platelet count. Those with bleeding should receive glucocorticoids, anti-D, or intravenous
immunoglobulin.
  Children
o Observe if cutaneous symptoms only
o Glucocorticoids, IVIG, or anti-D if bleeding
 Adults
o Observation if cutaneous symptoms AND platelets ≥30,000/mm3
o Glucocorticoids, IVIG, or anti-D if bleeding or platelets <30,000/mm3

7. In coining, a practice from China and Southeast Asia, a coin is rubbed on the body, producing linear erythema and
ecchymoses. Thought to alleviate illness and fever, it is usually safe. To provide culturally sensitive care,
physicians should not discourage patients from the practice or report them for misperceived abuse.
8. Treatment options for Tourette disorder include habit reversal training, antidopaminergic agents eg tetrabenazine
(dopamine deplete VMAT-2) antipsychotics (dopamine receptor blockers), and alpha-2 adrenergic receptor
agonists
9. Biliary atresia is a neonatal disorder in which extrahepatic bile ducts develop progressive fibrosis. Patients have
jaundice, pale stools, and a small or absent gallbladder. Laboratory findings include direct hyperbilirubinemia,
normal reticulocyte count, and elevated gamma-glutamyl transpeptidase.
10. Anaphylaxis, unstable neurologic disorders (infantile spasms, uncontrolled epilepsies) , and encephalopathy (eg,
coma, decreased consciousness, prolonged seizures) within a week of administration of the diphtheria–tetanus–
acellular pertussis vaccine are contraindications for future administration of pertussis-containing vaccines.
However, uncomplicated seizures are not.
11. Patient with cough, congestion, sore throat  Acute bacterial rhinosinusitis tx amoxicillin +clavulanate  Patient
with new onset head ache+ vomiting+ fever  brain abscess; CT scan shows ring enhancing lesions Tx IV Abxa
12. Retained foreign body should be suspected in a young child with recurrent pneumonia, particularly when the right
lower lobe is involved.
13. Peutz jeghers syndrome  AD disorder  Tumor suppressor gene mutation hyperpigmented mucocutaneous
macules, GI polys bleed microcytic anemia; upper endoscopy and colonoscopy screening; increase risk for breast
cancer and other cancers
14. Placental aromatase deficiency  prevents androgen to estrogen virilisation of mother and female fetus
15. Androgen insensitivity syndrome  defect in androgen receptor  genotypically male with undervirilized or
female external genitilia; presence of breasts
16. 5 alpha reductases def presents in genotypically male  def in test to dihydrotestosterone conversion 
undervirilised or female external genitilia; testosterone normal; no breast
17. CAH  def in 21 oh hydroxylase deficiency  increased 17-hydroxyprogrestrone; decreased cortisol decreased
aldosterone increased androgen virilization of female genitilia (ambiguous genitilia), testosterone would be
high ; Tx glucocorticoids and mineralocorticoids to avoid life threatening adrenal crisis ( hypotension, dehydration,
vomiting; electrolyte disturbances does not occur until 1-2 weeks of life
18. A voiding cystourethrogram (VCUG) is often obtained in children with UTI in whom VUR should be excluded.
Indications for VCUG include: ≥2 febrile UTIs; abnormal renal ultrasound; fever ≥39 C (102.2 F) with bacteria other
than E coli; signs of chronic kidney disease (ie, poor growth, hypertension).
19. Necrotizing enterocolitis should be suspected in an enterally fed, premature or very-low-birth-weight infant with
nonspecific apnea, lethargy, and abdominal distension. Pneumatosis intestinalis on abdominal x-ray is diagnostic.
Abdominal x-ray findings include pneumatosis intestinalis (intramural air) and portal venous air. Management of
suspected NEC includes discontinuation of enteral feeds and administration of antibiotics; surgery may be required
in severe cases.
20. Epidural hematoma  rupture of middle meningeal artery. Brief loss of consciousness followed by lucid interval,
head ache, nausea, vomiting. Uncal herniation causes ipsilateral pupillary dilation and contralateral hemiparesis.
21. IgA deficiency  Mostly asymptomatic and presents with chronic diarrhea
22. Initial treatment of pediatric patients who have hypovolemic hypernatremia with signs of dehydration (eg, dry
mucous membranes, tachycardia) is to restore circulatory volume and tissue perfusion by emergency fluid
resuscitation with an isotonic solution (eg, 0.9% normal saline).

23. X-linked agammaglobulinemia  BTK gene Impaired B cell maturation and antibody production  recurrent
sinopulmonary infections and chronic enteroviral meningoencephalitis and prolonged diarrheal illness
24. CGD  Impaired oxidative burst  recurrent skin and pulmonary infections causes by catalase positive staph and
serratia
25. First step after ingesting caustic substance  removal of clothing. Upper GI endoscopy for diagnosis. Nasogastric
lavage if nasogastric tube placed
26. Untreated acute bacterial rhinosinusitis  brain abscess (head ache, fever vomiting), CT ring enhanced lesion Tx
surgical drainage and intravenous abxs
27. GERD in infants  poorly developed LES, sxs spit up, normal weight gain. Tx reassurance, cholecalciferol, upright
positioning after feeds, burping during feeds and frequent small volume meals
28. NAGMA  Loss bicarb  severe diarrhea, RTA, saline infusion
29. AGMA accumulation of unmeasured acidic compounds  DKA, lactic acidosis, renal failure, methanol, ethylene
glycol
30. Calcaneal apophysitis –> heal pain, dec gastrenemus /soleus flexibility, pain with calcaneal compression/palpation
Tx NSAIDS use, ice, compression, activity limitation

31.
32. A newborn with a unilateral undescended testis and normal penis (ie, no hypospadias) requires no
immediate work-up because there is a high likelihood of spontaneous testicular descent in the first few months of
life.

33. Full-term infants are born with adequate iron stores to prevent anemia for the first 4-6 months of life regardless of
dietary intake. Preterm infants are at significantly increased risk for iron deficiency anemia. Iron supplementation
should be started at birth in exclusively breastfed preterm infants and continued until age 1 year. All exclusively
breastfed infants should also be started on vitamin D supplementation.
34. S. Aureus is most common cause of bacterial pneumonia in kids with CF. Cover with vancomycin
35. Beckwidth Wiedemann syndrome  Path: deregulation of imprinted gene impression in chr 11p15; sxs
omphalocele or umblical hernia, fetal macrosomia, macroglossia, hemihyperplasia ; complications : wilms tumor
and hepatoblastoma , surveillance : serum AFP, liver/abd U/S
36. Abd U/S needed in beckwidth Wiedemann syndrome to monitor for hepatoblastoma or wilms tumor
37. Fanconi anemia  congenital bone marrow failure  defective DNA repair. Short strature, thumb anomalies,
abnormal skin pigmentation. Labs pancytopenia, positive chromosomal breakage testing. Tx HSCT
38. Purulent monoarthritis or triad of tenosynovitis+ migratory polyarthritis+ dermatitis  DGI Dx NAAT Tx IV
ceftriaxone
39. Neonatal sepsis and meningitis (GEL)  irritability+ hypothermia+ poor feeding +lethargy. Dx blood, urine, CSF
cultures Tx amoxicillin+gentamicin
40. Recurrent intusuccepstion  pathologic lead point like Meckel diverticulum  Dx nuclear scinctiography
41. Physiologic anemia of infancy  Increased tissue oxygenation at birth  Drop in EPO
Physiologic anemia of infancy is an asymptomatic condition characterized by a normal decrease in hemoglobin
with a nadir at age 2-3 months. Pathophysiology involves a transient down-regulation of erythropoietin due to
increased tissue oxygenation after birth.
42. Most common nonhereditary SNHL in children  congenital CMV infection
43. Severe vesicoureteral reflex  recurrent or chronic pyelonephritis  parenchymal scarring, hypertension and
renal insufficiency  Voiding cystourethrogram Tx daily antibiotics
44. Posterior urethral valve present only in boys  valves present in the distal urinary tract secondary reflux 
Chronic renal failure
45. Trendelberg sign  slipped capital femoral epyphysis should be suspected in kids Dx Xray
46. Systemic juvenile idiopathic arthiris  joint pain >6 weeks Tx aspirin
47. Bone pain + pancytopenia + fever+ pallor+ bruising + hepatosplenomegaly - ALL
48. Photokeratitis  caused by UV exposure in the absence of Uv protective eyewear, seeks 6-12 hrs after exposure
for severe bilateral eye pain and photophobia. Punctuate staining of cornea in fluorescein is characteristic
49. Neonatal sepsis  poor feeding, irritability, lethargy  abnormal leukocyte count Abxs ampicillin and
gentamicin; GEL organisms
50. Ceftriaxone and vancomycin for more than 1 month old for neonatal sepsis
51. Painless bloody stool  Meckel’s diverticulum
52. Abd pain + currant jelly in 6mons to 3 year  intussusception
53. Watery  bloody stool within 3 days, no fever  STEC
54. Diamond black fan anemia  congenital erythroid aplasia craniofacial abnormalities+ triphalageal thumbs
+increased risk of malignancy  labs: macrocytic anemia, reticulocytopenia and normal Plt and wbc Tx
corticosteroids and RBC transfusion
55. Bronchiolitis caused by RSV in <2 years old presents with upper resp sxs, wheezes, crackles and RDS  apnea and
respiratory failure. Cough, congestion and increased work of breathing.

56. Acetaminophen intoxication  nausea, vomiting, RUQ pain, GI sxs, LFT’s in 1000
potential liver failure and death
57. In case of fetal anomalies prefer vaginal over cesarean delivery for the preference over maternal obstetric care
58. Brain abscess in children frequently presents with headache, fever, focal neurologic deficits, and seizure. Cyanotic
congenital heart disease is a risk factor for brain abscess due to hematogenous spread of bacteria.
59. Atopic dermatitis when flare meds are ineffective, most likely infectious etiology give topical mupirocin
60. Cerebral palsy is a nonprogressive neurologic injury that most commonly occurs in premature infants with
periventricular leukomalacia. Findings can include motor delay, early hand preference, spasticity, and
hyperreflexia. CP can vary in presentation depending on the severity of neurologic injury. The following early signs
should raise suspicion:
2. Motor delay (eg, not rolling over at age 4 months corrected)
3. Early hand preference (age <1 year)
4. Persistent neonatal reflexes (eg, tonic neck reflex at age >6 months)
5. Abnormal tone

49. HSP/Ig A vasculitis  lower extremity palpable purpura+ arthalgia/ arthritis + abd pain+ renal disease. Involves
scrotal swelling
50.URI tx with aspirin  reye’s syndrome  hepatomegaly with hyperammonemia, increased LFT,
encephalopathy and cerebral edema.

51.

51. Sydenham chorea is an autoimmune complication of group A Streptococcus infection caused by molecular
mimicry, in which antistreptococcal antibodies cross-react with neuronal antigens in the basal ganglia.
Neuropsychiatric manifestations include chorea, milkmaid grip, hypotonia, emotional lability, and obsessive-
compulsive behaviors.

52. Myotonic dystrophy is an autosomal dominant trinucleotide repeat disorder that most commonly presents in
adolescence or early adulthood with progressive weakness (eg, facial and hand muscles), muscle atrophy, grip
myotonia (delayed muscle relaxation), cardiac conduction anomalies, and gastrointestinal tract disturbances (eg,
dysphagia). Testicular atrophy can also occur

53. Trichotillomania is a behavioral disorder characterized by recurrent hair pulling. It results in irregular patches
of hair loss with broken hair shafts of differing length Tx CBT

54.Generalised LN+ aseptic meningitis +maculopapular rash  acute HIV infection

55. Acute uveitis  sensitivity to light+ ocular pain+ pupillary constriction+ ciliary flush

56. blepharospasm  focal dystonia with sensitivity to light

57. Behçet syndrome is a multisystem inflammatory condition characterized by recurrent oral and genital ulcers.
Skin and ocular involvement is common. Thrombosis is a major cause of morbidity. It is most common in patients
of Turkish, Middle Eastern, and Asian descent. The diagnosis is made based on clinical features.

58. Biliary atresia  progressive fibrosis and obliteration of extrahepatic bile ducts new born with 2-8 weeks
with jaundice, acholic stools and dark urine, hepatomegaly Dx U/S direct hyperbilirubinemia RUQ : absent
gallbladder and common bile duct and triangular cord sign ( fibrous remnant seen above porta hepatis) liver biopsy
shows intrahepatic bile duct proliferation, portal tract inflammation and edema and fibrosis ;gold standard 
intrahepatic cholangiography shows bile duct obstruction; Tx kasai procedure surgical hepatoportoenterostomy
and surgery

61. Congenital hypothyroidism  delayed passage of meconium (>48 hrs of life)

62. Celiac disease  Patients with type 1 diabetes are at increased risk  failure to thrive, nonspecific GI sxs,
microcytic anemia

63. Not all patients with cystic fibrosis are identified through newborn screening. Therefore, the presence of nasal
polyps, recurrent sinopulmonary infections, digital clubbing, and signs of pancreatic insufficiency (eg, poor growth,
deficiency of fat-soluble vitamins) should prompt an evaluation.

64. Nasal polyps+ recurrent sinopulmonary infections+ digital clubbing +signs of pancreatic insufficiency (poor
growth and pancreatic insufficiency)  CF

65. Jejunal atresia presents with bilious vomiting and abdominal distension. Abdominal x-ray reveals a triple
bubble sign and gasless colon. Risk factors include prenatal exposure to cocaine and other vasoconstrictive
substances.

66. Lead poisoning  basophilic stippling

Asplenia functional hyposplenism  precipitant of rRNA in RBC’s

67. Maternal sickle cell disease causes vasoocclusion that can result in placental infarction, ischemia, and
subsequent uteroplacental insufficiency. Uteroplacental insufficiency may present with decreased fetal
movement and oligohydramnios (ie, amniotic fluid index ≤5 cm) due to decreased fetal perfusion.

68. Turner’s syndrome  coarctation of aortic or aortic dissection

69. Intrahepatic cholestasis of pregnancy presents with pruritus that is worse on the hands and feet. Patients are
at increased risk of fetal complications, including intrauterine fetal demise, particularly with markedly elevated
total bile acids.

70. Blunt abdominal trauma (eg, motor vehicle collision) in pregnancy can cause severe maternal bleeding and
hemorrhagic shock (eg, abruptio placentae). Trauma patients with hemorrhagic shock require replacement of
intravascular volume, transitioning from crystalloid to blood product resuscitation as soon as possible.

71. McCune Albright  café au lait spots macules+ fibrous dysplasia of bone + gonadotropin independent
precocious puberty

72. croup  Tx mild to moderate humidified air +/- corticosteroids

Moderate to severe  corticosteroid +/-racemic epinephrine

73. fever+ rash after amoxicillin+ tonsilitis +/- exudates + posterior or diffuse cervical LN+ significant fatigue +
hepatosplenomegaly  IM; complication  acute airway obstruction, autoimmune hemolytic anemia,
thrombocytopenia and splenic rupture
74. Laryngomalacia presents with inspiratory stridor due to dynamic collapse of the supraglottic tissues on
inspiration. Stridor increases in periods of increased airflow (eg, crying, feeding). Associated with GERD

75. Vit K bleeding late onset present with obstructive hydrocephalus, sunset eyes and increased head
circumference

76. Chiari 2 malformations presents with inferior displacement of medulla and myelomeningocele

77. Excess cow milk in more than one year old can cause microcytic iron deficiency anemia and low erythrocyte
count and high RBC width

78. Ataxia telangiectasias  combined T and B cell deficiency+ cerebellar ataxia+ oculocutaneous telangiectasias+
recurrent sinopulmonary infections

79. Rabies virus transmit through saliva of the infected animal; bite mark becomes paresthesia. Patient has sxs
after 1-3 months later. Hydrophobia, dysautonomia, and encephalopathy.

80. Septic arthritis MC Staph aureus Tx vancomycin, if not working gram neg bacteria, add ceftriaxone

81. Pertussis in infants  cough paraxoxyms which may last for weeks subconjunctival hemorrhage, syncope
cyanosis, apnea and seizure during paroxysmal phase Tx Azithromycin

82. Peritonsillar abscess  fever + pharyngeal pain+ trismus+ muffled voice +soft palate with uvular deviation Tx
needle aspiration or incision with abxs therapy

83. Large VSD produces holosystolic murmur that is loudest at left LSB and an apical diastolic rumble due to
increase flow across mitral valve

84. ASD  widened and fixed S2

85. TOF  Harsh systolic ejection murmur at LUSB

86. Hypotonia is a common finding in neonates with Down syndrome. Poor muscle tone and a weak suck are key
findings. Additional features of Down syndrome in newborns include up slanting palpebral fissures, a protruding
tongue, and a single palmar crease.

87. Newborn with meconium ileus due to inspissated stool  CF  dilated small bowel on xray

88. Acute otalgia+ otorrhea+ ruptured TM  1st line : Amoxicillin; 2nd line Amoxicillin+ clavu 3 rd line clindamycin or
azithromycin

89. Edwards syndrome (Trisomy 18)  VSD

90. Due to falsely elevated lead results by capillary testing, venous lead testing performed to verify a high blood
lead level

91. Acute poststreptococcal glomerulonephritis, a complication of group A Streptococcus infection (eg,

pharyngitis), typically presents with hematuria, edema, and hypertension. Management is mainly supportive.
Complications of volume overload (eg, hypertension, edema) require treatment with loop diuretics.
92. Rett syndrome associated with microcephaly (head growth deceleration) and stereotypical hand movement
like wriging; MECP 2 mutation, autistic behaviour and seizure. Loss of speech, loss of hand movements and gait
abnormalities. Middle life expectancy, reduced speech, mobility, seizures and respiratory difficulties.

93. Hydrocephalus should be suspected in an infant or young child with a rapidly enlarging head circumference
crossing multiple growth percentiles. Signs/symptoms of increased intracranial pressure are more commonly seen
once the anterior fontanelle closes and include irritability, developmental delay, hypertension/bradycardia, and
papilledema.

94. Recurrent hematuria in boys <10 + senso-neural hearing loss or family history of renal failure  Alport
syndrome; Renal biopsy shows longitudinal splitting of GBM

95. Good pasture syndrome  pulm sxs+ progressive glomerularnephritis; Biopsy shows IgG deposition in GBM.
Management is supportive and may include transplant in patients with end-stage renal disease.

96. Transfusion associated volume overload  Large volume rapidly transfused for chronic anemia in kids <3 years
 respiratory distress, hypotension, tachycardia, pulmonary edema within 6 hours of transfusion initiation Tx Resp
support and furosemide

97. Sudden-onset respiratory distress with unilateral hyperinflation and mediastinal shift on x-ray are concerning
for foreign body aspiration. Rigid bronchoscopy can identify and remove the aspirated object

98. Tripod position+ dysphagia + drooling with acute respiratory distress  epiglottitis; Tx intubation

99. Splenic sequestration crisis  Reticulocytosis and thrombocytopenia

100. Stap aureus + Step pyogenes  acute, unilateral cervical lymphadenitis in children

111. VZV  Successive crops of intensely pruritic macules/papules, vesicles, and pustules. Breakthrough infection,
which is typically a milder infection with lower fever and fewer lesions, can occur in partially vaccinated patients.

112. Lesh Nyan syndrome  nephrolithiasis, gout or motor dysfunction

113. EBV mononucleosis  pharyngitis + fever + posterior cervical LN+ tonsillar exudate

115. Hereditary spherocytosis typically manifests as a triad of Coombs-negative hemolytic anemia, jaundice, and
splenomegaly. It should be suspected in patients with reticulocytosis, hyperbilirubinemia, spherocytosis, and
family history of anemia. Eosin-5-maleimide binding and acidified glycerol lysis tests are diagnostic.

116. Hereditary Spherocytosis  Coombs negative HA+ Splenomegaly + jaundice. Eosin-5-maleimide binding and
acidified glycerol lysis tests are diagnostic.

117. PNH  CD 55 and CD 59 protein testing. Hemolytic anemia+ cytopenia+ Hypercoagulability

118. Hypertrophic pyloric stenosis  intravenous hydration and potassium replacement

119. Lens dislocation  Marfan disease  echocardiography to rule our aortic disease

120. Cholesteatomas in children can either be congenital or acquired secondary to chronic middle ear disease.
New-onset hearing loss or chronic ear drainage despite antibiotic therapy are typical presenting symptoms of
cholesteatomas, and granulation tissue and skin debris may be seen within retraction pockets of the tympanic
membrane on otoscopy.

121. Otosclerosis is a condition in which there is bony overgrowth of the stapes footplate that results in conductive
hearing loss. Ear drainage would not be present.

122. Children with pharyngitis and no viral symptoms (eg, rhinorrhea, cough) should undergo group A
Streptococcus (GAS) rapid antigen detection testing. Due to the risk of acute rheumatic fever with untreated GAS,
a throat culture is performed to confirm a negative result.

123. Subgaleal hemorrage  shearing of veins between dural sinuses and scalp due to scalp traction during
surgery. Rapid hemorrhage expansion leads to hypovolemic shock , DIC and death

124. Purulent conjunctivitis and suppurative preauricular lymphadenitis (Parinaud oculoglandular syndrome)
should raise suspicion for infection with Francisella tularensis, a gram-negative coccobacillus spread by wild
animals and tick bites. Other causes include infection with Bartonella henselae and herpes simplex virus

125. Gaucher disease  AR, glucocerebrosidase deficiency  glucocerebroside accumulation in macrophages.

Hepatosplenomegaly. Infiltration in bone marrow anemia, thrombocytopenia, bone pain. Failure to thrive,
delayed puberty.

126. MCC pneumonia in CF children  s.Aureus; In adults  Pseudomonas aerogenosa

127. Juvenile myoclonic epilepsy presents in adolescents with myoclonic jerks immediately on wakening.
Absence and generalized tonic-clonic seizures may also be seen

128. Lennox-Gastaut syndrome typically presents by age 5 with intellectual disability and severe seizures of
varying types (eg, atypical absence, tonic). Interictal EEG demonstrates a slow spike-and-wave pattern.

129. Newborns of mothers with hepatitis B virus (HBV) infection should receive passive immunization with
hepatitis B immune globulin and active immunization with HBV vaccine within 12 hours of birth

130.

Lactation failure jaundice vs breast milk jaundice

Diagnosis Timing Pathophysiology Clinical features
Lactation failure Age <1 week Insufficient intake of breast milk:  Suboptimal
 breastfeeding
 ↓ Bilirubin elimination
 Signs of
jaundice  ↑ Enterohepatic dehydration
circulation

↑ β-glucuronidase in breast milk:

Age >1 week  Adequate
 ↑ Deconjugation of
Breast milk breastfeeding
intestinal bilirubin
jaundice (peaks at 2  Well-hydrated
 ↑ Enterohepatic
weeks)
circulation

130. Management of lactation failure jaundice focuses on increasing hydration and bilirubin excretion by
optimizing breastfeeding (eg, increasing frequency of feeds) with close follow-up. For continued signs of
dehydration and/or rising bilirubin levels, formula supplementation and/or phototherapy should be considered.

131. Food protein–induced allergic proctocolitis should be suspected in a well-appearing infant with painless,
bloody and mucus stools. Diagnosis is clinical, and management involves eliminating dairy from the maternal diet
(if breastfeeding) or switching to an extensively hydrolyzed formula.

132. Intussusception presents in children age 6-36 months with periodic abdominal pain. A target sign on
ultrasound should prompt reduction with air or water-soluble contrast enema.

133. Purpura is a late manifestation of meningococcal meningitis and suggests disseminated intravascular
coagulation (DIC), which is characterized by clotting factor and platelet consumption. Laboratory evidence of DIC
includes thrombocytopenia, elevated PT and PTT, and low fibrinogen.

134. Aplastic anemia  decreased production of bone marrow cell lines

135. Strep A pyogenes  ARF  Joints, carditis, Nodules, Erythema marginatum, Syndeham Chorea; benzathine
penicillin G

136. Sydenham chorea is an autoimmune complication of group A Streptococcus infection caused by

molecular mimicry, in which antistreptococcal antibodies cross-react with neuronal antigens in the basal
ganglia. Neuropsychiatric manifestations include chorea, milkmaid grip, hypotonia, emotional lability,
and obsessive-compulsive behaviors.
134. Struge weber syndrome  glaucoma in children Dx Tonometry
135. Duchenne muscular dystrophy should be suspected in a boy age <5 with proximal muscle weakness and calf
pseudohypertrophy. Patients have markedly reduced or absent dystrophin protein expression within the muscle

136. Nontypeable Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis are the most
common bacterial causes of acute bacterial rhinosinusitis, which commonly presents with ≥10 days of persistent
nasal discharge and cough.

137. Acute bacterial rhinosinusitis should be considered in children with cough or nasal discharge/congestion that
persists for ≥10 days without improvement. The 2 most common risk factors are viral upper respiratory infections
and allergic rhinitis

138. Drowned patients often require respiratory support to correct hypoxia. In patients who are unable to protect
their airway or who are hypoxic despite supplemental oxygen, intubation with mechanical ventilation should be
performed.

138. Long QT syndrome  Tx propranolol; Jervell-nielson syndrome AR  hearing loss and romano-ward
syndrome  AD

139. Acute rhinosinusitis presents with upper respiratory symptoms (eg, rhinorrhea, congestion, cough) and facial
pain/pressure, with or without fever. Viral rhinosinusitis is more likely than bacterial rhinosinusitis in patients who
are afebrile with mild symptoms that improve within 10 days. Treatment is supportive care (eg, nasal
saline/irrigation).

140. Chronic granulomatous disease presents with recurrent cutaneous and pulmonary infections with catalase-
positive organisms (eg, Staphylococcus aureus, Serratia). Abnormal oxidative burst (eg, dihydrorhodamine testing)
is consistent with the diagnosis, and antimicrobial prophylaxis with trimethoprim-sulfamethoxazole and
itraconazole is required.

141. Chronic arthritis+ quotidian fever + rash  systemic JIA.

142. well appearing+ limp+ can’t weight bear on the same joint+ hip join (Highly restricted ROM)  Transient
synovitis, normal ESR, CRP. Dx bilateral hip U/S Tx : ibuprofen

143. Radio-opaque pills on CXR Iron poisoning tx deforaxamine. Patients with acute iron poisoning have
abdominal pain, diarrhea, and hematemesis; in addition, they may develop hypovolemic shock within a few hours
due to gastrointestinal losses. Laboratory evaluation reveals an anion gap metabolic acidosis, and x-ray may show
radiopaque tablets.

144. Neonatal cephalic pustulosis presents with erythematous papules and pustules limited to the face and scalp
around age 3 weeks. Management is typically limited to daily cleansing with gentle soap and water, and self-
resolution without scarring is expected within weeks to months.
145. Trisomy 18 (Edwards syndrome) is characterized by micrognathia, microcephaly, rocker-bottom feet,
overlapping fingers, and absent palmar creases. Ventricular septal defect is common in these patients and
presents with a holosystolic murmur at the left lower sternal border

146. Giardia duodenalis disrupts the epithelial tight junctions between small intestinal enterocytes, leading to
malabsorption (eg, oily, nonbloody, foul-smelling diarrhea; weight loss) typically lasting up to a month. Chronic
infection in children may lead to failure to thrive and poor linear growth. Dx PCR or stool antigen Tx tinidazole,
nitazoxanide, metro in children, paramomycin in pregnant patients. Refractory/recurrent sxs, look for immune
deficiency

147. Late (months to years) manifestation of lyme disease  arthritis, encephalitis, peripheral neuropathy,
minimally painful but largely stiff, no organism on gram stain but neutrophils are 10,000-25,000

148. CGD ppx TMX-SMP, itraconozole, interferon gamma

149. Hypoxic-ischemic brain injury (eg, drowning) can lead to widespread neuronal cell death, cerebral edema, and
increased intracranial pressure (ICP). Severely increased ICP can cause Cushing triad, characterized by
hypertension, bradycardia, and irregular respirations.

150. Concussion is caused by rapid rotational acceleration of the brain during head trauma. Diagnosis is based on
clinical findings of neurologic disturbance (eg, headache, noise sensitivity, emotional changes) without evidence of
structural intracranial injury. Treatment is physical and cognitive rest followed by a gradual return to activity.
151. Serum sickness is an immune complex–mediated type III hypersensitivity reaction that occurs after exposure
to foreign proteins in antivenoms, antitoxins, monoclonal antibodies, or antigenic vaccinations. Manifestations
typically arise 5-14 days after exposure and include fever, urticarial rash, arthralgia, and mild proteinuria;
symptoms usually resolve over days without intervention as the immune complexes are cleared

152. Varicella zoster vaccine at 2 doses at age 1 and 4

153. Chorioretinitis, or inflammation and scarring of the retina and choroid, is typically caused by chronic infection
(eg, Toxoplasma gondii, cytomegalovirus). Congenital toxoplasmosis is the most common etiology, and additional
findings include macrocephaly (due to hydrocephalus), hepatosplenomegaly, and seizures.
154. Nighttime snoring and gasping for air is suspicious for obstructive sleep apnea, which is commonly caused
by adenotonsillar hypertrophy in children

155. Direct spread of bacteria from otitis media or mastoiditis can cause a temporal brain abscess. The
presentation can include severe headache, morning vomiting, fever, and focal neurologic deficits. Diagnosis is
confirmed by visualization of a ring-enhancing lesion on CT scan or MRI of the brain.

156. Pseudoappendicitis camphylobacter gastroenteritis (RLQ pain+ mucoid and bloody stools+ fever+
leuckocytosis)

157. Congenital hypothyroidism is associated with neurodevelopmental injury if not recognized and treated early.
Decreased activity, hoarse cry, and jaundice are commonly associated with congenital hypothyroidism, but the
majority of infants with congenital hypothyroidism are asymptomatic. Thyroid dysgenesis is the most common
cause of congenital hypothyroidism worldwide.

158. Intraabdominal testicular torsion should be suspected in a patient with cryptorchidism and an acute
abdomen. Infants may have irritability, inconsolable crying, and pain with abdominal palpation.

159. Metaphyseal corner fractures occur when an extremity is pulled or twisted. These fractures are a red flag for
child abuse and should prompt a skeletal survey to evaluate for additional occult fractures.

160. Retinitis pigmentosa is a genetic condition resulting in progressive degeneration of the retina. Patients have
progressive night blindness and peripheral vision loss. Funduscopic examination may show retinal pigment
deposition in addition to retinal vessel attenuation and optic disc pallor.
161. Hyper-IgE syndrome is a primary immunodeficiency characterized by severe atopic dermatitis and recurrent
infections (eg, sinopulmonary, noninflammatory abscesses). Eosinophilia is classic, and the white blood cell count
is generally normal despite infection.

162. Patients with cystic fibrosis are at risk for fat-soluble vitamin (ie, A, D, E, and K) deficiency due to fat
malabsorption from pancreatic insufficiency. Vitamin K is an important cofactor in coagulation factor activation;
deficiency causes easy bruising and mucosal bleeding.

163. Retropharyngeal abscess in children presents with fever, dysphagia, muffled voice, and pain with neck
extension. Lateral neck soft-tissue x-ray shows a widened prevertebral space.

164. Postconcussion syndrome is characterized by prolonged (>4 weeks) concussion symptoms (eg, headache,
sleep disturbance). Management is symptomatic care because most patients improve within 3 months

165. Group B Streptococcus (S agalactiae) is the most common pathogen in early-onset (age <7 days) neonatal
pneumonia. Symptoms include respiratory distress (eg, retractions, tachypnea) and hypoxia, and chest x-ray
reveals diffuse alveolar opacities, often with pleural effusions.

166. Systemic juvenile idiopathic arthritis is an autoinflammatory disorder of childhood characterized by arthritis
for ≥6 weeks and fever for ≥2 weeks. Hepatosplenomegaly and lymphadenopathy are common, and quotidian
fevers (spiking once daily) are often accompanied by an evanescent pink rash.

167. The differential diagnosis for polyuria and dilute urine includes central or nephrogenic diabetes insipidus (DI)
or primary polydipsia. The water deprivation test can differentiate between DI and primary polydipsia. Following
water deprivation, urine osmolality remains unchanged in DI but increases in primary polydipsia.
168. Eczema herpeticum, or herpes simplex virus infection associated with atopic dermatitis, presents with painful
vesicles that evolve into "punched-out" erosions with hemorrhagic crusting. Due to the risk of visceral
dissemination and death, systemic acyclovir or valacyclovir should be initiated immediately.

169. Fluoroquinolones are avoided in children because of cartilage damage. UTI 3rd gen cephalosporin, cefixime

170. Symptoms of orbital cellulitis include proptosis, ophthalmoplegia, and visual changes. Bacterial sinusitis is
the most common predisposing factor for orbital cellulitis.

171. Aspirin-exacerbated respiratory disease is a clinical condition defined by the triad of asthma, bronchospasm
or nasal congestion following the ingestion of aspirin or nonsteroidal anti-inflammatory drugs, and chronic
rhinosinusitis with nasal polyposis.

172. Patent ductus arteriosus (PDA) is recognized by a continuous murmur best heard in the left infraclavicular
area. Despite preserved left ventricular contractility, a large PDA can cause decompensated heart failure in infants
due to left ventricular volume overload from left-to-right shunting.

173. Secondary lactase deficiency caused by intestinal epithelial damage (eg, gastroenteritis, celiac disease) leads
to carbohydrate (ie, lactose) malabsorption and transient symptoms of diarrhea, crampy abdominal pain, and
bloating

174. Milk protein–induced proctocolitis is a non–IgE-mediated reaction that usually causes blood-streaked, mucoid
stools in early infancy.

175. Bronchopulmonary dysplasia  Prolonged oxygen requirements in infants born prematurely systemic
hypertension due to increased catecholamines
176. Cystic fibrosis–related diabetes mellitus, a common complication of cystic fibrosis, is caused primarily by
insulin deficiency due to fibrosis and fatty infiltration of the pancreas. Management is with insulin therapy, and
appropriate glucose control contributes to improved overall lung function and nutritional status.

177. Malrotation with midgut volvulus usually presents with bilious vomiting in neonates. Initial evaluation in
clinically stable patients includes abdominal x-ray, which may be normal. The gold standard for diagnosis is
an upper gastrointestinal series, which shows a right-sided ligament of Treitz and a corkscrew duodenum

178. Functional constipation in infants usually presents after introduction of solid foods (eg, lower fiber, decreased
fluids) and without alarm signs (eg, poor growth, severe abdominal distension). Initial treatment is with
nondigestible osmotically active carbohydrates (eg, fruit juice/puree) vs food induced allergic proctocolitis has
loose stools with mucus and blood. Tx hydrolyzed food, soy containing food

180. Persistent pulmonary hypertension of the newborn (PPHN) can be caused by conditions that injure the lungs
(eg, meconium aspiration syndrome). Abnormal persistent of elevated pulmonary vascular resistance  R to L
shifting via patent ductus arteriosus. Risk factors: pulmonary hypoplasia, meconium aspiration syndrome, neonatal
pneumonia. Sx respiratory distress and cyanosis is common but can be asymptomatic. Treatment of PPHN includes
oxygenation, ventilation, and administration of pulmonary vasodilators (eg, inhaled nitric oxide).

181. Beckwith-Wiedemann syndrome (BWS) is characterized by macrosomia, macroglossia, hemihyperplasia,

umbilical hernia/omphalocele, and neonatal hypoglycemia. Because patients with BWS are at increased risk of
developing Wilms tumor and hepatoblastoma, abdominal ultrasound and alpha-fetoprotein level testing are
recommended.

182. GER by 6 mons  Immature lower esophageal sphincter  Spit up, normal weight gain, No pain/ back
arching, Tx upright positioning after feeding, burping after feeds, frequent, small meal feeds. Management with
cholecalciferol D

183. An empyema occurs after bacterial pneumonia leads to bacterial colonization of the pleural fluid. Pleural
fluid shows a pH <7.2, a low glucose level, neutrophil-predominant leukocyte counts >50,000/mm 3, and a
significantly elevated lactate dehydrogenase level.

184.

Management of salicylate toxicity

Activated charcoal  Binds salicylate in gastrointestinal tract and decreases systemic absorption
 Give within 2 hr of acute ingestion (unlikely helpful in chronic ingestion)
  Avoid in confused or obtunded patients (risk of aspiration)

 Alkalinizes urine and serum, enhancing salicylate excretion

Intravenous sodium
 Requires large volumes of fluid to be administered
bicarbonate

 Inability to tolerate large volumes of sodium bicarbonate: pulmonary edema,

acute or chronic renal failure
Indications for
 Persistent acidosis or worsening clinical condition despite sodium bicarbonate
therapy
hemodialysis  Severe ingestions: shock, seizures, CNS dysfunction, cerebral edema

185. Malignant effusion is an exudative fluid containing malignant cells in the pleural space. Fluid analysis can have
an elevated LDH and low glucose; however, there is typically a low leukocyte count (<5,000/mm3)

186. For patients who present within 4 hours after a single, potentially toxic ingestion of acetaminophen (≥7.5 g in
adults), the first step in management is gastric decontamination with activated charcoal. An acetaminophen level
should then be obtained 4 hours post ingestion and plotted on the Rumack-Matthew nomogram, which is used to
guide treatment with N-acetylcysteine.

IM-Epi

1. Internal validity refers to the ability of a research design to provide evidence of a causal relationship between a
treatment and an outcome. Blinding increases the internal validity of a study.
2. In ecological studies, the unit of observation is the population, not the individual. Disease rates and exposures are
measured in each of a series of populations and their associations determined. Results about associations at the
population level may not translate to the individual level.
3. Institutional review boards (IRBs) review research protocols to ensure that participants' rights (eg, autonomy,
privacy) are protected and that the research minimizes risks to participants. IRB review is generally required for
research that uses protected health information (eg, identifiable, individual patient information), even when such
research is restricted to chart review.
4. Framing bias is characterized by the formation of an incomplete differential diagnosis due to the influence of
contextual or prior information (eg, past evaluations). It frequently affects the evaluation of patients with multiple
visits in busy settings and can cause a physician to miss potentially serious disease.
5. Availability bias describes the excessive influence of commonly seen (ie, "available") etiologies in determining a
diagnosis (eg, attributing the cause of dyspnea to influenza during a busy winter season). This physician's
diagnostic approach is most closely influenced by this patient's chart information.
6. A run chart is a quality improvement tool that graphs a process performance outcome (eg, no-show rate) over
time (eg, before and after a quality improvement intervention). Run charts allow visualization of trends (≥5
consecutive points with consistent directional change) and systematically determines effectiveness of a quality
improvement intervention. Run charts enable systematic assessment of an intervention's effect on process
performance (eg, no-show rate). Presence of a desired trend (ie, consistent directional change for 5 or more data
points in a row) post-intervention suggests potential effectiveness; persistent underperformance or excessive
variation suggests the intervention only partially address factors influencing performance.

7. The odds ratio (OR) is a measure of association in case-control studies to compare the odds of exposure in cases
relative to controls. The OR is not a direct measure of risk.
8. ARR = Rate control- Rate treatment; Rate treatment = (number of infections)/n
9. A cross-sectional study is an observational study commonly used to estimate the prevalence of disease, but it may
also be used to examine associations between potential risk factors and disease. However, exposure to risk factors
and disease status are measured simultaneously at a particular point in time (ie, snapshot).

10. An increasing prevalence but stable incidence of a disease can be attributed to factors that prolong the duration of
the disease (eg, improved quality of care and disease management).

11. In a normal (bell-shaped) distribution:

68% of all values are within 1 standard deviation from the mean
 95% of all values are within 2 standard deviations from the mean
99.7% of all values are within 3 standard deviations from the mean
12. High-value health care optimizes quality while minimizing costs and waste. The value of an intervention can be
assessed by comparing the ratio of quality metrics (eg, outcomes, safety, patient satisfaction) to the total costs of
care per patient over the length of treatment. Value = Quality/Costs

6. Quality includes patient outcomes (eg, mortality, morbidity), safety (eg, adverse events), and patient care
metrics (eg, patient satisfaction, wait times).

7. Costs include the total costs (ie, not only short-term costs) of care per patient over the entire course of
treatment. Costs may be assessed from the perspective of the patient, health care system, or society at large.

3. Positive predictive value is the probability that an individual has a disease given a positive test result.
Negative predictive value is the probability that an individual does not have a disease given a negative test
result

PPV= TP/TP+FP NPV=TN/TN+FN

4. Negative likelihood ratio (LR) describes the probability of a negative test result occurring in an individual
with disease compared to an individual without disease; it is calculated as (1 − sensitivity) /
specificity. Positive LR describes the probability of a positive test result occurring in an individual with
disease compared to an individual without disease; it is calculated as sensitivity / (1 − specificity).

5. Hazard ratio (HR) is the hazard rate of an event (eg, composite cardiovascular event) in the intervention
group (eg, toraflozin) divided by the hazard rate of the same event in the control group (eg, placebo). HR is
determined as follows:

HR = (hazard rate in the intervention group) / (hazard rate in the control group)

The HR is interpreted as follows:

 HR < 1.0: At any time, the hazard rate of the event is lower in the intervention group than in the control
group (ie, a smaller proportion of patients in the intervention group are experiencing an event compared
to the control group).
 HR = 1.0 (null value): At any time, the hazard rate of the event is the same in both groups.
 HR > 1.0: At any time, the hazard rate of the event is greater in the intervention group than in the control
group.

6. Failure mode and effects analysis (FMEA) is a prospective, systematic, team-based approach that consists of
identifying steps in a process and finding solutions to any problems that may arise, with the goal of ensuring
safe outcomes. FMEA can be performed before any problems are identified.

7. A case-control study is used to compare the exposure of people with the disease (cases) to the exposure of the
people without the disease (controls). The main measure of association is the exposure odds ratio.

8. Defensive medicine refers to clinical services that are intended primarily to reduce physician liability without
providing significant benefit to the patient. It can result in overuse and worse patient outcomes.
 Implementing evidence-based clinical pathways or practice guidelines can minimize physician liability and
reduce defensive medicine.

9. Continuity of care for medications at the time of transitions of care, between inpatient and outpatient facilities
and within inpatient facilities, is a potential source of medical error. Interventions that target pharmacy
personnel and high-risk patients appear to be the most effective in improving the quality of patient care

Mixed

10. Delusions, tactile hallucinations, poor dentitions and aggressive behaviour  Methamphetamine use disorder
11. Self-induced vomiting  hypokalemia, hypochloremia alkalosis with secondary hyperaldosteronism
1. Chronic lead toxicity  neuropsychiatry manifestations ( cognitive defecits, PN ) + GI manifestations (abd
pain) + hypertension+ nephrotoxicity ( increased creatinine) +Hematologic ( anemia )
2. B12 def  macroctyic anemia+ dementia+SCD with progressive weakness, spasticity and incontinence
3. Patient with SLE  neonatal lupus due to transfer of anti- SSA and and anti SSB abs increased risk of AV
block due to antibody attack on fetus’s heart cells  irreversible injury to AV node persistent
bradycardia on FHR
4. Syringomyelia  Chiari Arnold malformation 1 (inferior displacement of cerebellar tonsils through
foramen magnum)
5. Ovarian torsion  Dx clinical Tx diagnostic laprascopy for manual detorsion; oophorectomy is ovary is
necrotic
6. Dopamine blocking agents dopamine receptor upregulation prolonged use or sudden discontinuation
 tardive dyskinesia
7. Acute cervicitis  first trimester bleeding and mucopurulent discharge empiric tx with ceftriaxone and
azithromycin followed by test of cure
8. Transient myelitis  Rapidly progressive weakness with UMN signs (hyperreflexia) + sensation deficits
with localizing spinal senory level and bladder dysfunction
9. Acute spinal injury above T1 interruption of descending sympathetic fibers  unopposed
parasympathetic fibers of vessels and heart  spinal shock  hypotension and bradycardia
10. Chronic excessive noise exposure  cochlear ear cell damage  high frequency SNHL  protection
needed. Hearing loss is permanent. Avoid further hearing loss
11. OCD  CBT and SSRI
45. Tx for allergic rhinitis intranasal glucoticorticoids
46. Traztuzumab  cardiotoxicity
47. Loss of fetal station  uterine rupture  lapratomy and caesarian
17. Hard signs
 Observed pulsatile bleeding
 Presence of bruit/thrill over injury
 Expanding hematoma
 Signs of distal ischemia

Soft signs

 History of hemorrhage
 Diminished pulses
 Bony injury
  Neurologic abnormality

If hard signs or hemodynamic instability Surgical exploration

Otherwise  Injured extremity index

 CT scan or conventional angiography

 Duplex Doppler ultrasonography

Alpha thalassemia
Genotype Disorder Clinical features
1 gene loss
Alpha thalassemia minima Asymptomatic, silent carrier
(αα/α−)
2 gene loss
Alpha thalassemia minor Mild microcytic anemia
(αα/−−) or (α−/α−)
3 gene loss
Hemoglobin H disease Chronic hemolytic anemia
(α−/−−)
Hydrops fetalis: anasarca,
4 gene loss Alpha thalassemia major,
high-output cardiac failure,
(−−/−−) hemoglobin Barts disease
death in utero
 a. Vaccines during pregnancy

 Tdap

 Inactivated influenza
Recommended
 Rho(D) immunoglobulin

 Hepatitis B

 Hepatitis A

 Pneumococcus
Indicated for high-risk
patients  Haemophilus influenzae

 Meningococcus

 Varicella-zoster immunoglobulin

 HPV

 MMR

 Live attenuated influenza

 Varicella

Transfusion reactions
Anaphylactic Urticarial

 Anti-IgA antibodies (IgG or IgE) in IgA-deficient patient  Preformed recipient IgE antibodies against soluble
Mechanism against donor blood IgA allergen in donated plasma

Contraindicated
 Seconds to minutes  Hours
Onset

 Respiratory distress/wheeze

 Angioedema  Hives
Findings  Hypotension  Itching

 Hives

 Immediate cessation of transfusion  Immediate cessation of transfusion

 Epinephrine  Antihistamines
Treatment
 Antihistamines, oxygen, fluids & vasopressors  Resume transfusion if patient is otherwise asymptomatic

a. HELLP syndrome  distention of hepatic capsule RUQ pain+ proteinuria+ elevated blood
pressure
b. AFLD  Fatty infiltration of hepatocytes  Hypertension+ RUQ pain+ elevated transaminases,
jaundice, encephalopathy, hypoglycemia and coagulopathy
c. Posterior oropharyngeal injuries can result in internal carotid artery dissection or thrombus
formation, which can present with hemiplegia, facial droop, and aphasia.
d. Magnesium toxicity  Neuromuscular depression, decreased respiratory effort/ apnea, muscle
paralysis and somnolence, decreased deep tendon reflexes
 e. Patients with endometrial hyperplasia are at risk for progression to endometrial cancer. Patients
who desire future fertility are treated with progestin therapy (eg, progestin-releasing
intrauterine device).
f. Functional (psychogenic) tremors often present abruptly with significant disability. They often
decrease with distraction, have changeable or inconsistent features, and are not consistent with
known tremor syndromes. Not associated with any neurologic causes. They present while rest
and movement. Fingers are often spared. Physical and occupational therapy, sometimes
including intensive inpatient rehabilitation, is another important component of management.
g. A physiologic tremor is not normally visible, although in some patients it can be augmented and
become visible by increased sympathetic activity (eg, caffeine, hyperthyroidism, anxiety). In
contrast to a functional tremor, it is typically low amplitude and is relatively fast (10-12 Hz). It
also typically worsens with movement and improves with rest.
h. An orthostatic tremor typically affects the legs and trunk, rather than the hands, and occurs only
when standing.
i. Although essential tremor is often seen most prominently in the hands and can be worsened by
anxiety, it most often presents in older adults as a tremor of the hands that is suppressed at rest,
exacerbated by outstretched arms, and more pronounced at the end of goal-directed
movements
j. Hypercalcemia >14  saline calcitonin (short) ; bisphonates (long)
k. Hypothyroidism Inc TRH Inc TSH and prolactin dec gnrh  dec hypogonadism 
menstrual irregularities
1. Hemodynamically stable in fracture pts with no underlying disorder  sugery within 24 hrs
Surgery can be delayed upto 72 hrs to find out underlying condition
2. Posterior urethral valves present in newborn boys with bladder distension, decreased urine output, and
respiratory distress (due to oligohydramnios and subsequent lung hypoplasia). Initial evaluation
includes renal and bladder ultrasound and voiding cystourethrogram. Tx bladder drainage and
electrolyte correction by cystoscopy to confirm diagnosis and ablate PUV
3. Bilious emesis and abdominal distention  malrotation Dx Upper GI series
4. Maternal vaccination 27-36 weeks gestation with dtap is effective, pts with obesity during initial visit
needs screening for DM
5. Lithium toxicity  GI (vomiting, diarrhea) and neurological (AMS, tremors, seizure) manifestation Tx:
Hemodialysis. Lithium bicarbonate  increases serotonin - serotonin syndrome
6. Lithium is indicated both for the treatment of acute mania and for maintenance therapy in bipolar
disorder. Long-term side effects include hyperparathyroidism with hypercalcemia, nephrogenic diabetes
insipidus, chronic kidney disease, and thyroid dysfunction, as well as teratogenic effects
7. Lithium side effects  myalgias, fatigue, constipation and bradycardia are most consistent with lithium
induced hypothyroidism
8. TCA toxicity  activated charcoal
9. Lamotrigine for bipolar disorder during pregnancy
10. Common biliary duct cyst  surgery now to prevent cholangiocarcinoma, gallbladder cancer, pancreatic
cancer
11. Metronidazole  distal symmetric polyneuropathy Tx Stop the drug ,pregabalin, gabapentin
12. Casts
RBC cast glomerular pathologies
WBC cast  AIN
Muddy brown cast  ATN
13. Aseptic meningitis in 18 month old with no hx of vaccination  mumps
139.Hydroxychloroquine  retinal toxicity; ophthalmology evaluation every 5 years
140.ACA  contralateral leg; MCA  contralateral face and arm
141.OA X ray show narrow joint space, subchondral sclerosis and periarticular osteophytes
142.Preclampsia  increased risk of acute stroke
143.Persistence of nocturnal and early-morning penileerections helps differentiate psychogenic from organic
causes of male erectile dysfunction. Normal nocturnal erections indicate intact vascular and nerve function in
the penis.
144.Opiod withdrawal  subQ buprenorphine or IV methadone
145.Transverse myelitis  Lhermitte sign + rapidly worsening weakness wtih UMN signs ( hyperreflexia and
postive Babinski + sensation defecits at local dermatomal level
146.Chronic glucorticoid therapy  PCP  CXR bilateral interstitial infiltrates Tx TMP-SMP

1. Langerhans histiocytosis  single lytic bone lesions and SIADH, papules on chest
2. ILD  antifibrotic therapy ( pirfenidone, nintedanib) decreased fibroblast activity  decline in FVC
3. Vulvar lichen sclerosis  vulovaginal and perianal involvement  vulvar biopsy  rule out cancer Tx
corticosteroids
4. Vulvar lichen planus  wichkiham striae + vulvar itching and purplish.
Vulvar lichen planus is a chronic inflammatory disorder that can present with multiple glazed, erythematous
vulvar erosions bordered by white striae (ie, Wickham striae). Patients often have associated vaginal and oral
lesions. Treatment is with topical corticosteroids.
5. CMV – interventricular calcification+ micropcephaly+ thrombocytopenia+Hepatosplenomagaly+ growth
restricition
Transmission- Saliva / urine of infected child
Tx- valgalcyclovir
6. Meckel’s diverticulum- Abd pain+ Lower GI bleeding+ N&D
7. The risk for testicular germ cell tumor for both ipsi and contralateral testis remains the same even after
orchipexy for cryptorchidism
8. Narrowed intercoastal space , opacification and mediastinal shift on CXray on a postoperative patient with
decreased breast sounds and dullness to percussion Atelectasis. Chest physiotherapy for small atelectasis
and bronchoscopy for large atelectasis
9. Recurrent pneumonia+ foul smelling breath + dysphagia and neck mass in elderly male zenkers
diverticulum. NBSIM- swallow study with constrast esophagography
1. Alcoholic hepatitis Alcohol use+ jaundice+ anorexia+ tender hepatomegaly+ fever+ RUQ pain, AST>ALT but
always AST<500, ggt and ferrtin elevated
2. DKA metabolic acidosis with resp alkalosis, PH is still acidic
3. Primary biliary Cholangitis (Autoimmune destruction for intrahepatic bile ducts)- Pruitis+
fatigue+xanthelasma+xanthomas+ positive anti- mitochondrial Abs has increased risk for osteosarcoma
4. Esophageal perforation- Intrascapular chest pain+ fever+ esophageal instrumentation and widened
mediastinum on CXR; Dx: water soluble contrast esophagography
5. Dyspnea+ third heart sound+ bibasilar crackles and low EF on setting on heavy alcohol use and no CAD
Alcholic cardiomyopathy (AST>ALT)
6. Epiglottitis  sore throat+ hoarseness+ stridor+ pooled oral secretions, and drooling. Risk factors include
diabetes mellitus, obesity, and preceding upper respiratory infection. The diagnosis can be confirmed (in
those with stable respiratory status) using lateral neck radiograph.
7. Epiglottis in children  Drooling+ dysphagia + distress
8. Annular pruritic rash with raised borders and central clearing Tinea corporis
Tx- Topical antifungals ( Terfbinafine, clotimazole) 2nd Oral antifungals ( Terbinafine, griseofulvin)
9. Triglyceride induced pancreatitis TG>500 insulin infusion, >1000 aphresis
10. Biliary atresia Asymptomatic at birth shows jaundice in 2-8 weeks, ele LFT, acholic stools and dark urine,
hepatomegaly. Liver biopsy shows intrahepatic bileduct proliferation and portal tract inflammation
11. FiO2 and PEEP determine PO2; TV and RR determine CO2
12. Parkland formula : 4 * weight in kg* % area
13. Acute cholecystitis vs cholangitis
Cholangitis has jaundice and elevated bilirubin
14. Mediastinitis infection of the deep tissues; it classically presents with systemic symptoms (eg, fever,
tachycardia), chest pain, chest wall erythema, edema/crepitus, and purulent discharge.
15. Hx diarrheal epidoes + hypochlorhydria+ hypokalemia+ cutaneous flushing + hypercalcemia+ hyperglycemia 
VIPoma

Vs Diarrhea+tachycardia+ flushing +asthma like attacks+ valvular lesiosn Serotonin syndrome

16. Budd-chiari Syndrome- Thrombosis of hepatic vein, associated with hypercoagulable state. Abd pain+
jaundice+ tender hepatomegaly+ ele LFT+ massive ascites causing abd distention and dyspnea
17. Shiga-like toxin Hemolytic uremic syndrome Bloody diarrhea+ elevated creatinine and dec hemoglobin
and platelets
18. Gastroenteritis due to Shiga toxin–producing Escherichia coli begins with watery diarrhea that becomes bloody
(ie, inflammatory diarrhea). Patients are typically afebrile; the presence of high fever suggests another
diagnosis.
19. Hereditary spherocytosis is an inherited defect in the red blood cell membrane that presents with hemolytic
anemia, jaundice, and splenomegaly. Acute cholecystitis from pigmented gallstones is a common
complication.

20. ADAMTS13 deficiency in thrombotic thrombocytic purpura- Acute kidney injury + thrombocytopenia+ HA;
FATRN  Fever+ Anemia+ thrombocytopenia+ renal issue+ neuro issue Dx peripheral blood smear TX plasma
exchange, glucocorticoids, rituximab, capalizumab
21. Immune thrombotic thrombocytopenia IgG Abs against platelets  Petechiae+ Mucosal bleeding+
thrombocytopeniae
22. Serotonin syndrome Mental status change+ neuromuscular excitability + autonomic dysregulation
Mx: Removal of the offending agent, cooling, BP control. Tx: Benzodiazepines to decrease
agitation and muscle contractions. Cyproheptidine for decreased central sertonergic activity
23. Vague LLQ pain before with anorexia and constipation now with diffuse severe pain peritonitis due to most
likely due to diverticular perforation from diverticulitis. Abd imaging shows intraperitoneal free air
Tx: Emergency needs surgical washout and resection of ruptured bowel segment
24. ARDS Fio2 <60% to prevent oxygen toxicity and Spo2 within 92-96%
25. Rapid Hyperandrogenism Test for DHEA-S and testosterone to locate adrenal or ovarian tumor
High test and normal DHEAS ovarian
High DHEA Adrenal
26. Adjustment disorder Emotional or behavioral symptoms that develop within 3 months of exposure to
identifiable stressor and last no longer than 6 months. Lacks sxs of MDD like impaired conc, low energy and
appetite, psychomotor retardation.
27. Emphysematous cholecystitis: Risk factors DM, vascular compromise, immunosuppression, ( gall bladder
infection due to gas producing organisms)  Fever+ RUQ pain+ gas in the gallbladder wall+ ileus ( decreased
or absent bowel sounds). Crepitus in the abdominal wall adjacent to gallbladder.
Tx; Emergency cholecystectomy , broad spectrum Abxs with clostridium species ( pipercillin and
tazobactam)
28. Vulvar lichen planus wickham striae+ vaginal pruritis and itching
29. Lichen simplex chronicus repetitive scratching hyperplastic response that causes thickened, leathery
skin
30. Lichen Sclerosis Only vulvar pruritis and lesions, no vaginal involvement
Tx High potency corticosteroids

31. Entamoeba Histolytica Bloody / mucoid stools for > 2weeks+ travelling

Tx Metronidazole/ tinidazole for luminal absorption paramomycin

32. Giardia Intestinalis Watery / fat stools with malabsorption

33. 90% TR due to secondary cause ( functional) than primary (anatomic) which is rare. Prominent v waves is
highly specific for tricuspid regurgitation
34. Patients with Wolff-Parkinson-White syndrome who develop atrial fibrillation with a rapid ventricular rate
should be treated with cardioversion or antiarrhythmics such as procainamide. Atrioventricular nodal
blockers such as beta blockers, calcium channel blockers, digoxin, and adenosine should be avoided as they
can cause increased conduction through the accessory pathway.
35. Blunt thoracic injury CT angiogram of the chest
36. Slow onset malaise+ cough+ dyspnea+ fever+ CXR shows patchy or reticulonodular bilateral pulmonary
infiltrates. Tx Azithromycin
37. Focal nodular hyperplasia benign liver lesion due to aberrant congenital artery+ stellate central scar +
radiating fibrous bands
38. Hepatic adenoma Women on contraceptives+ possible hemorrhage or malignant transformation
39. Cryptococcal meningitis Patient with HIV+ low grade fever+ headache+ inc ICP
Tx: Initial: Amphotericin B with flucystosine; Maintenance : Flucanozole
40. Meningoencephalitis in patients with HIV cause
41. Early meningococceal infection  Non-specific ( fever, sorethroat) progresses rapidly to severe myalgia and
poor perfusion of extremities in young adults/ adolescents; Dx; Lumbar pucture
42. Painful HSV Pustules, vesicles or small ulcers on erythematous base, tender lymphadenopathy, systemic
sxs common
43. Painful H.Ducreyi Large, deep ulcers with gray/yellow exudate, well demarcated borders and soft, friable
base. Suppurative adenopathy that may suppurate
44. Painless Treponema pallidum (syphilis ) Usually single ulcer ( chancre), indurated borders & hard, non
purulent base
45. C.trachomatis L1-L3  Initial small, shallow ulcers (often missed)+ painful, fluctuant adenitis.
46. Fever+ lower abdominal pain+ purulent cervical discharge + cervical motion and adnexal tenderness- PID; Tx
Inpatient doxycycline and cephalosporin
47. Single painless chancre that begins as a papule+ nonexudative ulcer with indurated borders+ mild, moderate
painless lymphadenopathy is present Primary Syphillis
48. Mccune Albright syndrome polyostatic fibrous dysplasia+ café au lait spots+ autonomous endocrine
hyperfunction ie gonadotropin independent precocious puberty
49. Focal headache+ fever+ early morning vomiting in the setting of acute bacterial rhino sinusitis Brain
abscesss; Need CT scan of brain
50. Interstitial cystitis Lower abd pain relieved while voiding, > 6 weeks +urinary urgency and frequency +
dysparenuia
51. Traveller’s diarrhea Enterotoxigenic E.coli with mild abd pain+ watery diarrhea
52. Unilateral benign nipple discharge without coexisting breast mass and no LN Intraductal papilloma
53. Adenomyosis
Dx pelvic mri/ U/S
54. Heat exhaustion  exercise intolerance+ increased body temp+ absence of neurological signs
Vs Heat stroke  Hyperthermia+ variable physical based on severity + AMS or neurological
defecits

NBME

1. Umblical hernia reassurance within 3 years of age but persist beyond age 4 need surgical
intervention due to incarceration
2. Polycthemia vera  increased production of erythrocyte secondary to JAK2 STAT mutation. Sx
pruritis, hyperviscosity syndrome, venous thromboembolism and erythromelalgia ( redness,
warmth and burning sensation of extremities); Px Splenomegaly and plethora.
3. Secondary polycthemia vera can be caused by OSA, COPD, cyanotic disease  decreased oxygen
sat can increase release of EPO from kidneys.
4. Septic arthritis MCC in both children and adult  Stap aureus
5. Blunt trauma to the chest  chest pain, increased concentration of troponins , ECGN shows T
waves  Myocardial contusion  serial ECGs
6. Afib with normal ventricular rate  treat underlying condition
7. Patient with one or two tubular adenomas should undergo colonoscopy every 5 years.
8. Polys with atypical and large size should undergo colonoscopy every 3 years.
9. Diabetic foot osteomyelitis mixed aerobes and anaerobes
10. Valproic acid  leukopenia, thrombocytopenia and hepatotoxicity
11. Long term immunosuppression therapy  development of squamous cell carcinoma
12.

Psychiatry
1. Serotonin-norepinephrine reuptake inhibitors (eg, duloxetine) have analgesic properties that can be
helpful in treating patients with comorbid depression and chronic neuropathic pain, including painful
diabetic neuropathy.
2. Prazosin, an alpha-1 adrenergic receptor antagonist, is effective for the treatment of posttraumatic stress
disorder–related nightmares. It is particularly helpful as an adjunct to selective serotonin reuptake
inhibitor or serotonin norepinephrine reuptake inhibitor treatment.
3. MDMA (3,4-methylenedioxy-methamphetamine) is a synthetic amphetamine with mild hallucinogenic
properties. It can cause euphoria, increased sexual desire, and empathy. Intoxication may lead to
hypertension, tachycardia, hyperthermia, serotonin syndrome, and hyponatremia. Coma, seizures, and
death may occur.
4. Generalized anxiety disorder presents with excessive concern about a range of issues, which can result in
irritability, poor sleep, and trouble concentrating. Children with anxiety commonly experience somatic
symptoms.
5. Stimulant medication is a first-line treatment for most adults with ADHD. The nonstimulant atomoxetine,
however, is preferred in patients with a history of substance use disorders or who have expressed
concerns about the risks of addiction.
6. Autism spectrum disorder is characterized by deficits in social interaction, restricted interests, repetitive
behaviors, and abnormal sensory perception. Food selectivity is common.