ABFM

• PCP
• Intoxication produces maladaptive behaviors and nystagmus
• (PCP/"angel dust")
• -hallucinogen that causes psychotic reactions and impaired judgment
• -OD leads to nystagmus, life-threatening HTN, and seizures
• -NMDA receptor antagonist

• Autosomal disorder
• Destroys exocrine glands that produce saliva and tears
• disease with chronic inflammatory autoimmune attack resulting in dryness of mucous membranes and lymphocyte infiltration. Dry mouth and eyes.

• Gram-; Rod; Enterobacteriaceae; Non-Lactose;
• Non-H2S-
• • Non-motile, Only in humans, can cause HUS
  • Very LOW infectious dose
  • GI-->large intesting--> Gastroenteritis, meningitis, seizures
  • high sequence homology w/ E.coli b/c of plasmids
  • Tx with Rocephin x 5 days

• Plavix
• Higher risk of bleeding in older patients

• Indication after non embolic TIA
• Stroke secondary prophylaxis
• inhibitor adenosine uptake and cGMP phosphodiesterase activity; vasodilator

• Sever migraine for more than 72 hrs.
• B blockers are used for recurrent HA's

Do not use topical anesthetic due to corneal toxicity

• By rubbing foreign body
• SX: pain, watering or eye, photophobia, spasm of orbicular muscle of eyelid
• TX: patch and refer, antibiotic ointment, do not use topical anesthetic due to corneal toxicity

• Life threatening drug reaction
• Hallmark is massive keratinocyte apoptosis

• Stool is negative for leukocytes
• Waterborne transmission
• Hikers/campers
• Most common parasite GI infection
• Oro-fecal transmission
• Asymptomatic carriers need to be treated to avoid transmission of cysts.
• Cysts are resistant to chlorination
• Cysts are sensitive to heat.
• Tx with Flagyl

• Clue cells
• Fishy odor
• Gardnerella vaginalis, Mobiluncus species, Mycoplasma hominis, Peptostreptococcus.
• Tx with Flagyl BID x 7 days or Clindamycin po x 7 days
• -vaginal infection from sex (NOT STD)
• -aka Gardnerella vaginalis, Haemophilus vaginalis, or Nonspecific Vaginitis, CLUE CELLS
• S: profuse discharge "constant wetness" with "foul, fishy, rotten" odor
• O: thin, creamy, gray-white malodorous discharge; surface parasite; no inflammation on vaginal wall or cervix; vaginal pH >4.5; "whiff test"
• Tx: Flagyl, Clindamycin

Best confirmatory test is biopsy of affected tissue

Papule or plaque with dermal edema, white central pallor and irregular borders.

Virtually bypassed in fetal circulation

• Risk of converting to a stroke in 30 days:
• 1. Age >60
• 2. Blood pressure >140/90
• 3. Clinical sx of unilateral weakness and speech impediment
• 4. Duration of sx x >10 minutes.

• Autoimmune disease
• Vasculitis of medium size vessels
• Children < 5 y/o

• -Mucocutaneous lymphoid syndrome w/ no known toxin
• -fever 5+ days
• -red/edematous palms/soles-->desquamation
• -exanthem on trunk
• -mucosal erythema
• -cervical lymphadenopathy -conjunctivitis

• NO SCUBA or STRENUOUS EXERCISE
• Tx. Exercise, MTV, Flu vaccine. Fluids
• inherited condition of exocrine gland malfunction causing secretion of abnormally thick, viscous mucus that obstructs passageways within the body, commonly affecting the lungs and digestive tract; mucus that obstructs the airways leads to infection, inflammation, and damage of lung tissue
• Tx: Running is ok, MTV, Fluids, Exercise, Flu vaccine.
• No scuba or marathon running

• Increases: 
• Cardiac output, BP, HR, Oxygen consumption, Risk of MI, Incidence of cancer

heavy drinking: M: drinking more than 2 drinks/day, F: more than 1 drink/day

• binge drinking: M: 5 or more drinks in single sitting, F: 4 or more drinks in single sitting
• Increases: Cardiac output, BP, HR, Risk MI, Myocardial Oxygen consumption

• E. coli
• Tx with Ampicillin and Gentamycin IV
• -Kidney infection, results from UTI.
• -Sx= Pain, hematuria, dysuria BUT SYSTEMIC TOO (fever, chills, N/V).
• -Mx=Admission, IV abx Ampicillin and Gentamycin. FLUOROQUINOLONES.only oral approved.

• Best test is real time reverse transcriptase by PCR
• sometimes called “swine flu” is a new influenza virus causing illness in people.

Associated with bird poop (chicken coop)

• • Dimorphic fungi (mold in soil; yeast in tissue). Hides within macrophages!
  • Mississippi and Ohio River valleys.
  • Associated with bird/bat droppings. chicken coop
  • infected person usually has no symptoms/generally self limiting.
  • Rx: amphotericin B, followed by oral itraconazole.

• Overlap between them and some genetic underpinnings
• share genetic, neuroanatomical, and cognitive abnormalities
• -some think bipolar is more closely related to schizophrenia than depression (especially bipolar I)

• Sx of angina, ST depression, T wave inversion, blood clot is the most common cause
• NSTEMI does not have to have increased troponin.
• signs and symptoms resulting from conditions in which the coronary arteries are suddenly narrowed or occluded(thrombus) and lead to cardiac cell hypoxia

• manifests as:
• ST elevation/T wave inversion
• unstable angina
• myocardial infarction(NSTEMI (no need for increase in Troponin or STEMI)

Less than 50 ml/day of urine

Less than 400 ml of urine per day

• WBC in fluid of > 50,000/mm is a diagnosis until proven otherwise
• Gram stain only 50% sensitive
• Crystals make diagnosis less likely
• RA and Gout increase risk
• caused by an agent invading the joint cavity.

• • hematogenous seeding - comes through blood from a distant site that is actively infected
  • also introduced through trauma or surgery
  • usually impact large joints of knee/hip

• Defect of the short arm of Chromosome X
• Disease of the muscle contractile proteins, most severe and most common of MD in childhood, x-linked recessive trait, 1: 3600 male births
• Characteristics: onset age 3-5, progressive muscle weakness, wasting and contractures, progressive generalized weakness in adolescence, death from resp or cardiac failure
• DX: clinical appearance, family hx, confirmation by EMG, muscle biopsy, and DNA, may detect prenatally by 12 wks - amnio

• Philadelphia chromosome
• Translocation of chromosomes 9,22

• intermittent attacks of vasoconstriction of the arterioles (causing pallor of the fingers or toes), followed by cyanosis and then redness before returning to normal color; initiated by exposure to cold or emotional disturbance.
• No need to do provocative test.
• Tx Nifedipine, Prazosin, Amlodipine

• Primrose oil increases PT.
• Coenzyme Q, melatonin, St. John's wort decrease PT.

Fatal form of pneumonia that leads to multi-organ failure.

• • gram neg, not seen in gram stain, no person-person
  • granulomatous response (facultative intracellular)
  • legionnaries disease - severe pneumonia with multiorgan failure, AC units
  • Pontiac fever - mild flu like symptoms
  • fluoroquinolones (Cipro) or macrolide

• T score less than -2.5.
• Tx with Calcium, Vit D and Fosamax 70 mg /wk
• - Associated with calcium deficiency (need 1000-1500 mg/day)
• - Loss of bone density, bones become brittle - break easily and hunched posture
• - Occurs in 50% of older women and 25% of older men
• - Also associated with Vitamin D deficiency, smoking, excessive alcohol intake, sedentary lifestyle, being thin (BMI<19)

T score between -1.5 to -2.5

Painless black eschar

• • bacillus anthracis, gram(+) , spore forming rod produces anthrax toxin
  • only bacterium w a polypeptide capsule (contains D-gluatamate)
  • Black skin lesions -Painless black eschar (necrosis) surrounded by edematous ring. caused by lethal factor and edema factor

• Pasteurella multocida highest rate in cats
• The definitive host of toxoplasmosis

• Increase CHD
• Pathogen Actinobacillus actinomycetem comitans
• (infection and inflammation of the soft tissue & bones that support the teeth) main cause of tooth loss

• Lovenox
• Tx for prophylaxis for DVT and PE x 7-10 days
• Targets factor Xa specifically, more predictable effects, longer half life, subcutaneous 1-2xdaily, weight dosed, used for prophylaxis DVT and PE x 7-10 days, thromboembolic disorders, ACS, monitor for bleeding, thrombocytopenia
• Generally does not increase PT or PTT.

• Ulcer
• Gram (-) spiral rod, urease (+)Virulence factors: CagA, VacA. No known reservoirs except humans and primates, Causes gastric cancers, MALT lymphomas, ulcers (duodenal more than gastric)
• Dx: Best is breath test. After treatment also can follow up with stool antigen test.

• • • Treatment requires triple therapy for long duration (2 wks) - 1 or 2 antibiotics + antacid

• • • Triple therapy advised- Peptobismol + Flagyl + Tetracycline or Amoxicillin x 4 weeks.

• • • Double therapy- Omeprazole + Amoxicillin x 2 weeks

• • • Short course- 1 week of Flagyl + Omeprazole + Biaxin

• Used against E coli and Staph
• Work by inhibiting bacterial protein synthesis

• • • Amino group bonded to carbs

• • • affects protein synthesis

• • • binds to bacterial ribosome

• • • active against mainly Gram negative bacteria and mycobacterium

• • • Ototoxicity affects CN VIII

• • • ex streptomycin, neomycin, tobramycin

• Rule out pregnancy
• First line tx for infertility is Clomiphene
• If that does not help you can add Metformin
• increased LH --> increased testosterone and estrogen, decreased FSH
• rule out pregnancy
• tx: weight loss, low-dose OCP's (decrease LH and androgenesis), spironolactone (acne/hirsutism)

• Best for monitoring COPD
• Measures obstructive lung disease
• forced expiratory volume
• -vol of air that can be expired in 1st sec of forced max exp
• -normally 80% of FVC

• Screen pregnant women early
• Tx if positive even in asymptomatic pt
• Could become pyelonephritis
• Antibiotics x 3-7 days
• refers to > 10⁵cfu/mL in pt w/o complaints consistent of UTI

• no tx required unless pregnant (screen early) or preschool child
• If + treat for 3-7 days

• Pericarditis after MI
• Usually 2-3 weeks after
• Tx with NSAID's and stop anticoagulation
• An autoimmune reaction with fever, pericarditis, and increased ESR occurring 2-4 weeks post-MI
• Tx; NSAID's and stop  anticoagulation

• Independent risk factors:
• Hyperthyroidism
• Male
• Age> 60 y/o
• Obesity
• DM
• Alcohol
• Sleep apnea
• Caffeine
• Stress
• Rheumatic heart disease
• atria quivering 350 -600 bpm
• the is no P wave (no atrial contraction)
• QRS is present
• most common dysrhythmia
• Thrombus and Embolus risk from pooling
• metoprolol used to decrease HR
• coumadin used for long term anticoagulant

• Caused by failure of the body to recognize self antigens
• Examples: SLE and Hashimoto's thyroiditis

• Age > 50 y/o
• Elevated CRP, ESR
• Symmetrical gallium uptake in shoulders and pelvis
• Refractory to NSAID's

• Negative findings in X Rays
• -usually large joint involvement (hips/shoulders)
• -systemic S/S, age >50 y/o, elevated ESR
• -similar lab results as seen in RA, elevated CRP
• -often seen with giant cell arteritis
• -treat with course of higher dose systemic corticosteroids
• 
  

• Dwarfism
• • AD disease.
• • Cell-signaling defect of fibroblast growth factor (FGF) receptor 3.  
• • Results in dwarfism; short limbs, but head and trunk are normal size.
• • Associated with advanced paternal age.

• Hereditary hemorrhagic telangiectasia
• Affects blood vessels and produces bleeding
• Recurrent epistaxis, oral telangiectasia, pulmonary AVM.
• Worsens with physical activity.

• Granulomatous vasculitis with eosinophilia.Worse w exercise.
• Presents with asthma, sinusitis, skin lesions, and peripheral neuropathy (foot/wrist drop)
• p-ANCA is a strong marker

• Neurodegenerative genetic disease
• Affects muscle coordination
• Chorea- abnormal involuntary movements
• Autosomal dominant
• - Condition caused by a genetically programmed degeneration of neurons in the brain- Autosomal dominant disorder involving a defect on chromosome 4- Leads to progressive atrophy of the brain, particularly in the basal ganglia and frontal cortex
• -Abnormal involuntary movements

• Genetic condition
• Autosomal dominant
• Cafe au lait spots
• High risk of tumor formation
• - Condition caused by a genetically programmed degeneration of neurons in the brain- Autosomal dominant disorder involving a defect on chromosome 4- Leads to progressive atrophy of the brain, particularly in the basal ganglia and frontal cortex
• • von Recklinghausen’s disease
• autosomal dominant

• • Multiple skin/oral neurofibromas
• • Oral lesions may be pendulous
• • May be hundreds of neurofibromas
• • Skin pigmentation (cafe au lait spots)

• Congenital neurological condition and skin disorder
• Port wine stains of face
• Glaucoma
• Meningiomas
• Seizures and mental retardation
• Congenital

CM: Port-wine stains in V1 distribution, ipsi leptomeningeal angioma, pheochromocytoma

Also causes glaucoma, seizure, hemiparesis, mental retardation

a neurological disorder characterized by tremors, rigidity of the limbs, poor balance, and difficulty in initiating movements; caused by degeneration of a system of dopamine-secreting neurons.

characterized by sclerotic plaque replacement of the myelin sheath on nerve cells in the central nervous system.

• PIP, metcarpophalangeal, wrist most affected.
• Fusiform or spindle-shaped swelling of PIP in acute.
• Chronic disease swelling of metacarpophalangeal and PIP joints.
• "Swan Neck" seen
• produce antibodies against cartilage of uncleared Ig+Ag complexes deposits in joints

deficiency in vitamin D in children. since vitamin D controls the proper absorption of Ca++ from the gut, therefore a deficiency leads to hypocalcemia (low serum Ca++) and resulting in skeletal and dental deformities (as well as neuromuscular problems). due to lack of Ca++ there is no mineralization of the cartilage at the epiphyseal plate and bone osteoid. therefore, bones lack structural strength and bend due to the enlarged zone of calcification (because the cartilage cells don’t die). this is characterized by ‘bow legs’. note that low Ca++ in diet can also cause rickets, but most common cause is low vit D. treat with vitamin D and calcium.

• increase in both osteoblastic and osteclastic activity
• maybe viral - like paramyxovirus
• Alkaline Phosphatase increased!

• hat size increase
• hearing loss is common due to auditory canal narrowing
• increased blood flow from AV shunts
• osteogenic sarcoma

a progressive autoimmune disorder characterized b inflammation that causes demyelination of the myelin sheath. This scars the brain, spinal cord, and optic nerves and disrupts the transmission of nerve impulses. This damage leaves the patient with varying degrees of pain plus physical and cognitive problems

• 1) develops in response to high doses of Atropine or scopolamine
• 2) s/s: central: restlessness, agitation, shivering, mania, hallucinations, delirium, drowsiness, excitation, disorientation, short-term memory loss, motor incoordination; peripheral: blurred vision, dry mouth and skin, ST, rash on face, neck, chest, HOTN
• 3) peds and elderly are most sensitive   
• 4) TX: physostigmine 15-60 mcq/kg IV, crosses BBB   
• 5) Red as beet, dry as a bone, blind as a bat, mad as a hatter, hot as hell

• I- Intermittent
• II- Mild persistent- Think about pulmonology referral
• III-Moderate persistent
• IV-Severe persistent
• Clinically classified according to the frequency of sx and the forced FEV1
• Bronchoprovocation with Methacholine, histamine, cold air or exercise is the only definitive diagnostic test.

• -clopidogrel
• -anti-platelet agent
• -covalently modifies ADP receptor, preventing ADP action
• -higher risk of bleeding in older patients

• Upper: peptic ulcers, gastritits, varices, esophagitis, Mallory-Weiss tear, AV malformation
• Lower: diverticula, IBD, perianal disorders, carcinoma, AV malformation
• Can be also caused by: stress, NSAIDS, alcohol, steroids, and aspirin.
• Early endoscopy is the first test to order

• -delayed emptying
• -Gastric atony in DM

• -associated with chemical/neurological factors
• -causes many times unknown (idiopathic)
• -causes can be diabetes/obstruction/surgery
• -In DM it means a disease of > 10 yrs.

• Valve is insufficient or doesn't close all the way.
• Backward flow causes turbulent sound.
• Mitral and tricuspid.
• Usually harsh and pansystolic.

• Fracture of the Pars Interarticularis
• L4-L5 usually
• Spondylolysis
• Spondylolisthesis

• Aortic-R sternal border
• Pulmonic- L sternal border
• Erb's point- 3rd L ICS
• Tricuspid- 4th L ICS
• Mitral- 5th L Mid clavicular

• • Petechiae
  • Abdominal pain
  • Renal involvement (IgA) can produce persistent nephritis
  • Self limited in children
  • Can be triggered by infections, medications, chemicals or vaccines.

• Does not change mortality in CHF.
• Improves morbidity in CHF.

• Aspirin or anti platelet agent in first 48 hrs.
• Heparin not indicated.
• IV rt-PA should be given in first 3 hrs.
• Neither bed positioning, O2, IVF's are helpful.

• - osmotic diarrhea
• - deficiency in intestinal lactase
• - watery large volume
• - follows ingestion of milk products
• - Can tolerate up to 1 cup of milk (12 gm of lactose) with no sx

• -Chronic inflammatory bowel disease affecting the terminal ileum and sometimes the colon.
• -More likely to be smokers than pts with UC.
• -Multi-factorial pathogenesis.

Can occur with recent and chronic alcohol use.

• -common cause of sudden cardiac death in young athletes
• -LVH
• -B blockers are the treatment of choice

• -In cases of elevated IgA you can see high fructosamine levels.
• -It is an alternative to HgbA1c in pts with Sickle cell.
• -Burn pts have low levels of fructosamine.

• Autoimmune disease that causes chronic, progressive damage of the neuromuscular junction.
• Immune system produces antibodies that bind and block ACh receptors.May be related to thymus. More seen in women.Muscles in face and neck are affected. Weakness of eye muscles. Double vision.Weakness of throat muscles. Death from paralysis of the respiratory muscles. Progressive weakness

Tx: Anticholinesterase drugs, plasmopheresis, thymectomy in patients below 60 y/o.

• Amyloid-beta protein-forming plaques,
• Neurofibrillary tangles,
• Decreased acetylcholine production – decreased transmission of impulses across conduction
• Memoryimpairment
• Apraxia

• - clinical features: either Parkinsonism s/s OR dementia, hallucinations
• - eye movements: vertical gaze palsy
• - pathology: Lewy bodies in cerebral cortex
• - cause: unknown

• Rare cause of dementia characterized by the destruction of frontal lobes.
• -pronounced atrophy of the temporal and frontal lobe (not diffuse atrophy like in AZD)
• -Neuronal loss only in the frontotemporal lobes
• -Pick bodies (cytoplasmic inclusions of microtubule-associated Tau proteins)
• -Behavior abnormalities, speech and language decline
• -urinary incontinence

• Characterized by instability in relationships, self-image, mode, and lack of impulse control.
• Intense anger, mood swings

• thyrotoxicosis; most common type of hyperthyroidismtachycardia, palpitations, excessive perspiration, heat intolerance, nervousness, irritability, exophthalmos, and weight loss
• Autoimmune disease
• Goiter

• -Principal cause is infection
• -Usually presents with transient vertigo and tinnitus
• -Select worse ear to fix first
• -No high dose antibiotics needed

• Fracture of the Pars Interarticularis
• L4-L5 usually
• Spondylolysis
• Spondylolisthesis

• -coughing is only symptom
• -bronchospasm is not severe enough to cause airflow obstruction
• -difficulty w/ air movement can create a feeling of suffocation
• -Pt may feel increasingly anxious
• -Normal spirometry
• -Nocturnal persistent dry cough

90% cure if used for 8 weeks

• Recurrent infections in ears, sinuses, nose, bronchi and lungs
• Most common organism; H. flu, Pneumococci and Staph.

• Definition: Sleep disorder characterized by walking in one's sleep during Stage 3 or 4 of NREM sleep; aka somnambulism
• 4-8 y/o/ 15 % of children/ more common boys and it runs in families.

• CT needed for wood and plastic.
• X Ray can see glass and metal.

1. Wash the wound with soap and water2. Administration of rabies Ig (RIg) so as to infiltrate all around the wound (neutralizes the virus locally)3. Administration of rabies virus vaccines on days 0, 3, 7, 14. Test animal and treat only if positive. Skunks, raccoons, foxes or bats are regarded as rabid. Bites from squirrells, hamsters, guinea pigs, gerbils, chipmunks, rats, mice, rabbits almost never require prophylaxis

• Post-menopausal women with the following conditions:
• -Prolonged use of steroids
• -Past or recurrent Anorexia Nervosa
• -Prolonged or recurrent amenorrhea
• -Hyperparathyroidism
• -RA
• -Hyperthyroidism

Suggestive of Renal, Hepatic, Cardiac disease, Pneumonia, Hypoalbuminemia and Arsenic poisoning.

• - acute, life threatening!!
• - hemorrhage into vessel wall w/  longitudinal tearing or separation
• Marfan Syndrome is the most common disorder of connective tissue.
• Marfan patients have a predisposition to Aortic dissection.

• Tx w anticholinergicsdry mouth, constipation, dry eyes, retention, narrow angle glaucoma.
• They block muscarinic receptors at the detrussor muscle reducing bladder contractility.

Daily recommendation is 0.4 mg

• 10 yrs- if no polyps or if polyps are hyperplastic
• Less than 3 yrs - if >10 polyps

• - Peri orbital swelling and redness. Painful limited extra ocular movement
• - Req IV abx and admit.
• - Usually stept pna or staph aur
• - Blood cultures and periorbital tissue fluid. CT scan to r/o intracranial involvement.
• - Referral

• Beta-pleated sheet: visualized by apple-green birefringence on Congo Red stainunder Polarized Light.
• Often accompanying diseases like Multiple myeloma, TB and RA.
• eg. Artery wall is waxy

Soft red brown papules and plaques located around eyes and ears.

Several days of high fever, rash appears as fever resolves, cause by herpes 6, generalized more subtle pink rash

• Caused by r. rickettsi carried by dog and wood ticks.
• Infection causes distinct spotted migratory rash. Acute reactions include heart and CNS damage. IT IS POTENTIALLY FATAL AND REQUIRES IMMEDIATE TREATMENT.
• Tx: Doxycycline

Pinkish maculopapular rash in face with adenopathy

• -maculopapular viral disease caused by rubeola virus (RNA)
• -extremely infectious (airborne)
• -acquired by respiratory route, systemic disease with rash
• -often complicated by secondary infections like S. aureus pneumonia and ear infections
• -Koplik's spots- bright red spots with bluish center in molars.

Homatropine or Cyclopentolate

Rust ring that forms in cornea as a reaction to a metal foreign body

Perforated ruptured globe

• -collection of leukocytes/pus (white blood cells) in anterior chamber
• -treat aggressively
• -white/gray exudates in anterior chamber, injected bulbar conj, pain
• -no direct treatment; fix underlying cause:
• 1. Penetration
• 2. Infection
• 3. chronic uveitis

herpes zoster lesions on tip/side of nose

• Systolic murmur
• Mitral position

• Systolic murmur
• Mitral position
• Mid systolic click

• Systolic murmur
• Mitral position
• Holo-systolic murmur
• 3rd heart sound gallop in diastole

• Systolic murmur
• Holo-systolic

• Systolic murmur
• Aortic position
• Aortic ejection click

• Systolic murmur
• Aortic position
• Loud in early systole
• Musical murmur

• Systolic murmur
• Pulmonic position
• Early systole
• Present in pregnancy, hyperthyroidism, exercise, anemia.

• Innocent murmur
• Aortic sclerosis murmur
• Aortic stenosis mild
• Aortic stenosis severe
• Mitral regurgitation
• MVP
• Hypertrophic cardiomyopathy

Adverse event is prolonged QT and Torsades de pointes

• Clinical manifestations when the blood's viscocity is 4-5 times of normal serum.
• IgA has the highest viscocity
• Initial treatment is diuresis and IVF's

• Etiology: defective spectrin or ankryn
• Elevated MCHC, RDW
• Splenomegaly, APLASTIC CRISIS
•          (B19 suppresses BM)
• Positive osmotic fragility test (lyse to NaCL)
• Tx: splenectomy is curative.

Epiglottitis- mostly now seen in older population.

Abscess- seen in children

• Peptide that causes natriuresis. Elevation indicates presence of heart failure. Helps distinguish between respiratory and cardiac dyspnea.
• Above 100 is abnormal.

Vomiting is the clinical sign mostly associated.

A more serious form of preeclampsia, is characterized by convulsions and sometimes coma. treatment for this condition is delivery of the fetus

Hypertension, proteinuria, and edema in pregnancy due to decreased blood flow to organs and activated coagulation cascade.

►A complication of pre-eclampsia with a combined liver and blood clotting disorder ►HELLP syndrome occurs in approximately 10% of pregnant women with pre-eclampsia or eclampsia (seizures).  HELLP may occur without an associated elevation of blood pressure. ►H = hemolysis, EL = Elevated Liver Enzymes, and LP = Low Platelets ►ONLY treatment:  DELIVER THE BABY!!!!

• 5 yrs shot- no need to re-vaccinate even if the wound is contaminated.
• Surgical debridment needs to happen after the shots are given.

Droplet precautions

Adverse event is prolonged QT and Torsades de pointes

• Clinical manifestations when the blood's viscocity is 4-5 times of normal serum.
• IgA has the highest viscocity
• Initial treatment is diuresis and IVF's

• Chicago criteria:
• Normal- AHI < 5 per hour.
• Mild- AHI 5-15 per hour.
• Moderate- AHI 15-30 per hour.
• Severe- AHI >30 per hour.

• Rash: Bulls-eye lesion.
• Tx only if tick is in for >24 hrs.
• Tx with Doxycycline x 21 days.
• Amoxicillin in young children and pregnancy.
• Dx: Western Blot assay Antibody test

An infolding of a segment of the intestine within another segment; usually occurs in infants and young children and may result in bowel obstruction.

Tx: DONT forget.

• D- Dextrose
• O- Oxygen
• N- Narcan
• T- Thiamine

Central activation of the NMDA receptors.

Delirium is not present

In patients with PCN allergy you give Vancomycin.

• Tx with B blocker only in unstable patient as 1st choice.
• If B blockers cannot be tolerated use Amiodarone.

• Contraindications:
• Breast feeding, Immunodeficiency, Liver disease, Acute pulmonary disease, PUD

• Relative contraindication:
• Mass greater than 3.5 cm/Cardiac arrhythmia/ Undesired fertility

1/3 of elderly patients with head injuries

• A transiet period functional loss following injury.
• Penetrating spinal cord trauma rarely results in spinal shock.

• Cardioembolism in non rheumatic heart AF patients is not the main cause.
• Unknown etiology is the most common cause.

• Autosomal dominant.
• <10% of breast cancers.
• Genetic testing should be done in index case when feasible.
• If index case is not available or dead then genetic counseling should be offered.
• BRCA1- medullary CA and serous CA of ovary
• BRCA2- breast CA in males (invasive ductal)

No need for B blocker administration.

If neg X ray it is a Neurosurgical emergency due to elasticity of tissues.

Crystalloid resuscitation is given even in the presence of pulmonary edema.

In aging patient results due to apoptosis of AV pacemaker cells.

Women of childbearing age should use 0.4 mg per day.

In a classic presentation no need for CT, surgery should be the course of treatment.

Main cause is IHD

In children can be caused by Rheumatic fever. Also associated with athletes due to their increased vagal tone at rest.

• Amaryl
• Glyburide

Precose does not cause hypoglycemia.

• If c peptide is low then the insulin is exogenous.
• If c peptide is high then the insulin is produced in islet cells.

Islet cell hyperplasia.

Inflammation of deep layer of sclera with deep boring pain.

Superficial inflammation of sclera. No pain.

• Bluish discoloration of umbilicus.
• Sx of intra-abdominal or retro peritoneal hemorrhage.

• Bluish discoloration or echymosis of abdominal wall or flank.
• Sx of intra-abdominal or retro peritoneal hemorrhage.

• Very low incidence of potentially serious complications in ED.
• Can cause muscle rigidity.
• It can be absorbed orally.

Os is closed although patient is bleeding.

Os is open and patient is bleeding.

• 250 micrograms can be given at any time of the day.
• Useless in adrenal failure due to acute ACTH deficiency.

Most common cause is viral by Adenovirus.

Area most suitable for biopsy is the periphery of the ulcer adjacent to normal healthy tissue.

Do echo only in the presence of increased JVD.

• Drugs that produce it:
• Anti-psychotics, Cocaine, Opiates, MAOI, SSRI's, Verapamil, Methyldopa

Target lesions after antibiotic use.

• Visual color disturbances, weakness, nausea and arrhythmias.
• Hypokalemia due to diuretics can cause digoxin toxicity.

• MI, malignancy, collagen vascular disease and uremia.
• Alcohol is not a direct cause.

• Plaques in MRI are not definitive dx.
• There is no single test for diagnosis.

Effective tx is extra corporeal Ig elimination by immunoadsorption.

Birefringent crystals in joint fluid. It can cause meniscal calcium in X-rays of the affected joint.

Iron overload.

• - disorder of platelet function, most common hereditary coagulopathy
• - normal platelet count, but bleeding time is markedly prolonged (normal is 3-10 min)
• - may have prolonged PTT
• - mucus membrane bleeding common = epistaxis, easy bruising, menorrhagia, gingival & GI bleeding
• - may also have low factor VIII

• Genetic disorder of connective tissue.
• Sx: Long limbs, dislocated lenses, aortic root dilatation

Muscle weakness, anorexia, polyuria, polydipsia, HTN, hypercalcemia

Tx with Lyrica, Savella or Cymbalta.

In patients with anemia that have uncontrolled DM you can see a normal HgbA1c level due to new RBC not having time to accumulate glycosylated Hgb.

• Hereditary polyposis syndrome.
• Polyps and pigmentation in lips.

• Parathyroid hyperplasia.
• Parathyroid adenoma.
• Pituitary adenoma (Prolactinoma)
• Pancreatic tumors

• -Medullary thyroid CA
• -Pheo
• -Parathyroid adenoma or hyperplasia.

• Medullary thyroid CA.
• Pheo
• Mucosal and GI ganglio-neuromatosis.

• Bilateral pheo
• Hyper-parathyroidism
• Paraganglioma
• Thyroid hyperplasia
• Carcinoid tumor
• Hyperplasia of endocrine pancreas

• Ribavarin
• Peg Interferon

• -More common in men.
• -Especially at night.
• -Last 30-60 min.
• -Sympathethic paresis.

Major component of Antioxidant System.

• MMR
• Oral polio
• Varicella

• Ortho emergency.
• Treat as an undisplaced fracture of elbow, supracondylar fracture is the most common.

• Triad of initial symptoms:
• -Gross hematuria.
• -Flank pain.
• -Abdominal mass.

• Mid-line rupture of disc at L4-L5.
• Urinary retention is the most consistent finding.

• Scleroderma
• Raynaud's
• Tumors
• Increased intracranial pressure.
• Sickle cell
• DVT
• Vascular insufficiency

Due to exanguination and the use of tourniquet.

• Fastest test for diagnosis is
• Urine Elisa test for antigen.

Respiratory damage plus renal disease with mild glomerulitis with proteinuria, hematuria and RBC casts.

• Associated with paraneoplastic syndromes.
• Cushing's and Lambert Eaton.

2ry to inadequate intake of CARBOHYDRATES

• • due to increased dopamine blockade throughout the body 2nd to anti-psychotic tx
  • usually early in tx course
  • FEVER: Fever, Encephalopathy, Vital signs are unstable, Elevated creatine phosphokinase 2nd to muscle breakdown and Rigid muscles
  • Treat with dantrolene and bromocriptine

• Pityriasis rosea
• Causes discomfort

• First line of tx for infertility is Clomiphene.
• If that fails you can add Metformin.

• False + = BCG vaccine (assume they have TB)
• False - = Immunodeficiency
• Positives: induration
• • 5mm: close contacts, old CXR evidence, HIV
• • 10mm: foreigner, prison, IVDU, Health Care worker, infants
• • 15mm: pt's with no other risk factors

• Determining the need for a CXR in a patient with pneumonia.
• Fever >100
• HR >100
• Tachypnea >20
• Decreased BS, rales in the absence of asthma

Can produce dyspnea by producing pulmonary fibrosis.

• Hyperthyroidism
• Pregnancy

• Can use opiates at low dose for anxiety.
• Do not use Benzodiazepine because of sedation and decreased respiratory effort.

Lasting more than 30 days.

• -Up to 11 times a day in children.
• -Maybe habit in adults.
• -Tourette's syndrome

• Red mucosa in pt with a cold.
• Pale mucosa in pt with allergies.

• Check blood flow and ventilation exchange
• For Pulmonary Embolism- normal ventilation with decreased perfusion.

• D dimer is sensitive. Will rule out the diagnosis.
• Treatment for reversible causes is Warfarin for 3 months.

• Sensitive- If + rules out SNOUT
• Specificity- If + rules in SPIN

• -Migratory thrombophlebitis.
• -Sign of  malignancy.
• -Warfarin does not work, treat with Heparin.

• -Direct factor Xa inhibitor.
• -No need for INR monitoring.
• -Cannot be reversed rapidly.
• -Interacts with Plavix.

• -GI and Pulmonary sx especially in children and adolescents.
• -GI- Pale and clay color stools
• -Dx test is sweat chloride test
• -Avoid contact sports, can exercise.
• -Vaccines up to date, Pneumovax and Influenza.
• -MTV with D, E, K, A.
• -Pancreatic enzyme supplementation.

• Risk is 20X in smokers, Menthol cigarettes higher risk, Radon gas, Cigar smoking but not marihuana.
• Screening- CXR no benefit. CT only in high risk. (current or former smokers, Age 55-74, 30 pack year hx, no lung CA)
• Gold standard for diagnosis is BIOPSY.
• Small cell- SIADH secretion, very low 5 yr survival.
• Non-small cell- Better survival than small cell.
• Prevention: Eat more vegetables.

• Biomarker that becomes elevated during bacterial infections; appears to reflect severity of infections. Viral infections level less than 0.25.
• Bacterial infection >0.50

• Who to hospitalize?
• CURB65
• C- Confusion-
• U- Urea BUN > 19-
• R- Tachypnea >30-
• B- Systolic BP<90 or diastolic <60
• 65- Age > 65 y/o
• 1 point each- >= 3 points need to hospitalize.

Tx with Macrolide, Doxycycline or Fluoroquinolone but no Cipro.

• All children <23 months.
• High risk children older than 2 y/o should get PCV7 if no prior vaccination.

• All adults > 65 y/o.
• Insitutionalize adults.
• Co-morbidities.
• Alcoholics and HIV.
• Splenectomy pt or Sickle cell do q 5 yrs.

•   Inflammation of the trachea and bronchi that is self-limiting, of short to moderate duration
•         DX: few pulmonary signs but may be the result of chemical irritants or virus 90%
•         Complications: Usually mild except w/ elderly and chronic disease
•   Treatment is symptomatic, involving cough 
•  suppressants, rest, and hydration

• 2. Catarrhal stage: Unidentifiable cough/cold, low fever, 1-2 weeks
  Paroxysmal stage: rapid outbreaks of coughing, difficulty expelling thick mucus, high pitched whoop, 2-5 weeks
• Convalescent stage: gradual recovery, subsequent respiratory infections, 1-2 weeks.

• Whooping cough, DTap vacc.
• Tx 1.Macrolide 2. Rifampin
• Rifampin can cause orange coloration of mucosa.
• Respiratory isolation until 5th day of antibiotic is given.

• RSV is main cause.
• Prevention only in premature children with Synagis.
• High risk infants:
• -Less than 2 yrs with chronic lung disease
• -Less than 1 yr old born 28 weeks or earlier
• -Less than 6 mo old born 29-32 weeks
• -Less than 6 mo born 32-35 weeks with one risk factor (day care or 3+ siblings)

• Best diagnosis in physical exam is rales in apex after cough.
• Newer screening method in BCG + pt is IGRA which is a test  for response of Mycobacterium tuberculosis antigens.
• Tx: INH 6-9 mo. or Rifampin.

• Screening tool in:
• -Smokers age >56
• -Preop testing
• -Occupational exposure
• -Baseline testing before chemo or Amiodarone.

• Both show abnormal spirometry.
• Difference is reversibility.
• Asthma will show FEV1 increase by 15%. COPD will show no or minimal reversibility.

• Gold criteria
• Stage 0- Normal spirometry
• Stage I- Mild COPD
• Stage II- Moderate COPD
• Stage III- Severe COPD
• Stage IV- Very severe COPD- resp failure or Right heart failure.

• Stage 0- Decrease risks
• Stage I- Short acting bronchodilator
• (1st anticholinergics- Atrovent to decrease mucus)
• Stage II- Combination bronchodilators
• Stage III- Add inhaled corticosteroid
• Stage IV- Add O2 and consider lung reduction surgery

• 5A's
• Ask, Advise, Asses, Assist, Arrange
• Pulmonary rehab does not increase survival.
• O2 and smoking cessation improve survival in COPD.

• Intermittent- Sx < 2 d/wk
• Mild persistent- Sx>2 d/wk minor interference w activities
• Moderate persistent- Sx daily.
• Severe persistent- Sx throughout the day.

• Step 1- Albuterol
• Step 2- Low dose ICS
• Step 3- Low dose ICS + LABA (Serevent)= Advair
• Step 4- Medium dose ICS + LABA
• Step 5- High dose ICS + LABA
• Step 6- High dose ICS + LABA + oral steroid
• Leukotriene- can be steroid sparing
• Do not use LABA by itself use w ICS
• Xolair for allergic patients, Mag sulfate in children.
• Bronchial thermoplasty very mild response

• Personal best!
• Green zone: 80-100%
• Yellow zone: 50-79%
• Red zone: <50%
• Start plan of action in yellow zone.

• Increases murmur of hypertrophic cardiomyopathy.
• Decreases most other murmurs.

• Risk of use of restraints increases.
• No decreased risk of aspiration.
• Do not improve nutritional status or quality of life in dementia patients.

• Should have visual acuity tested first.
• Exception is chemical burn where you irrigate for 30 minutes first.

Most common cause is genetics.

• • Due to destruction of pituitary gland
  • Loss of TSH
  • Results in low T₃/T₄, high TRH, low TSH

• Kava
• Caution alcohol use due to liver mechanism.

• • If unstable, cardioversion
  • If stable or chronic, rate control with calcium channel blockers or beta-blockers AND anticoagulate

• unknown cause
• incidence: lower in 1st month, increased at 2nd mo, peak at 3-4 mos, usually no chance after 6 mos
• seasonal variability

• -goal is to achieve 10-15% reduction in BP w/in the 1st 12-24 hours!!
• -lower if:
• --->BP is> 220-140mmHg (if NOT eligible for t-PA)
• --->BP is >180/105mmHg in pts. given t-PA
• --->evidence of aortic dissection or MI
• --->Pulmonary edema, hypertensive encephalopathy, or acute renal failure

Can happen in patients with myocardial damage after chemotherapy.

• Atherogenic dyslipidemia- High Trig + Low HDL
• Insulin resistance
• Elevated BP
• Obesity (waist circumference)

• Age
• Family Hx- Male <55 y/o, Female <65 y/o

• -DM
• -Atherosclerosis of non-coronary arteries- (low ABI, carotid bruits, TIA or ischemic stroke, aortic aneurysm)
• -CKD
• -Framingham risk score >20%

• Age, gender, TC, HDL, smoking status, systolic BP, diagnosis of HTN.
• It predicts 10 year risk of MI or cardiac death.

• OCP use in non-smokers
• HIV infected patients
• Dairy consumption
• Egg consumption <2/day
• Coffee consumption
• Serum K level
• Leptin level

• Early sx response education
• NTG SL use
• LDL <100
• HDL >40 (Niacin best alternative)
• Dietary restrictions (Low fat, low cholesterol, low trans fatty acids)
• Dietary supplements (Fiber, Omega 3 fatty acids)
• Weight loss (loss of 10% body weight)
• Exercise (30 min/day 5 d/wk)
• Smoking cessation
• BP control (Procardia should never be used for tx of HTN)
• ACE or ARB for STEMI patients
• B blockers for MI, ACS or systolic dysfunction
• ASA (75-162 mg)
• ASA + Plavix for 1 year in post PCI pt's
• ASA + Plavix + Warfarin if in addition the pt has a DVT.

• Multiple studies show no difference in rate of MI or death between revascularization and medical management.
• Decision to pursue intervention is dependent on sx, severity of ischemia on imaging, prognosis and an informed discussion.

• B blockers
• Long acting Ca channel blockers
• Nitrates (not better than B blockers or Ca++)
• Ranolazine (Ranexa) slight reduction
• Atorvastatin
• Magnesium supplementation
• Coenzyme Q10
• Chinese herbal medications (Shenshao tablets)
• Testosterone

• Does not offer cardioprotection.
• Use Carvedilol instead.

• Most patients graduate to HTN in less than 1 year.
• BP 120-139/80-89

• Dysfunctional urinary bladder due to lesion of central or peripheral nervous system.
• Causes: DM, MS, Spinal cord injury.
• Tx: DO NOT USE DETROL.
• A set schedule for urination is the treatment .

• More than 3 RBC/hpf.
• Up to 10% have malignancies.
• Need to do complete workup.
• US, Cytology and Cystoscopy.

Associated with occult colonic malignancies

The ability of the test to identify correctly those who do not have the disease.

FP/FP+TN

Proportion of diseased correctly identified as positive.

TP/(TP+FN)

The expected number of people who would have to receive a treatment to prevent an unfavorable outcome in one person; a small NNT indicates a more effective intervention.

NNT=1/ARR (or Absolute Rate Reduction)

Proportion of persons w/ negative test who do not have condition

NPV= d / (c+d)

Proportion who test positive with disease. Probability that a person that tests positive actually has the disease.

True positives / all those with a positive test result.

• C: concerned, cut down
• A: annoyed
• G: guilty
• E: eye-opener

Adapted to Include Drugs

Should be avoided in elderly due to risk of seizures.

• Adults- Cipro
• Children less than 12- Zithromax

There is no increase in CK levels.

Can have allergies to foods:

• Avocados
• Bananas
• Chestnuts
• Kiwi

• Decrease urinary Calcium
• Decrease risk in kidney stones

• Increase urinary Calcium
• Increased risk of kidney stones

• Self limiting immune response to unknown Ag causing necrosis and granulomas.
• No treatment needed.

• • • • assesses shoulder rotator cuff impingement or tear

• • • • abduct shoulder 90*

• • • • flex elbow90*, internally rotate to it's limit

• • • • pain indicates inflammation or tear

• • • • Rotator cuff: Supraspinatus, Infraspinatus, teres minor and subscapularis muscles.

IGRA-Interferon Gamma Release assay

• First choice INH for 9 mo
• 2nd Rifampin for 4 months

FEV1 low, FVC normal, FEV1/FVC ratio low

FEV1 low, FVC low, FEV1/FVC ratio normal

• 5A's
• Ask
• Advise
• Assess
• Assist
• Arrange

• Pulmonary rehab does not improve survival.
• Oxygen supplementation improves survival.
• Smoking cessation improves survival.

• Intermittent- B agonist prn
• Mild persistent- Add medium strength ICS
• Moderate persistent- Add LABA
• Severe persistent- Add LK or oral steroid

• LK is steroid sparring drug.
• Xolair for patients with severe allergic asthma.
• Systemic steroids work in 6-8 hours.
• Magnesium sulfate improves lung function.

• Use personal best.
• Green zone- >80% of personal best
• Yellow zone- 50-80% of personal best
• Red zone- <50% of personal best
• Start plan of action when in yellow zone.

• Apnea Hypopnea Index (AHI)
• Chicago criteria:
• Normal- AHI < 5 events per hour of sleep
• Mild OSA- AHI 5-15 events/ hr
• Moderate OSA- AHI 15-30 events/hr
• Severs OSA- AHI >30 events/hr

• Atherogenic dyslipidemia- High TG and Low HDL
• Insulin resistance
• Elevated BP
• Obesity (waist circumference)

• Age
• FHX on 1st degree relative M<55 y/o, F<65 y/o
• Smoking
• Elevated C reactive protein
• DM

• DM
• Atherosclerosis of non coronary vessels
• CKD
• Framingham score >20%
•       Framingham score predicts the 10 yr risk of cardiac death using the following; Age, gender, TC, BP, smoking status.

• Diet restrictions
• Low saturated fats <7%
• Cholesterol <200 mg/day
• Minimize trans fatty acids

• Supplements:
• Fiber 10 g/day
• Omega 3 fatty acids 1g/day

• Prehypertension- 120-139/80-89
• Stage I- 140-159/90-99
• Stage II- >160/100

Home BP readings correlate better to target organ damage and CV outcomes

• Dietary Approaches to stop hypertension
• Is low in salt, saturated fat, cholesterol and total fat.
• Emphasizes fruits, vegetables, and fat-free or low-fat milk and milk products.
• Includes whole grains, fish, poultry and nuts.
• Limits the amount of red meat, sweets, added sugars and sugar-containing beverages in your diet.
• Is rich in potassium, magnesium and calcium, as well as protein and fiber.

• OCP's increase BP
• HRT does NOT increase BP.

• Do not forget Chlorthalidone.
• Double the potency of HCTZ.
• Produces hypokalemia.

BMI= Weight/Height to the square

• Cyanosis
• Pulmonary ejection systolic murmur
• RVH
• Single Second Sound (Aortic)

• Systolic CHF- EF <40%
• Diastolic CHF- EF >50%

• Staging of CHF:
• A- At risk for HF but no structural damage
• B- Structural heart disease without CHF sx.
• C- Structural heart damage with prior or current CHF sx.
• D- Refractory CHF.

Dx BNP secreted more in ventricles with increased intraventricular pressure. Level over 100 is very sensitive for dx of CHF.

• Galactorrhea
• Cushing's

Treatment with Fosamax

• Age
• Caffeine 
• Female sex
• Late menarche
• Early menopause
• Cigarette smoking
• Family history
• Low BMI
• Steroid use
• Asian ethnicity
• Heavy alcohol use
• Whites more than blacks or hispanics

• Not to be used in creatinine over
• >1.5 in males
• >1.4 females.
• Creatinine clearance less than 70 ml/min

• Normal less than 100.
• >400 is usually CHF

• Dysuria, frequency, urgency, nocturia, dyspareunia, pelvic pain.
• Sx with negative urine culture, no genital infection sx, no radiation.
• Dx with cystoscopy.

• Increased:
•      Acidic environment
•      Ascorbic acid Vit C
• Decreased:
•      Antacids
•      Soy protein
•      Tea
•      Bran

4 days

• BMI >35 with medical conditions
• BMI >40 with associated medical conditions.

Alcohol abuse is a contraindication for bariatric surgery.

Transmitted by Lone Star Tick

Fresh water snails

Fleas

Torsades de pointes (V fib)

Hereditary hemochromatosis

• Classic triad is: Cutaneous hyper pigmentation
•                      Cirrhosis
•                      DM

Sea level PO2 less than 70

Epo levels are low  in primary cases

Liver and germ cell tumors

• Most common presentation:
•       Anemia (Iron deficiency) and Osteoporosis or Osteopenia
• Lab for diagnosis:
•       Endomysial antibody
• Diet intolerance to GLUTEN
• Diagnostic test: Xylose absorption test, biopsy of jejunum.

Adenosine

• Observation
• Antibiotics are contraindicated because they tend to prolong the carrier state.

Dopamine agonist

• Delta waves (Ski slope in QRS)
• Widened QRS
• Short PR interval
• Bradycardia
• Inverted T wave without reciprocal ST elevation.

Medications that can cause V Fib in these patients are: Digoxin and Verapamil.

HYDROXYUREA

• Bell's palsy there is weakness of the entire face.
• Supranuclear process the weakness is partial.

Parasitic infection of Ascariasis

Alpha antagonist like Clonidine

• Hypothyroidism
• Pulmonary toxicity (Pulmonary hypertension)

• • metabolic disorder
  • abnormally increased secretion of cortisol, caused by increased amounts of adrenocorticotropic hormone (ACTH) secreted by pituitary gland
  • Dx test: Dexamethasone suppression test

• Primary adrenal insufficiency
• hyperkalemia (>5),
• hyponatremic (131) b/c secreting K means losing Na + b/c ↓cortisol>> BP low >> SIADH secretion (↑water retention, losing Na/ dilutes Na concentration)
• hyperpigmentation
• Dx; ACTH (Cosyntropin) stimulation test

• "Mad cow disease" in humans
• Spongiform changes in brain
• Seizures
• FATAL

• Antithrombin III deficiency
• Protein C deficiency
• Protein S deficiency
• Factor V Leiden mutation
• Lupus anticoagulant
• Antiphospholipid syndrome

Glomerulonephritis with deafness

• Pancreatic cancer- CA 19-9
• Breast cancer- CA 15-3, 27-29
• Bladder cancer- NMP22
• Melanoma- S-100
• Testicular cancer- LDH
• Medullary carcinoma of thyroid- Calcitonin

• >15 in 25-48 hrs old
• >18 in 48-72 hrs old
• >20 in older than 72 hrs old.

Myopia

Type 1: distal tubules, can't excrete H+ (hypokalemia)

Type 2: proximal tubules, can't reabsorb HCO3- (hypokalemia)

Type 4: can't respond to aldosterone (hyperkalemia)

• UV B rays are the dangerous.
• PABA is used in sunscreens.
• Pt's with allergy to Thiazides, benzocaine and sulfonamides can react to PABA.

• Diazepam for neurologic symptoms.
• Phentolamine for arrhythmias.

• C = cardiac failure
• H = HTN
• A = Age >75 y/o
• D = Diabetes
• (Each 1 point)
• Stroke or TIA= 2 points
• More than 2 points you anticoagulate with Warfarin. Less than 2 points only ASA needed.
• determines risk of stroke
• Regardless of the approach, the need for anticoagulation is based on stroke risk and not on whether sinus rhythm is maintained.

Hypokalemia

• Calcium
• Magnesium

• Rate control is as effective as rhythm control.
• 10% EF improvement can be seen with rate control.

• Indication for AF.
• Direct thrombin inhibitor.
• Less variable anticoagulant effect.
• No antidote
• It is dialyzable. Renal metabolism, no hepatic metabolism.

• Indication for AF, DVT and PE.
• Factor Xa inhibitor

• MVP with or without murmur
• Bicuspid aortic valve
• GI/GU procedures

• Amoxicillin 2gm 30-60 min before procedure
• In Pen allergic patient is Cephalexin, Zithromax, Biaxin or Clindamycin.

• Pig valves- No
• Mechanical valves- Yes

• Austin flint murmur in diastole
• Heard in L sternal border

• Thrombolysis in MI risk score is used to risk stratify patients to help determine which should undergo aggressive treatment. Event rates increase significantly as the TIMI risk score increases. Each of the 7 risk factors is one point.
• Age >65
• > 3 CAD risk factors
• Known CAD
• ASA less than 7 days ago
• Recent angina
• Increased Troponin
• ST elevation

• Major:
• Carditis
• Polyarthritis
• Sydenham chorea
• Erythema marginatum (painless rash)
• Subcutaneous nodules

• Minor:
• Arthralgia
• Fever
• Elevated acute phase reactant
• Prolonged PR interval

• When non painful things become painful.
• Disorder of pain processing.
• Fibromyalgia

Few joints affected < than 5.

Polyarticular- many joints

• You can see morning stiffness
• Lasts 15 min v/s RA which lasts 1-2 hrs.

• Heberden nodules- DIP
• Bouchard nodules- PIP

Substance P depleter

• Malignant kidney tumor (Nephrobalstoma)
• Small round blue cell tumor of kidney of
•         1-5 y/o
• Presentation: flank mass + hematuria

• Likes to invade vessels
• Tx- surgery, chemo

• RA 80%
• SLE, Sjogren's
• Hep B and C
• SBE
• Lung disease

Anti-citrullinated protein antibody

• Most specific than RF
• Correlates with erosive arthritis.

• Earliest X Ray finding is periarticular osteopenia.
• Most common X Ray findings is articular joint erosions.

Cervical spine due to possibility of medullary cord compression.

• Methotrexate is the best drug. Adding folate decreases the toxicity.
• DMARD start early to reduce joint damage.
• Plaquenil- yearly retinal exam due to retinal toxicity.
• TNF- tumor necrosis factor inhibitors- may reactivate TB and risk of lymphoma

• More common in girls < 7 y/o
• Associated with + ANA and uveitis.
• RF + has worse prognosis

• RA
• Splenomegaly
• Granulocytopenia

Long term Penicillin G or Macrolide prevents recurrences.

• Most specific test is
•      Positive antibody against double stranded DNA. dsDNA
• Best treatment is Cell-cept since it is less toxic.

• Joint
• Eye
• GU inflammation

Asymmetric arthritis

Anti-Scl-70-topoisomerase antibody is highly specific.

• Can present with hip or knee pain when hip is moved.
• Hip osteochondritis with idiopathic avascular osteonecrosis.
• Young kids

• Fracture of the growth plate of head of the femur.
• Can present with knee and hip pain.
• Adolescents

Used for bone pain in Multiple Myeloma patients.

Will not look up due to neck pain.

• C5- weak biceps
• C7- weak triceps
• C8-T1- weak hand

Loss of pain and temperature sensation in back and arms.

Disc herniation- Decreased reflexes

Myelopathy- Increased reflexes

• L2- Decreased hip flexor strength
• L3- Decreased patellar reflex, weakness in quadriceps muscle
• L4- Pain in anterior leg
• L5- Weakness in anterior tibialis, great toe, and hip
• S1- Decreased Achilles tendon reflex

Always X Ray the low back due to high probability of lumbar fracture due to fall.

• 5th metatarsal fracture
• High degree of non-union without fixation.

• Entrapment of the tibial nerve.
• Dx with EMG.

• Can happen with Dexamethasone and Quinolones.
• Clinical diagnosis- Thompson test

If related to intra-articular condition fixing the condition will make the Baker's cyst get better.

• ACL- usually need surgery.
•         Lachman test +

PCL- no need for surgery

Epiphysitis of the tibial tubercle.

Risk factor is daily alcohol use > than 3 drinks per day.

• Barlow and Ortolani Maneuver
• Dx: Early with US, after 3 months X Ray.

90% are posterior.

Transverse proximal femoral shaft fracture

Most respond to conservative treatment.

Most are anterior

• Frequent delay in diagnosis
• Splint for 7-10 days then redo X Ray.
• If after that still pain then do CT, MRI or bone scan.
• Frequent non-unions.

Tear of the ulnar collateral ligament

Mallet is DIP

Boutonniere is PIP

Impaired by:

• Colchicine
• NSAID's
• Steroids

Lead kettle (Pb Kettle)

• Prostate
• Breast
• Kidney
• Thyroid
• Lung

Systemic Inflammatory Response Syndrome

• Temp <36 or >38.
• Heart rate >90
• Respiratory rate >20 or PCO2 <32
• WBC's <4,000 or >12,000 or >10% bands

In a diabetic patient BYETTA worsens gastroparesis.

Initial treatment is Insulin.

Every other oral medication will decrease A1c by 1 point each.

Average sugar= (HgbA1c -2) x 30.

• Every pregnant patient should have a Glucola test with 50gm of sugar.
• If abnormal then needs a 3 hr GTT.
• Abnormal results would be:
•      Fasting >95
•      1 hr >180
•      2 hrs >155
•      3 hrs >140
• Elevations in any two is abnormal

• C peptide levels are absent.
• Insulin usually split 50-50 between long acting and short acting.

• High glucose but no ketones.
• Is a precursor of DKA

Start replacing K when K is below 5.

• ADH
• Oxytocin

• Come from posterior pituitary.
• PAO

Excess ACTH.

Sx. weight gain, hypertension, DM, proximal muscle weakness, violaceous striae, acne and hirsutism

Adrenal insufficiency (WADAO- weak and dizzy all over)

• Sx:
• Weakness
• Fatigue
• Anorexia
• Abdominal pain
• Orthostatic hypotension
• Salt craving
• Hyperpigmentation of the skin

Low TSH and Low T4. Increased TRH

T4 main product of thyroid gland. Levothyroxine or T4 is the tretment of choice for hypothyroidism.

• T3 is the active hormone at the cellular level.
• T3 comes from the peripheral conversion of T4.

Stunted physical and mental growth due to congenital thyroid deficiency.

Iodine 123 is for diagnosis.

Iodine 131 is for treatment

PTU and Methimazole have high risk of agranulocytosis.

• If TSH is normal then do FNA then get thyroid scan. If cancer or microfollicular disease then surgical referral.
• If macrofollicular disease then follow exam and US.

Better to worse:

• Papillary
• Follicular
• Medullary
• Anaplastic- worse prognosis, does not produce thyroglobulin

Prostate- do not produce PSA

Thyroid- do not produce thyroglobulin.

Will require 25-30% more thyroid hormone in pregnancy after the first month.

Increased in GRAVES' disease, decreased in others.

Thiazides- decrease Calcium in urine and increase in blood.

Loop diuretics- increase Calcium in urine and decrease in blood. Used in kidney stones pts.

• Produced by hypoparathyroidism
• Vit D deficiency.

Produces QT prolongation.

• Thyrotoxicosis
• Vitamin D intoxication
• Adrenal insufficiency
• Milk alkali syndrome
• Thiazide diuretics
• Lithium
• Sarcoidosis
• TB

• PTH- Raises Ca+, Slight lowering of PO4.
• Vit D 1-25- Raises Ca+, Raises PO4.
• Calcitonin- Lowers Ca+, lowers PO4

Infection of the distal pulp space of a phalanx.

Parasitic infection from eating raw PORK, BEAR or WALRUS.

Tx with Antimonial compound

Most common ligament affected is

Anterior Talofibular Ligament.

Is not a risk factor for MI

• Small cell- SIADH secretion, Cushing's, Eaton Lambert.
• Squamous cell- Hypercalcemia
• Large cell- gynecomastia
• Adenocarcinoma- Clubbing, thrombophlebitis

R sided diverticuli are more likely to bleed than L sided.

L sided get more infected.

• Males
• 1st child
• Neonates
• Metabolic alkalosis
• Hypochloremia

• Gastrinoma
• Sx: severe PUD, diarrhea
• Tx: PPI, surgery

Associated with gastric polyps which are pre-malignant.

• Vit B12
• CBC and ferritin
• PTH and Calcium
• Vit D

Colonic pseudoobstruction- tx with colonoscopic decompression

Toxic megacolon- Colonoscopy contra-indicated.

Anti-HBSAg

Non Alcoholic Steatohepatitis

• Benign non alcoholic fatty liver
• Can lead to cirrhosis

No treatment

• Satellite lesions
• Involves genitocrural folds

• Spares the crural folds
• Do not use combination steroid and antifungal creams in neonates.

• Hyper IgE and eosinophilia
• Triad:
• 1. eczema (atopic dermatitis)
• 2. recurrent S. aureus abscess (biblical Job with boils)
• 3. course facial features, frontal bossing, doughy skin; 2 ROWS OF TEETH

Emollients- wet based creams

Pink scaly plaques

• Extensor surfaces of elbows and knees
• Base of scalp
• Peri-umbilical area
• Lower back
• Nail disease- more in psoriatic arthritis

• Benzoyl peroxide- most common
• Retin A-

Do not use both in the same treatment

Accutane- Tx of severe nodular or cystic acne.

• Avoid concurrent administration with;
•        Antacids
•        Iron
•        Dairy products

Associated with HPV types 6 and 11

Pathognomonic is the Fitzpatrick's sign

Explosive onset of seborrheic keratosis lesions is associated with underlying malignancies of the stomach, colon or breast.

ABCDEF

• Asymmetry
• Border irregularity
• Color variation
• Diameter
• Enlargement
• Family history

Most commonly in the shins of diabetic patients

Tx: Topical and intralesional steroids

ALL- 1st- Staph 2nd Group A Strep

EXTREMITIES- 1st- Strep 2nd Staph

MRSA- Tx Bactrim and if allergic Doxycycline or Clindamycin

• Avoid Bactrim in last trimester of pregnancy and children less than 2 months old.
• Avoid Tetracyclines in pregnancy and children less than 8 y/o.

• Strep infection
• Pharyngitis may precede rash.
• Usually in face and it looks like malar rash of SLE.
• Tx: PCN

• Intertriginous superficial bacterial infection
• Dx: Wood's lamp flouresces coral red
• Tx: Erythromycin po

• Most common bacterial infection in children.
• Staph aureus and Group A Strep

Tx: Bactroban, Keflex

• Pseudomonas infection
• Tx: Bactroban

• Tx can start as long as 72 hrs after appearance of lesion.
• Papules to grouped vesicles on an erythematous base.
• Tx: Acyclovir, Valtrex, Abreva cream

• Recommended exclusion from school for 5 days from start of rash.
• Prodrome 1-3 days with fever and malaise then the rash.
• Lesions in many stages. Clear teardrop vesicles.
• Tzanck smear shows multinucleated giant cells.
• Tx: within 24 hrs of rash shown to reduce sx.
• Post-herpetic neuralgia- Age is the biggest predictor.

• Recommended after age 60.
• Contraindication is pregnancy.
• To avoid reduce immune response give Zostavax and Pneumovax 4 weeks apart.

• DNA poxvirus
• Transmission is direct contact.
• Tx: Avoidance.
• Aldara cream works.

Etiology- HPV

• Callus do not contain black dots.
• Callus do not interrupt skin markings like warts do.
• Calluses are more painful on direct contact than lateral pressure and warts are more painful on lateral pressure than direct pressure.

• Very contagious
• Sx: Scalp pruritus, Scalp scaling, Alopecia, occipital adenopathy
• Tx: Grispeg

• Rash is a delayed hypersensitivity reaction.
• Tx: Elimite (Permethrine)

Kwell lotion has a blackbox warning due to severe neurotoxicity.

Removal of nits is not necessary to reduce spread or return to school.

• Post-partum- Telogen effluvium
• Post chemo tx- Anagen effluvium

Infections with Staph in nails.

• Tx: Acute- antibiotics
•       Chronic- topical steroids

Antibiotics have shown to not improve outcomes and should not delay surgery.

• Oral lesions (stomatitis) in children
• Caused by Coxsackie virus group A.

• Coxsackie virus A16.
• Tx: Supportive.

Can produce Persistent Pulmonary Hypertension of the newborn

Contraindicated in bulimia due to seizures

• Hyperprolactinemia producing galactorrhea.
• Gynecomastia.

Visual or tactile hallucinations

• I- Mental condition
• II- Trait condition (personality disorder or mental retardation)
• III- Medical comorbid condition
• IV- Psychosocial stressors
• V- Global assessment of function 1-100

Has SNRI properties so it should not be used in pt's on SSRI or SNRI because it can cause serotonin syndrome.

• Sx before age 7.
• Tx w Amphetamine decreases the risk of developing a substance abuse condition.

• Less than 70 is mental retardation if dx before age 18.
• IQ= (Mental age/Chronological age) x 100

• FMR-1 gene is the test for diagnosis.
• MR most common inherited cause.

Fluorescent in Situ Hybridization:

Test for identifying chromosomal and genetic abnormalities

• Most common inherited- Fragile X
• Most common chromosomal- Down's Syndrome
• Most preventable- Fetal Alcohol Syndrome

• Trisomy 21
• Macroglosia
• Iris white spots (Brushfield spots)
• Congenital hypothyroidism
• ASD, VSD

• Severe MR
• Deficiency in purine metabolism
• Increased in uric acid- sever gout
• Deficiency in B12

• Deficiency of hepatic enzyme phenylalanine hydroxylase.
• Diagnosed in neonates screening after 2nd day of life. Test has to be done after first feeding has occurred.

Facies: short palpabreal fissure, microcephaly, epicanthal folds, thin upper lip, short nose, micrognathia, ear abnormalities.

Abuse or neglect children

Pervasive Developmental Disorder PDD

• Highly genetic disorder
• Some recognized teratogens are:
•     Lead
•     Mercury
•     Thalidomide
•     Cytotec
•     Valproic acid

6 symptoms in 3 categories

• Social and communication problems before the age of 3.
• >2 social criteria
• >1 Communication criteria
• >1 behavior problem criteria

• MR
• Seizures
• Hamartomas or angiofibromas

Autism lite

• Type I-
• Type II- No cognitive or language delay.

• Normal development until 5 months of age.
• After that;
• Deceleration of head growth
• Loss of hand skills
• Loss of social engagement
• Poorly coordinated gait
• Psychomotor retardation

Only on girls because boys do not survive.

• Time- MDD > 2 mo
• Suicidal ideation- MDD often present, absent in bereavement.
• Emotional state- MDD- guilt, worthlessness
• Psychotic sx- MDD Sustained, transient in bereavement.
• Function is normal in bereavement.

Effexor and Cymbalta

• Use SSRI except Paxil which is Category D.
• Usually Prozac or Zoloft are the first choice.

• Depression does not need to be present.
• Bipolar I- Mania or mixed.
• Bipolar II- Hypomania

Can produce PCOS

Can produce Steven-Johnson's syndrome or TEN.

• Highest rate and highest completion is in
• ELDERLY.

Diagnosis:

• Exposure
• Re-experiencing
• Avoidance
• Arousal

Debriefing is contraindicated in PTSD.

You do not have to have obsessions and compulsions for the diagnosis.

Temporal lobe epilepsy

TRAP

• Tremor
• Rigidity
• Akinesia
• Postural instability

FEVER

• Fever
• Encephalopathy
• Vital sign instability
• Elevated CK
• Rigidity

Tx: Stop antipsychotic, IVF's, Dantrolene.

• Complications:
• Russel's sign- abrasion in knuckles from purging.

Hypokalemia, hyponatremia, hypomagnesemia, hypocalcemia, hypophosphatemia

Do dexa scan if amenorrheic for more than 3 months.

• Complement factor 3 is a sensitive measure of malnutrition
• Tx: Cognitive Behavioral Treatment. There are no medications approved by FDA.

Tx: Prozac.

• Precontemplation
• Contemplation
• Determination
• Action
• Maintenance with some relapses.

Randomized clinical trial

Assigns causality v/s association in an observational study.

• A- Consistent, good quality patient oriented evidence
• B- Inconsistent or limited quality evidence
• C- Consensus, usual practice, expert opinion.

Useful to study rare outcomes.

• People without disease are followed up to see if they develop the disease.
• Observational study.
• Two types: Prospective and retrospective.
• In prospective the exposure occurs now and then you observe for outcome later.
• In retrospective the exposure occurred time ago and you observe to see if the outcome occurred.

• Precision is how reliable the results are.
• Accuracy is how valid the results are.

They do not depend on the prevalence of the condition.

RR= Risk of exposed group/Risk of unexposed group

• Odds ratio= used in case control studies
•    Odds that case was exposed/odds that a control was exposed.

NNT= 1/ARR

The lower the number the better.

• Primary: Prevent disease from happening thus preventing its complications.
•     Immunizations, Fluorinated drinking water, diet, exercise, helmets, seatbelts, screening tests.

• Secondary: Aimed at early detection of the disease and preventing progression.
•      In DM checking BS, eye exam,HgbA1c.

• Tertiary: Disease is already present and you attempt to minimize complications.
•       In a pt with recent stroke is smoking cessation, daily aspirin, cholesterol control, rehabilitation.

Increased reticulocyte count

Cooley's anemia- severe microcytic anemia that need transfusions.

• Osteoporosis
• Dilated cardiomyopathy
• Delayed growth and development
• Hepatomegaly

• From pain in old homes made before 1970
• Produces microcytic anemia that is refractory to Iron supplementation.
• Lab finding- basophilic stippling

• Pernicious anemia- no Intrinsic factor
• Need to test for thyroid disease q 1-2 yrs.

Dilantin can produce it.

Prenatal have more Iron and folate.

• X linked disorder
• Men have it and women are carriers.
• Hemolysis.

• JAK-2- signal for normal cell growth
• Mutation of this gen produces proliferation

• Polycythemia vera- Tx Phlebotomy and  
•                Hydroxyurea
• ASA 81mg to prevent vascular complications.

• A- Factor 8
• B- Factor 9

Only men have disease, women are carriers.

• Affected is the synthesis in endothelium and megakaryocytes.
• PTT is not prolonged.

Migratory thrombophlebitis in a cancer patient.

• Thrombotic Thrombocytopenic Purpura
• Schistocytes

• Clinical findings:
• Fever
• Neurologic changes
• Renal impairement
• Hemolytic anemia
• Thrombocytopenia

Decreased antibody to ADAMTS-13.

• Protein S deficiency
• Protein C deficiency
• Antithrombin deficiency
• Factor V Leiden is the most common factor

D dimer when negative it rules out PE. It has a high negative predictive value.

A positive D dimer does not rule in a PE.

• Minimal change disease does not produce renal failure.
• It responds to steroids.

20%

• Fever
• Splinter hemorrhage
• New murmur

• Pre-renal- Most common of AKI
•                 BUN/Creatinine ratio >20
•                 Urine osmolality >500
•                 Urine specific gravity >1.020
•                 Urine sediment - Hyaline casts
•                 FENa- <1% (suggests preserved kidney function)

• Intra-renal- BUN/Creatinine ratio 10-20
•                   Urine specific gravity 1.01-1.02 
•                   Urine osmolality- 300-500
•                   Urine sediment- granular casts
•                   FENa- >1-2
• FENa is the fractional excretion of Na. It is low if the kidneys are still working.

Nephrotic range- 3-3.5 gm/day

• Males- Posterior urethral valves
• Females- Vesicoureteral reflux

• Workup: VCUG and US
• -Children under 5 y/o with UTI
• -Any child with UTI and fever
• -School aged children who have had two or more UTI's
• -Any boy with an UTI.

HSP- Henoch Schonlein Purpura

Increased anion gap metabolic acidosis

MUDPILES

• Methanol
• Uremia
• DKA
• Paraldehyde
• Isoniazid
• Lactic acidosis
• Ethylene glycol
• Salicylates

Is positive in condition of spinal cord causing sensory ataxia.

Is not a cerebellar function test.

• Upper- origin of nerve root
• Lower- innervate skeletal muscle cells

Lesions of upper motor neurons- Disinhibition produce spasticity, hyperreflexia, clonus

Lesions of lower motor neurons- Flaccidity and hyporeflexia.

• C5- Biceps
• C7- Triceps
• L3-4- Knee jerk
• L5- No reflex
• S1- Ankle reflex

• SO4- Superior oblique CN4
• LR6- Lateral rectus CN6
• Everything else CN3

• Sympathetic nervous system
• -Ptosis
• -Myosis
• -Anhydrosis

• Caused by:
• Cluster headaches
• Carotid artery dissection
• Posterior cerebral artery infarctions
• Pancoast lung tumor

Strong risk factor for MI and stroke.

Psychiatric comorbidities are much higher with migraine with aura.

Middle cerebral artery stroke- CONTRALATERAL

Brain stem- IPSILATERAL.

• Expressive- Broca's from medial insular cortex
• Receptive- Wernicke's- posterior temporal lobe

• Pontine lesions
• Heroin
• Pilocarpine

Conn's syndrome is primary hyperaldosteronism caused by an aldosterone-producing adenoma.

JC virus, a papovavirus. Most commonly seen as a complication of AIDS.

Factors 2, 7, 9, 10

• Angioedema
• Pregnancy
• Renal artery stenosis

Could have cross reaction with Thiazide diuretics.

• Bloody diarrhea
• Tx is supportive only
• If antibiotics are given you can produce HUS

Rowing because it is static exercise in which BP load is more significantly increased.

Done in all women over 65 y/o and all men over 70 y/o

• Staph aureus- Incubation 1-6 hrs
• Clostridium botulinum- canned foods
• Campylobacter jejuni- Incubation 2-4 days
• Enterohemorrhagic E. coli- produces bloody diarrhea and antibiotics should not be given due to HUS.

• A pt with high dose of levothyroxine and a low TSH.
• Higher risk of vertebral and hip fracture.

Limited internal rotation of the flexed hip

• DM
• Smoking
• Hypertension
• Hyperlipidemia

At least given for 5 days and discontinued when the INR has been at 2.0 for 24 hrs

• Skin condition with no treatment.
• Usually in patients with severe renal dysfunction on dialysis.
• A skin biopsy is diagnostic.

• The best predictor of Vancomycin efficacy is
• TROUGH SERUM CONCENTRATION.

• Infertility
• Increased risk of prostate cancer
• Increased sx of BPH
• Liver toxicity and tumor
• Worsening of sleep apnea
• Heart failure
• Gynecomastia
• Skin diseases

Transmission disturbance on the output side. Pt understands the task but cannot do it immediately and can do it with a delay.

Inability to recognize previously familiar sensory inputs.

Glaucoma- pain

Retinal detachment- painless

(HgbA1c-2)x 30

Needs to be discontinued in patients with gastroparesis

PE

Hashimoto's- Hypothyroidism and TSH receptor blocking antibodies

Graves- Hyperthyroidism and TSH receptor site antibodies.

Indicated in patients with severe osteoporosis with failure to biphosphonates.

Best initial therapy is Methotrexate.

Patient behaviors that may occur when pain is under-treated. It is distinguished from addiction because the behaviors disappear when the pain is effectively treated.

An exaggerated response to tactile stimuli by the CNS

Treatment of sustained ventricular tachyarrhythmias in patients with poor hemodynamic stability.

Perioperative period of cardiac surgery.

AF in symptomatic patients.

• Normal 6-12
• Pulmonary edema- More than 20