Basic books

Basic books: -
All India Pevious years' solved papers by Mudit Khanna - AIIMS solved papers by Amit and Ashish - Tehalaka by Dr. Rajesh Prasad (it contains solved mcqs of anatomy, physiology, biochemistry and forensic medicine)...Must read book according to me - Sure Success By Ramgopal - Chauthary For PGI (not that useful for all india)

These are the basic mcq books that should be done thoroughly. If u done with them, than you can do salgunan. In my opinion, this book is not necessary for all india. atleast i didnt read it Regardless of what i write here, you must follow your own plan according to your strengths and weaknesses. Spend more time on the subjects in which you are weak. This is the kkey to success. You have to identify which subjects made you suffer during your profs or during your previous attempt(s). Its always a good idea to finish them first. You can follow any order in doing subjects as u like. Try to finish all subjects atleast2-3 months beforte the main exam so that you can have adequate time to give the revisions. For each subject, you have to do the previous years' questions(AIIMS and All India), corresponding theory book and Ramgopal sure success. I also would recommend to keep Harrison alongside as a referance while doing any subject. It will always come handy. I also recommend you to take a small notebook and start taking notes of difficult to remember points, some important flow charts and tables. These come really handy for last day revision before the exam. You have to make sure that you don get too carried away with writing more and more as it will just waste your time and you may not be able to revise the whole things in one day before the exam. You ma do it subjectwise (if u have the patience)...or you can just write the points randomly (just like me).

Anatomy:
This is the subject i never did all through my preparation! Indeed it seems too much for an effort to read through all volumes of chaurasiya and still not able to solve the mcqs. Recommended Books: Chaurasiya (all 3 volumes), Sure success by Ramgopal(big book), Tehalaka by Dr. Rajesh Prasad(for mcqs) if u ae short on time, i would suggest to read the anatomy pages from ramgopal's book and do mcqs from tehalaka...this way you should be able to answer more than half the questions from anatomy, which according to my opinion is quite good. you should concentrate on nerve injuries, nerve entrapment syndromes, muscles nerve supply and actions(especially upper limb), various type of joints(asked many times!), various fossa and there contents and cranial nerves. anyway one should not be spending too much of time on anatomy as itsa low yielding subject.

Physiology:
Recommended books: Ganong (very good book), Guyton (only for referance), Tehalaka. Here tehalaka comes in very handy. if you read all the mcqs with explaination from this, you would be able to solve majority of the common questions from physiology. supplement it with ganong with selected reading with special emphasis on general physiology topics Biochemistry: Recommonded books: Harper, Tehalaka, lippincott (as an alternative) lot of people will say that lippincott is very good, but i never found it that good. I would recommend reading Harper. The newer editions of Harper have been progressively trimmed, so it should not take more that 10 days to read on the first go. Topics that should be stressed are genetics(obviously!), chapters at the beginning(like enzymes, amino acids and some general chapters), regarding metabolism, it would certainly help, if you take notes of some important points on a note book for quick revision before exam. It will certainly help.. Tehalaka is nice for revising the facts quickly

Forensic Medicine:
Recommended books: Pareikh, Tehalaka, forensic SARP Here again Tehalaka comes in very handy. you can solve most of the mcqs from this book. Also forensic SARP is not bad at all for poisonings (especially do lead, mercuary, arsenic and others commonly asked). I would suggest you to make small notes of important features of common poisonings for quick revision later on. From Pareikh, do only selected reading. Always spend some time on ballistics...they need to be understood properly to solve the related mcqs.

Pathology:
Recommended books: Robbins(big) This is the only book thats needed...and of course, i am not including harrison, because i persume that you keep it alongside for referance while doning any subject. This in my opinion is the most important subject(even more than medicine, surgery). If u have good grasp of pathology, it would certainly go a long way to improve your chances in PG exams. I recommend you to read this book thoroughly with more emphasis on blood, GIT, kidney and general pathology...things that you can probably skip or do selectively are: CNS, Musculoskeletal system and other chapters towards the end of the book. I you have read this book during your prof, it would certainly help.

Pharmacology:
Recommended books: Tripathi, Katzung (Referance), Goodman & Gilman (only for referance, not at all essential!), Tumors SARP Agian this is a very important and productive subject. In tripathi, more stress should be on ANS and CVS. Tumors SARP is also quite good...just to be read selectively

Microbiology:
Recommended books: Ananthnarayan(very good book), jawetz(review), chatterjee(parsitology), SARP microbiology Jawetz (review, not the text book) i recommend for reading the immunology part. it will help you understand the basics of immunology in a very easy manner. For rest, Ananthnarayan is good enough...special emphasis should be on general microbiology. Virology can be done selectively like doing common ones like hepatitis, rabies, AIDS, rota virus, polio and from parts you see the questions...never forget to do general virology. Bacteriology has be done thoroughly in my view. For mycology, ananthnarayan is good. you may also look at SARP for mycology. For parasitology, although chatterjee is the recommended book but it consumes much of time..i would suggest just reading it from jawetz and doing mcqs. that should be enough for only 1-2 quesions are asked from parasitology.

SPM:
Recommended books: Park (what else!), High yield biostats by tyagi or Mahajan SPM is the subject thats often said to decide matters. If prepared properly, it can be quite scoring subject as well ...as hardly anything is asked outside Park. Important topics are first 116 (or something like that) pages. I mean up to the chapter about screening. Learn all the concepts properly. this will help you solve more than half the mcqs of SPM. Diseases should be done selectively. Do the more important diseases like tuberculosis, polio, leprosy, rabies, AIDS, syphilis, respiratory infections, rickettsial diseases, dengue, yellow fever(who cares it doesn’t occur in India!), diptheria and as you see the questions. From the remaining chapters, you should do environment and health chapter, contraceptives, health and nutrition and disease control programmes, health goals and about the health workers and their population allocations....rest can be done selectively. Biostats you can do from high yield biostats. Its quite good. and you can do it in just one day. Nowadays some questions may even be out of that book. Ypu can also do Mahajan for biostats. Its better but consumes more time

Eye:
Recommended books: Khurana, kaski (referance), parson(referance) Khurana will do for most of the questions. for some really hard questions, kanski comes in handy . important topics are... Cataracts, ocular injuries, uveitis, corneal ulcer, refractive errors, tumors(retinoblastoma, melanoma), retinitis pigmentosa, optic atrophy, papiloedema, chalazion.

ENT:
Recommended books: Dhingra Nothing much to say. Dhingra will do for most of the questions. read selectively. more impotant topics acoustic neuroma, facial nerve course and palsy, otosclerosis, CSOM and its complications, layrngeal polps, nodules and cancer, DNS, sinusitis, epistaxis, abscess in reation to pharynx, tonsils.

Paediatrics:
Recommended books: Ghai, Nelson(referance) Sometimes questions seem to be set from nelson and ghai seems to be insufficient. while thats true, but thats not a reason to read nelson. you cant gain much by reading nelson(its too huge a book). rather reading some selected topics may be useful. In Ghai, more stress should be on nenatology part, also CVS in quite good. also dont forget metabolic diseases and genetic diseases. Use nelson for refreance purpose as and when required. If u can spare some time, try to read the kidney part..that is cysts, dysplasias and vesicoureteric reflux.

Gynae and Obs:
Recommended books: Shaw(Gynae) and Dutta(Obs.) Both very good books. in gynae, more stress should be on oncology, endometriosis, menstural disorders, infertility, fibroids. In Obs., do all the tables and flow charts. that makes it very easy to understand and most of the questions can be solved quite easily. And dont forget chapter of population dynamics and birth control.

Surgery:
Recommended books: Bailey & Love, Sabiston pretest, Schwartz (reference) Bailey has to be done selectively according to the topics from which mcqs appear. More stress should be on GIT and genitourinary system. Schwartz can be useful for referance especially in GIT

Medicine:
Recommended books: HARRISON or CMDT(depending upon what u have already read), Harrison pretest, Medicine self assessment guide by Amit Ashish Both books are good. Do the one that you have read during your profs. If u read Davidson during profs, i would suggest to do important topics from CMDT and less important topics from Davidson. As for Harrison, if u have read during your profs, it would certainly give you an edge.

Some high yielding topics in Harrison are: CVS, Kidney(especially glomerulonephritis, renal failure), acid base imbalance, Hematology, Genetics, Viral Hepatitis.

Important thing is not to get lost in reading medicine alone. Its huge subject and will never finish. So do selectively. Keep more stress on previous years' papers and the topics asked there. Medicine self assessment guide by Amit Ashish come handy for reading selectively from Harrison in retrograde manner

Skin:
Harrison, Sure Success Ramgopal, Roxberg (referance) Harisson and previous years, mcqs will do for most of the questions. Do it from sure success(ramgopal) also. Roxberg has to be used for referance as and when needed. Anaesthesia: Sure Success Ramgopal, Lee(referance), Yadav Nothing much to say. Mainly concentrate on previous years, questions. Yadav is said to be very good. But personally I never read it.

Ortho:
maheshwari This is the only book you should do. even though these days some questions are asked which have referances from PG level books. You are not expected to answer that. Remember you don’t need to score 100%. A score of around 65% actually will give you a very good rank

Psychiatry:
Sure Success Ramgopal, Ahuja, High yield psychiatry. Concentrate on schezophrenia, mood disorders, substance abuse, sleep cycle and disorders, autistc disorder Radiology : No books needed here in my opinion. Just do previous years, mcqs and also do from Sure Success Ramgopal.

Time to spend on each subject: It depends upon how strong(or weak) you are in a particular subject. also you have to spend less time on subjects from which less questions area asked. anyway, i will try to give a rough idea...
Anatomy-3days(will mainly do questions from Tehalka)
Physio- 5 days Biochemistry-10days
Forensic- 2days Patho- 30days P
harma- 10days Micro- 10days Eye-7days
ENT- 5days
SPM- 20days
Gynae & Obs.- 20days
Medicine-30days
Surgery-20days Paeds- 7 days
SARP- 5 days
Ortho- 5daysThis roughly comes out to be a little more than 6months.
You may take some more or some less time depending upon your level of preparation. Its very important not to get stuck at one subject for too long.Best of luck all of you my friends

PUBLIC HEALTH

PUBLIC HEALTH
1. Levels of Prevention: 1o = actions to decr. incidence of health problems (prenatal care, immunizations)
2. 2o = interventions at early stage of disease to limit development (DM screen, PAP)
3. 3o = interventions to treat problem and prevent further morbidity & mortality

4. Special Tests Complement & Complement disorders C3, C4, CH50
5. Rheumatiod - ANA, RF
6. Lupus - DNA, Anti Smith Antibody
7. Scleroderma - Scl-70, Anti Centromere
8. Sjogrens -SSA Anti Ro, Anti LA
9. Prostate = PSA, Pancreatic = CA 19-9,Ovarian=CA125; Breast = CA15-3 & CA27-29
10. Testiclar = BHCG, AFP, Thyroid = Calcitonin
11. 10 Biliary Cirrhosis = Anti mitochondrial antibody
12. Wilson's Disease = Ceroluplasmin Antibody
13. Liver = Alpha 1 antitrypsin
14. Thyroid - Antimicrosomal antibody, Thyroglobin antibody
15. Incidence # new cases / total population
16. Prevalence # cases at a given time / total pop at that time
17. Disease Frequency # people w/ disease / population at risk
18. Case Fatality # who die in a given period/ # people w/ disease

19. Relative Risk Only from cohort study; a/a+b divided by c/c+d; >1 positive assoc, < association ="=""> disease if exposed /disease if not exposed

20. Odds Ratio Only from case control; odds of getting if exposed / odds of getting if not exposed (ad/bc)

21. Mortality Rate # people that die w/ in current population
22. Std Mortality Rate Adjusted according to age distribution
23. Attributable Risk exposed rate - unexposed rate
24. Sensitivity a/a+c; accurate diagnose ; incr. False +
25. Specificity d/b+d; Prob of neg test in those truly neg; incr. false neg
26. OMM
27. Fryettes Laws 1. Side bending then rotation in neutral position
1. Flexion or extension with rotation then side bending
2. Motion free in one direction is restricted in the other

28. Ribs 1-5 pump handle, 6-10 bucket handle, 11-12 caliper; Elevated = expiration restricted Treat lower ribs 1st; Depressed = inhalation restriction, treat upper ribs 1st

29. Flexion Test Standing = ilia sacral; Seated = sacroiliac; false neg = tight hamstrings on standing flexion; False positive = tight quads on standing flexion

30. Sympathetic Innervations Head & Neck = T1-4; Lung T2-5 bilat; Heart T2-5 Left, Stomach T5-9 Left; Duodenum T10 rt; Gall Bladder T9 rt; Liver T5-9 Rt, Pancreas T6-9 bilat, Kidneys, Ovaries, Testes T10-L1 of respective side; Adrenals T10-11, Appendix T11-12 Rt, Bladder L3-4, Uterus L4-5, Rectum & Anus L4-5

31. Parasympathetic Innervations Eyes=CN III; Nasal sinuses, Eustachian Tube=CN VII; Soft Palate, Salivary Glands=CN IX; Thyroid thru Transverse Colon=CN X (Vagus); Right Colon & Pelvis= Pelvic Splanchnic Nerves S2-4

32. Somatic Dysfunction An altered or impaired function of related components of the somatic system
33. Qualities: Texture chg, asymmetry, decr. ROM, tenderness

34. Treatment Types Direct = engages restricted barrier & pushes thru it, Force takes it from where it is to where it will not go
35. Indirect = Move away from the barrier, Leaves the structure in the position it was

36. Direct Technique Used For: Subacute or chronic, no assoc osseous pathology post closure of epiphyseal plate, Short restrictors

37. Indirect Technique Used For Acute, A lot of pain, a lot of restriction, non closure of epiphysis

38. HVLA Contraindications
39. Direct, Passive Absolute = Weak bony structure, spinal cord, nerve compressions, Danger of vascular damage;
40. Relative: lax ligament, acute inflammation, pregnancy, Calcification of aorta, Recent MI, spondylosis, Ankylosin Spondylitis, Osteoporosis, Chronic Steroid use, Acute disk disease, Extreme scoliosis, Cauda Equina Syndrome, Adv. Degenerative disease, Severe DM, Hx or current malignancy, Agenesis Odontoid process, Vertigo

41. Counter Strain
42. Passive Indirect Put joint into position of greatest comfort; Agonist-Antagonist pair; Strain due to rapid stretching followed by protective immediate shortening of agonist along with rapid shortening then lengthening of antagonist
43. Most comfort of pt (70%) Hold for 90 sec (120 secs for ribs) Reactions to Tx: generalized soreness, treat no more than 6 TP at a time, 3 days between Tx;

44. Muscle Energy
45. (Active then passive, direct) Type I = Joint mobilization using direct muscle force
46. Type II = Muscle lengthening using postisometric relaxation, "Resetting the Gamma Gap or Synaptic Fatigue
47. Type III = Muscle lengthening using Reciprocal Inhibition
48. Type IV = Muscle relaxation using Crossed Extensor Reflex - Used w/ sever injury (flexor muscle on one extremity is contracted the flexor on opposite extremity relaxes & extensor contracts)

49. Natural Body Rhythms Cardiac/Vascular, Ventilatory, Visceral, Cranial Rhythmic Impulse (CRI), Slow Undulating (Breath of life)

50. Articular Mobility of Cranial Bones Newborn: Base is cartilage for stability, vault is membrane for accommodation Sphenoid motion - influences facial & frontal bones; Occipital Motion - influences temporals (mandible & hyoid) & parietals

51. Motion of Sacrum between the Ilium Superior transverse axis, Located at S2, Only area of anterior convergence & posterior divergence of the SI joint

52. Coordination of motion Inhalation = midline flex, paired ext rotate, sacral base post, SBS rises
53. Exhalation = midline extension, paired int. rotation, sacral base anterior SBS falls
54. Sacrum & Temporal follow movement of occiput; Facial bones follow motion of sphenoid

55. Strain Patterns Torsion, Side bending rotation, Vertical Strain, Lateral Strain, Compression

56. Naming Convention Vert unit, AP, side bending, rotation

57. Type of Motion C0-C1 (OA) Type I; C1-C2 Rotation; C2-C7 Type II; C7-L5 Type I & II

58. ACID BASE
59. pH acedemia < 7.35-7.45 < alkalemia
60. pCO2 Resp alkalosis < 35 - 45 < Resp acidosis
61. HCO3 Metabolic Acidosis < 22-26 < Metabolic alkalosis
62. Anion Gap = (NA) - [(Cl) + (HCO3)]
63. Primary disorder pCO2 or HCO3 altered same way as pH

POISONING & ACCIDENTS

POISONING & ACCIDENTS
1. Burns 1st= only epidermis, red no blister; 2nd = hyperemic, blister; partial thickness; 3rd = full thickness, leathery no pain; 4th = electrical injuries, damage to nerves & bone; entry & exit burn; Fluid resc. If > 20% Parkland formula = 3-4 ml/kg LR x % burn RULE of 9's: head = 9; ant trunk= 18 post trunk = 18, each incr. ext = 9; each decr. ext = 18, Perineum = 1

2. Common Poisons & Antidotes: Aspirin = Dialysis; Acetaminophen =N-acetylcystine; Digitalis = lidocaine; Methanol & Ethylene Glycol = Ethanol; CO = O2; Narcotics = Narcan, Naloxone; Iron = Deferoxamine; Cu, As, Pb = Penicillamine; Cyanide = Sodium nitrite, or sodium thiosulfate

3. Types of Fx Open(compound); Simple(closed); Greenstick (incomplete, children usually); Spiral (twisting breakage); Comminuted (multi bone fragments)

4. Vertebral Fx Most common cause of paraplegia & quadriplegia, Compression Fx seen in elderly due to osteoporosis & DJD

5. Hip Fx Avascular necrosis of femoral head if blood flow is compromised; Tx: immobilization, bedrest, surgery; Prevention= safety & Ca supplement in women

6. Skull Fx Signs of Fx: 1.Battle's Sign = discoloration over mastoid bone; 2. Blood draining from ears, 3. Bruising of orbit, CN palsies, CSF leakage from ears & nose

7. Rib Fx Most common thoracic injury; usually 5-9, local pain worse w/ inspiration

8. Colles Fx most common wrist fx; breakage & displacement of distal radius, Attempted to break fall on outstretched hand

9. Elbow Fx <10 care =""> Volkman's Ischemic Contracture

10. Pelvic Fx MVA, 30% blood volume can be lost; Tx as if shock victim

11. Tibial Fx Compartment syndrome= bleeding into tight compartments=> blood supply compression=>muscle ischemia; 6 Ps = pain, pallor, pulselessness, puffiness, parathesia & paresis (weakness) or paralysis. Surgical opening of compartment

12. Sprains Tx = RICE => Rest, Ice, Compression, Elevation

13. Concussion transient loss of consciousness; Coup = bruising under site of injury; Contrecoup = bruising on side contralateral to injury

14. Blunt Eye Trauma periorbital echymosis, hyphema (bleed into anterior chamber; edema; Blowout Fx = Fx of orbital bone; Aspirin & anticholinergics are contraindicated

15. Blunt Ear Trauma Auricular Hematoma (cauliflower ear) Tx prompt drainage to prevent dissolution of cartilage

16. Dog & Cat Bites Pasturella multocida; Tx tetanus & rabies if needed, antibiotics

17. Snake Bite Splint affected area & transport; In US usually pit vipers

18. Spider Bite Black Widow: Vomiting, abd pain, shock; Tx Calcium gluconate & methocarbamol; Local bite Tx not needed
19. Brown Recluse: bite becomes black scab w/ assoc fever, rash, vomiting & jaundice; DIC can occur; Tx: Dexamethasone, dapsone, colchcine & total excision of lesion

20. Hypovolemic Shock Hemorrhage, Burns, Vomiting, Diarrhea; pale skin, JVD, incr. vasc resistance, incr. pulse Tx: rehydrate, transfusions,

21. Septic Shock Infection, gangrene, necrosis,CV obstruction; pale/pink skin; flat neck veins, incr. pulse incr. or decr. vascular resistance Tx ventilation, Fluids, antibiotics

22. Cardiogenic Shock Pale skin, flat neck veins, incr. pulse, incr. vascular resistance; Tx: medication for underlying problem, pacemaker,

23. Neurogenic Shock Spinal cord injuries, drug OD; Pink skin, flat neck veins, normal => low pulse, low vascular resistance Tx: ventilation, fluids, drainage

PEDIATRICS

PSYCHIATRY
1. Axis Determination I = clinical psych disorders II personality disorders, III Coexisting medical conditions IV psychosocial stressors, V global assessment of functioning

2. Schizophrenia Positive Sx: delusions, hallucinations, bizarre behavior; Negative Sx: alteration of affect, ambivalence, apathy, loosening of associations; males=females; industrial nations have incr. prevalence; Misalignment of cells in cortex; incr. ventricle size; decr. activity in frontal cortex on PET scan.
3. Disorganized: insidious, incoherent, inappropriate affect, social impaired
4. Catatonic: rigidity, posturing or excitement, negativism
5. Paranoid: highest functioning type, grandiose, jealous, persecution
6. Undifferentiated: not defined by other subtypes
7. Melerill = Retrograde ejaculation, Tx: Respiradol (Best side effect profile), Clozaril (agranulocytosis w/ weekly CBC) prescribed weekly,
8. Neurolyptic Malignant Syndrome = incr. temp, incr. CPK, rigidity

9. Schizophrenifrom same sx as schizophrenia but have lasted for less than 6 months

10. Schizoaffective mood disorder and separate psychotic sx. Must experience 2 weeks of psychotic sx w/o mood impairment for dx to be made; Antidepressants are 1st line tx

11. Major Depression loss of interest in activities, sleep, wt, concentration, hopelessness, suicidal ideation, nihilism; Seasonal affective, Vegetative (non functioning can be terminal) Dysthymia(chronic low level); Reactive related to environment w/o severity id sx; Masked 1o depression denied or hidden by other sx
12. Depression & anxiety can occur together & can be treated w/ an antidepressent; Left anterior or rt posterior stroke => incr. possibility of depression; Tx: 1st Tricyclic (Imiprimine); SSRI = side effects; Trazadone=priapism Asendin (Amoxipine) = Extrapyramidal Symptoms

13. BiPolar Bimodal peak 20's & 30'sCycling mood= highs w/ euphoria, hyperactive, pressured speech, flight of ideas, decr need for sleep, delusions, inflated self esteem, risks, poor judgement; Lows are major depressive episodes tx: lithium

14. Panic Attacks Sudden, unprovoked onset of fear, impending doom, palpitations, SOB, chest pain, smothering, dizziness. May be associated w/ agoraphobia Tx: with SSRI's

15. Phobias Persistent and irrational fear of a specific object or activity or situation. Tx like a phobia

16. Obsessive Compulsive Persistent, unwanted thoughts, impulses or images
17. repetitive, purposeful intentional behaviors meant to decrease tension caused by the obsessive thoughts; genetic Tx: Anafranil (Tricyclic) Prozac & Luvox (SSRI)

18. PTSD intrusive recollections, daydreams, nightmares, poor concentration, psychic numbing; Tx: don't treat w/ meds unless compulsion component
19. Studies: Buffalo Creek Disaster, Beverly Hills Nightclub

20. Dissociative Disorder Amnesia = loss of memory, Fugue = assoc w/ physical flight, Identity Disorder = multiple ego states; Depersonalization = feelings of self estrangement or unreality

21. Whirndingo Fear of becoming a cannibal

22. Amok sudden unprovoked outburst of wild rage usually ending in homicide

23. Coprolalia Feces & filth

24. Koro penis is shrinking and may disappear

25. Latah imitate words or actions to which they are exposed

26. Piblotko Run around in snow naked

27. White Out Syndrome lack of diverse stimuli in snow clad environment

28. Narcolepsy REM sleep, sudden onset of daytime sleep and cataplexy; REM sleep is inappropriately present at beginning

29. Personality Disorders Cluster A = Bizarre = Paranoid, Schizoid (no close relationships, restricted emotions) Schizotypical (schizoid + odd or distorted behavior or cognition)
30. Cluster B = Over emotional = Antisocial (Disregard for social norms) Borderline, Histrionic, Narcissistic (self centered)
31. Cluster C = Anxiety & Fear = avoidant, dependent, Obsessive compulsive

GYNECOLOGY

GYNECOLOGY
1. Trichomonas Vaginitis Yellow green discharge, Strawberry patches, Motile flagellated, Tx: Metronidazole

2. Gardenerella Vaginitis KOH whiff test = fish; Clue cells, most common symptomatic infection; Metronidazole

3. Condyloma Acuminata Warts, HPV 6, 11, Not assoc w/ cervical cancer

4. PID Cervical motion tenderness, Purulent discharge, assoc w/ ectopic pregnancy & infertility; Leukocytosis, neutrophilia, incr. ESR

5. Candida cottage cheese, red vulva; Pseudohypahe & spores on wet mount, DM, antibiotics, OC, pregnancy

6. UTI E coli, Dysuria, frequency, urgency; Tx: TMP-SMX, Bactrim, Septra

7. Toxic Shock Syndrome Staph aureus exotoxin, rash, high fever, hypotensive shock

8. Chancroid H. Ducreyi, tropical & sub tropical climates, gram neg; Tx Emycin or Ceftriaxne

9. Chlamydia Trachomatis Intracellular, columnar epithelium, mucopurulent, Immunofluoresent discharge, Tx: Doxycycline (Emycine if pregnant)

10. Herpes Genitalis HSV II clear sores , multinucleated giant cells w/ intracell inclusions; Tzanck smear

11. Molluscum Contagiosum umbilicated nodule, remove & cauterize

12. Endometriosis Ectopic endometrium tissue, Dysmenorrhea, Dyspareunia, infertility

13. Paget's Disease of Breast Intraductal Ca in main excretory ducts; crusting erosion of nipples w/ or w/o discharge

14. Polycystic Ovarian Disease incr. LH, decr. or normal FSH; hirsutism, obesity, menstrual irregularities, infertility

15. Menopause Avg age =51; incr. FSH & LH; Hot flashes, Atrophic vaginal epithelium

16. Urinary Incontinence Stress = incr. intra abd pressure, leak small amts of urine; Kegel exercises, estrogen
17. Urge = detrussor instability; lg amts of urine leaked immediately after urge to void

18. 1o Amenorrhea Absence age 16 w/ 2o sex development or absence by age 14 w/o 2o characteristics
19. Anatomic Abnormalities; Ovary Failure ( incr. FSH & LH, decr. estradiol) (XO, turners, no ovary); Pituitary = Prolactinoma presents w/ galactorrhea (Bromocriptine to Tx), Hypothalamic = decr. FSH & LH, (anorexia, incr. exercise, stress); XY karotype

20. 2o Amenorrhea Absence for 6 mos if prev normal; absence for 12 months if prev oligomenorrhea; r/o pregnancy; Galactorrhea = prolactinoma; Hirsutism = polycystic ovarian; Tx: 1st = progestin challenge (bleed w/ in 2 wks) if no bleed measure FSH levels

21. 1o Dysmenorrhea correlates w/ 1st day of menses, cyclic, begins in adolescence, low back & abd pain, N/V/D, fatigue, HA

22. 2o Dysmenorrhea acquired, Sx don't correlate w/ 1st day of cycle, Endometriosis most common cause

23. Asherman's Syndrome intrauterine adhesions after D&C; destruction of endometrium => amenorrhea

24. Fibroademoma Age 19 -29, stromal fibrosis; nontender, estrogen sensitive, regress w/ menopause

25. Fibrocystic Breast Disease Age 29 - 39, may have green nipple discharge; tender w/ ovulation, regress w/ pregnancy,

26. Breast Disease Age 39-49 malignant = intraductal Ca (bloody nipple discharge); Papillary #1 cause of nipple discharge; Sclerosing Adenitis

27. Breast Ca Upper outer quadrant, Mets = bone, liver, lung, brain; Risks: Family Hx, menarche <> 35; late menopause, null parity, obesity, other breast, radiation, reserpine

28. PAP Smear Atypia = inflamm, infection HPV (16 & 1 ; Mild Dysplasia = lowgrade epithelial lesion; Mod/Severe=high grade intraepithelial;

29. Carcinoma in situ incr. nuclear/cytoplasm, dense chromatin, crowding, incr. mitosis; Koilocytes = HPV, pyknotic nucleus, perinuclear halo; Risks: early sex, multi partners, smoking, decr. social class, HPV; Culposcopy = white epithelium, mosiacism, punctation, atypical vessels

30. Cervical CA 90% squamous cell; s/sx: Early = postcoital bleeding, intermenstral bleed, Late= backache, leg pain, edema, hematuria Tx: Ia=TAH, iB & IIA = rad hysto & pelvic lymph nodes, IIB -IVA = Radiation - Brachytherapy => Radium, Cesium

31. Endometrium CA most common gyn malignancy; Risks: obesity, DM, HTN, anovulation, early menses, later menopause, nullparous, unopposed estrogen; Dx : abnormal menses, post menopausal bleeding; EMB, D&C; Histologic= grade 1-3 based on differentiation;
32. AdenoCA=70%; Adenocanthoma=benign squamous, best prog; adenosquamous= malig squam, poor prog; Papillary Serous = acts like ovarian CA, Clear Cell = poorest prog, older, DES, least common Tx; TAH/BSO, perioneal wash, pelvic & aortic nodes, Adjuvant Rad if + nodes, cervical +, > ½ myometrium, higrade

33. Ovarian CA Abd./pelvic mass, ascites, early satiety, CA125, CEA, CA19-9, 75% w/ stage 3; Path types = Serous (psammoma bodies), Mucinous, Endometroid, Clear Cell (hobnail bodies) Brenner; Staging: 1A= 1 ovary, 1B = both ovaries; 1C= + wash, tumor rupture; IIA = fall tubes/uterus, IIB other pelvic structures, IIB + wash rupture w/ spread; IIIA gros in pelvis, micro to diaphragm or omentum, IIIB Intra abd <> 2cm, pelvic/aortic nodes, inguinal nodes; IV = distant spread, pleural effusion w/ malig cells, liver/spleen mets; Tx: debulk tumor surgery, Chemo = cisplatin/cytotoxin, taxol; Radiation (bowel obstruction);

34. Teratomas immature (neuro epithelial); mature (dermoid)=95% of all teratomas, hemolytic anemia; LDH elev, CA125

35. Dysgerminomas most common malignant, 15% bilateral, radiosensitive

36. Endodermal Sinus Tumor Schiller Duvall Body, AFP

37. Embryonal CA HCG, AFP, CA125

38. Choriocarcinoma HCG

39. Sexcord-Stromal Tuors Granulosa: 50% post menopause, incr. estrogen, Call-Exner bodies
40. Sertoli-Leydig: most often virilizing; Gonado Blastoma: gonadal dysgenesis

41. Krukenburg Tumor: Ovarian mets from GI & breast; Signet ring cells

42. Vulvar CA TNM staging, squamous cell, Vulvar pruritus; Pagets= adenoca of vulva, 20% assoc w/ breast, GI, cervical CA

43. Gestational Trophoblastic - Benign: Complete Mole = 46 XX, paternal, no embryonic tissue; Incomplete = 69 XXY triploid, paternal, no fetal/ embryonic tissue
44. Malignant: Invasive= molar villi; Choriocarcinoma = no villi, any pregnancy; Placental Site = non molar gestations
45. S/Sx: size > dates, hyperemesis, hyperthyroid, large theca lutein cyst
46. F/U = CBC. Liver function, BUN, CR, TSH, HCG, US, CXR; TX = D&C
47. Weekly HCG' until 3 values that are non detectable then 1/mo x 1yr, BCP x 1 yr

48. Ca in Pregnancy Melanoma = worsened by preg, can met to placenta or fetus
49. Breast CA = most common CA in pregnancy

50. Chemotherapy Cyclophosphamide (Cytoxan) = ovarian, hem, cystits, alopecia, decr. bone marrow, N/V
51. Cisplatinum = ovaian, renal toxic, ototoxic, bone marrow ß, N/V
52. Adrimycin (Doxyrubicin)= endomet, ovarian; cardiotoxic (heart failure)
53. Bleomycin= cervical, germ cell, Pulmonary fibrosis
54. Vincristine= cervical germ cell; neurotoxic
55. Methotrexate = GTN, germ cell, hepatic & renal toxic, decr. bone marrow

OBSTETRICS
56. Hydantiform Mole Preeclampsia 1st TM, Very high Beta HCG, Snowstorm on US

57. Ectopic Pregnancy Beta HCG rises slowly, Amenorrhea, spotting, pain, Empty gestational sac on ultrasound, Ampulla of fallopian tube is most common site

58. Gestational Age Nagel's = Add 7 days to FDLMP subtract 3 months; fundal ht in cm after 13 weeks

59. Amniocentesis Adv maternal age, abn AFP - incr. Spina bifida, decr. Down's, detect lung maturity, early 2nd trimester

60. CVS Adv. Maternal age, late 1st trimester

61. Non stress Test > 2 fetal movements accompanied by incr. FHR of 15 bpm for at least 15 sec w/ in 20 min period

62. Contraction Stress Test Negative = 3 contractions in 10 min, lasting 40 sec w/o late decelerations
63. Positive = consistent & late decelerations

64. Biophysical Profile Nonstress test, fetal breathing, movement, adeq, amniotic fluid, limb extension

65. Fetal HR normal 120-160, Brady = mild 100-120, < tachy =" mild"> 180

66. Decelerations Early = shape is mirror of contraction, head compression
67. Variable = shape varies, cord compression
68. Late = starts as contraction peaks, recovery after contraction is terminated, uteroplacental insufficiency

69. Placental Previa Partial - partially over os; Complete= covers OS, Marginal = at edge of OS, Complete Previa is indication for C section

70. Placental Abruption Premature separation of a normally implanted placenta, vag bleed, uterine tenderness, back pain, hypertonic uterus, fetal distress

71. Preeclampsia HTN w/ proteinuria & edema after 20 wks gestation

72. Eclampsia Preeclampsia + seizures

73. Gestational Diabetes 1 hr > 140 then do 3 hr; 3hr test = fast > 120, 1 hr > 190; 2 hr > 165, 3 hr > 145; Macrosomia, RSD, Cong abnormalities

74. Types of Pelvises Gynecoid = round inlet, nonprominent spines, wide subpubic angle
75. Anthropoid = heart shaped inlet, decr. transverse and incr. AP diameters, decr. subpubic angle
76. Android= triangular inlet, decr. subpubic angle, prominent spines
77. Platypoid= incr. transverse and decr. AP diameters

78. Leopold's Maneuvers fundal palpation, sides of uterus from feet of mother, lower part of uterus, sides of uterus from head of mother

79. Stages of Labor 1. Onset contract => full dilation 2. Full dilation to delivery of head 3. Delivery of fetus to delivery of placenta 4. Delivery of placenta to 1 hr later

80. Cardinal Movements Engagement, descent, flexion, int rotation, extension, ext rotation, expulsion

81. Post Partum Hemorrhage Uterine Atony (most common); Placental Accreta: Accreta = superficial invasion into myometrium, Increta = deeper, Percreta = invasion to serosa of uterus; Undiagnosed lacerations, Coag defect; Retained placental fragments

82. Apgar Scoring Heart Rate, Resp. Effort, Muscle Tone, Reflex Irritability, Color

83. Shoulder Dystocia Maternal obesity, diabetes mellitus, postterm pregnancy

84. Cesarean Section Indications Health of mom or baby endangered by labor, Dystocia precludes vag delivery, Emergent situation, Herpes, Prev C section if contributing factor still exists, Malpresentation of fetus

85. Premature Rupture of Membranes Pooling of fluid in vagina, + nitrazine test, + ferning test, risk of endometritis

86. Polyhydraminos Duodenal Atresia, Tracheoesophageal fistula, Anencephaly

87. Oligohydraminos Renal Agenesis, Pulmonary hypoplasia

NEUROLOGY

NEUROLOGY
1. Blindness visual acuity 20/400 with best possible correction

2. Open Angle Glaucoma Increased intraocular pressure, gradual, bilateral vision loss => tunnel vision, elderly, diabetics, African Americans, familial; halos around lights, cuping of ocular disc, Beta Adrenergic blockers to treat; decr. amt aqueous humor produces

3. Closed Angle Glaucoma Rapid rise in pressure due to blockage of aqueous drainage in the eye; Severe pain, blurred vision, halos, Nausea, Abd pain; Reddened eye, upper lid edema, steamy cornea, dilated non-reactive pupil; mannitol, oral glycerin or carbonic anhydrase in acute attack, Beta adrenergic blockers for prevention

4. Diabetic Retinopathy Black spots, "cobwebs", flashing lights; cotton wool spots (infarct of vessel wall) neovascularization, hard yellow exudates

5. Cataracts Painless clouding of lens; Age most common cause, Assoc. W/ smoking & alcohol; Absent red reflex.

6. Senile Macular Degeneration Main cause of vision loss in the elderly; Atrophic degeneration or Leakage of Retinal Vessels , gradual loss of VA, Decr central vision, hemorrhagic or pigmented regions in the macula; Neovascular Membranes (Bruch's membrane)

7. Conjunctivitis Acute inflammation, Adenovirus, a lot of discharge, no blurring, purulent if bacteria

8. Uveitis Inflammation of the uveal tract (iris, ciliary body & choriod layer), haziness, floating spots; Photophobia & redness = iridocyclitis; "salt & pepper fundus = syphillis

9. Central Retinal Occlusion sudden painless loss of sight in one eye, Pale fundus, cherry red spot fovea & boxcar appearance of veins

10. Central Vein Occlusion unilateral loss of sight that is more gradual, Swelling of optic disc, cotton wool spots & tortuous dilated veins

11. Retinoblastoma Childhood malignancy of immature retina, associated with other malignancies later in life, "white reflex or "cat's eye.

12. Hearing Loss Rinne's Test: hold against mastoid process then adjacent to pinna, norm = pinna louder, if not maybe conductive loss; Weber Test: Midline of forehead, unilateral conductive loss = louder in affected ear; unilateral sensorineural = louder in unaffected ear

13. Presbycusis normal loss of hearing associated with age, sensorineural

14. Mastoiditis Usually following otitis media, Redness & swelling w/ fever & pain; X ray = destroyed mastoid air cells & fluid in the air pockets, IV antibiotics

15. Meniere's Disease Severe vertigo w/ N/V, hearing loss, tinnitus worse during attack of vertigo

16. Acoustic Neuroma Vestibular Schwannoma; tumor of CN VIII; Hearing loss, dizziness, tinnitus;

17. Migraine 2x women : men; Age of onset 10 - 30; gone by age 50; family Hx; stress, bright lights, menstruation, fatigue, tyramine, monosodium glutamate, nitrites; Aura prior to onset; visual, scintillating scotomas (small areas of visual loss) , dull throbbing, unilateral; N/V, photo & sound sensitivity;

18. Cluster Headache Men age 20-50; alcohol & vasodilators; severe, nonthrobbing, unilateral, recur same time each day for weeks, Horners syndrome & periorbital pain; Tx: ergot & lidocaine

19. Tension Headache cause unknown, most common type; bilateral, occipital, constant; muscles tight

20. Tumor Associated Headaches progressive, increasing, dull, nonthrobbing, worse w/ postural chgs, exertion. Disrupt sleep, assoc w/ N/V

21. Trigeminal Neuralgia Tic douloureux; severe, "lightening" pain in V1 & V2 distribution of CN V; Trigger Pts
22. Tx: carbamazepine & phenytoin; Surgical decompression of CN V

23. Partial Seizures Simple = focal sx, conscious, Jacksonian = simple muscle twitch that spreads progressively; 2o generalization = simple becomes grand mal; Complex Partial = automatism, olfactory hallucinations, fear, deja vu, loss of contact w/ environment; postictal confussion

24. Generalized Seizures Absence = petit mal; brief, freq. Loss of consciousness w/o loss of muscle tone, rapid eye blinks, no aura, no postictal
25. Grand Mal= tonic clonic, preceded by GI upset or mood chg; tonic - 30 sec, clonic 1-5 min w/ alternating relax & contract of muscles, unconscious, then confussion & postictal

26. Status Epilepticus continuous seizures w/o regained consciousness, grand mal progress or withdrawal of anticonvulsants; Complications = high fever, circulatory collapse, brain damage; Diazapam until controlled, Treat potential causes (glucose, thiamine, narcan)

27. TIA sudden, brief, emboli or arterial stenosis, Risks: obesity, smoking, DM, hyperlipidemia, Carotid artery= unilateral, contralateral hemiparesis & parathesia w/ ipsilateral blindness; Aphasia if dominant hemisphere involved, Vertebrobasillar = brainstem dysfunction => vertigo, confusion, blindness, diplopia, weakness, parathesia of extremities

28. Aneurysm localized vessel dilation, Berry Aneurysm = circle of Willis assoc w/ polycystic kidney disease & coarction of aorta

29. Subarachnoid Hemorrhage between pia & arachoid; usually rupture of a cerebral artery aneurysm or AV malformation; Worst HA, syncope, nuchal rigidity, vomiting, nonfocal abnormalities, decr consciousness, CT first if neg then lumbar puncture mandatory.

30. Intracerebral Hemorrhage Chronic HTN or local thrombus 2o to ischemia; Supratentorial: transtentorial herniation, w/ brainstem compression & midbrain bleeding, hemiparesis; Cerebellar : acute hydrocephalus due to CFS flow blockage; Acute onset HA w/ progressive neurological chgs.

31. Stroke Middle Cerebral: most often, contralateral limb weakness, sensory loss, homonymous hemianopsia, dominant hemisphere = aphasia, nondominant = sensory neglect & apraxia
32. Posterior Cerebral: contralateral homonymous hemianopsia & sensory loss, thalamic pain, hemiballistic movement disorder
33. Vertebrobasilar artery: fatal, unilateral occlusion = ipsilateral CN abnormalities, contralateral weakness; Complete occlusion = opthalmoplegia, defective pupil constriction, bilateral weakness, paralysis, decreased consciousness, dysphagia & dysarthria; completed = neuro stable; Evolution = progressive signs over 1-2 days
34. CT positive 48 - 72 hrs after onset.

35. Cavernous Sinus Thrombosis CN palsies, fever, exophthalmos, papilledema, HA, decr. consciousness, occasional seizures; IV antibiotics immediately

36. Acute Subdural Hematoma rapid bleed between arachnoid & dural layers; Tearing of bridging veins, Sx slower to progress, Signs of transtentorial herniation w/ deepening coma, progression from decorticate to decerebrate posture, mid position or fixed & dilated pupils, spastic hemiplegia w/ incr. DTR. LP is contraindicated because may lead to herniation

37. Chronic Subdural Hematoma Delayed formation of a subdural clot, Sx weeks after head injury, Elderly & alcoholics; Progressive daily HA, fluctuating consciousness & mild hemeparesis

38. Epidural Hematoma Between dura & skull, less common than subdural, injury to arteries (middle meningeal); Rapid brain compression, permanent neurological problems or death; Brief lucid period after head injury; progressive neuro signs

39. Concussion Injury due to blunt trauma; short loss of consciousness w/ intact brainstem function; post traumatic confussion syndrome w/ transient retrograde or anterograde amnesia; HA, vertigo, mild cognitive dysfunction

40. Toxic Vestibulopathies Alcohol: positional vertigo & nystagmus w/ in 2 hrs of ingestion
41. Aminoglycosides: ototoxic, vertigo, N/V ataxia, sx last 1-2 wks after ending tx
42. Salicylates: reversible vertigo, tinnitus, sensorineural hearing loss
43. Quinine & Quinidine: cinchonism (color vision defects, tinnitus, hearing loss, vertigo, flushed skin, N/V, abd pain & sweating
44. Cisplatin: ototoxic, reversible vertigo, tinnitus, hearing loss, sensory neuropathy

45. Toxic Neuropathies Lead: multi motor neuropathy; acute encephalopathy in children
46. Organophosphates: delayed motor neuropathies, cholinergic crisis
47. Arsenic and Thallium: acute onset symetrical sensorimotor polyneuropathy
48. Isoniazid: Reversible sensory polyneuropathy reversible w/ concurrent pyridoxine Gold: symetrical polyneuropathy

49. Bacterial Meningitis 1st month life = group B strep & E. coli; Older kids = H. flu; Adults = S. pneumonia
50. N. meningiditis at any age = 50% have petechial rash
51. Brudzinski sign = neck flexion when supine causes involuntary hip & knee flexion
52. Kernig's Sign: extension of knee in pt w/ flexed hip is painful
53. CSF: decr. glucose, incr. neutrophils, incr. protein, incr. opening pressure; Tx: ampicillin & cefotaxime = infants; 3rd generation cephlosporin in kids > 3mos and adults

54. Aseptic Meningitis nonbacterial meningeal irritation; CSF = incr. lymphocytes, normal glucose, neg gram stain & bacterial cultures, mild incr. protein, normal opening pressure; supportive Tx

55. Fungal/TB Meningitis CSF: incr. lymphocytes, decr. glucose, incr. protein, incr. opening pressure; AIDS = cryptococcal meningitis

56. Encephalitis Inflammation of brain tissue; Viral etiology = CSF lymphocytes, normal glucose & negative bacterial cultures; Acylcovir x10 days

57. Reye's Syndrome follows viral infection; fatty infiltrate of organs; Usually kids; Salicylates can induce
58. Sudden onset of encephalopathy, severe vomiting, & liver dysfunction; liver biopsy w/ fatty infiltrates confirms Dx.

59. Neurosyphillis Argyll Robertson Pupil (small, reacts to light but not accommodation); Psych disorders, Tabes Dorsalis; Tx: Procaine Penn G x 21 days; Examine CSF q 3-6 months until normal x 2 yrs.

60. Rabies Dogs worldwide; wild animals in US, Sx: malaise, fever, restlessness 1st. Sx progress to extreme excitement w/ painful laryngeal & pharyngeal spasms, Tx: Passive IG and active vaccine

61. Polio Fecal-oral; aseptic meningitis, paralysis w/o loss of sensation; Asymmetric paralysis during a febrile illness suggests it; Tx is palliative; OPV for all except immunocompromised who get IPV

62. Primary Neoplasms Glioblastoma Multiforme: most common in adults, high mortality; Meningioma: most common benign tumor in adults; Cerebellar Astrocytoma & Medulloblastoma: most common in kids

63. Huntington's Disease Autosomal dominant, Age 30-50; subtle dementia, irritability, antisocial, chorea, death 10-15 yrs after onset, atrophy of caudate nucleus & cerebral cortex, Tx D2-receptor antagonists (haloperidol)

64. Parkinsonism Idiopathic - loss of dopaminergic cells in substantia nigra; Pin rolling temor, masklike facies, lack of arm swing when walking, cogwheel rigidity, difficulty initiating movement, small shuffling steps w/ increasing speed (festinating gait). Tx: Levadopa (dopamine precursor), Amantadine, bromocriptine (dopaminergic agonists), Benzotropine (anticholinergic)

65. ALS
66. (Lou Gehrig's Disease) Progressive loss of anterior horn cell function; Initially = LMN dysfuntion w/ hand & foot weakness & atrophy; asymmetric progression, No sensory abnormalities; Later= UMN dysfunction w/ muscle spasticity, incr. DTR, extensor plantar reflexes

67. Tay Sachs Disease Autosomal recessive; Eastern Europe jews & french Canadians; Absence of Hexosaminidase A, can't metabolizes lipid gangliosides, build up in brain; Progressive dev. delay, paralysis, blindness, dementia; death by age 4

68. Multiple Sclerosis Progressive demyelinating, women>men; Peak onset 20 - 40; Gradual & variable CNS sx suggest dx; CSF = mild incr. proteins, mild lymphocytes , oligoclonal bands, MRI = multi plaques in white matter

69. Guillain-Barre Syndrome polyneuropathy after mild viral illness, inoculation or surgery; Most common acquired demyelinating disorder; progressive bilateral weakness of legs, proximal weakness, abnormal DTR, instability of temp & BP; CSF = incr. protein w/ normal pressure, glucose & cell numbers; Plasmaphresis speeds recovery; Corticosteroids are contraindicated

70. Cerebral Palsy CNS damage before age 5; Risks: Prematurity, IUGR, inutero complcations, neonatal jaundice, birth trauma, asphyxia, spastic syndrome, incr. DTR, incr. tone, weakness, toe walking, scissors gait

71. Myasthenia Gravis autoimmune, antibodies against acetylcholine receptors at neuromuscular junctions, incr. women, age 20 - 40; Ptosis, diplopia, dysarthria, enhanced muscle fatigue, thymoma on chest x-ray; Tx exogenous anticholinesterase (edrophonium or neostigmine); Thymectomy in pts < 60; steroids or azathioprine if unresponsive to tx

72. Muscular Dystrophy Duchenne most common type; X linked recessive, mutation in dystrophin gene; CK incr. before onset of sx; By age 5 toe walking, waddling gait, can't run; Prox legs 1st then prox arms; Pseudohypertrophy of calves = fat infiltrates in muscles;

73. Coma dysfunction both cerebral hemispheres or RAS; Acute onset = subarachnoid hemorrhage or brainstem infarct; progressive min-> hours = Intracerebral hemorrhage; days => weeks = chronic subdural hematoma, tumor or abscess; No laterialization following delirium = metabolic; Pupil size: dilated nonreactive = at or below midbrain, pinpoint = pontine; opiod OD, Constriction intact w or w/o extraoccular impairment = metabolic; Localizing response to pain = superficial coma; Decorticate (flex @ elbow, ext leg) = thalamic lesion of compression; Decerebrate (elbow & leg extension) = midbrain; No response to pain = pontine or medullary

74. Gait Abnormality Cerebellar lesions = truncal ataxia, broad based, unsteady, irregular; can't turn
75. Corticospinal = affected leg circumducts as it steps forward, scissors if bilateral
76. Extrapyramidal = festinating gait, flexed posture, small rapid steps, no arm swing
77. Motor System = Footdrop - anterior tibial; Calf muscle - can't toe walk; Pelvic muscle - waddling gait.

78. Arnold Chiari Syndrome Cong. Protrusion of medulla thru foramen magnum; unusual sensory & motor chgs, Onset ~ 40

79. Cold Calorics Test vestibular system, Slow deviation toward ear w/ cold water = brainstem intact, fast nystagmus away = contralateral cortex intact; COWS = cold opposite Warm same for fast component

SURGERY

· SURGERY
· Hypotension not responsive to fluid administration is suggestive of ongoing blood loss and such patients with abdominal trauma need an immediate exploratory laparotomy.

· Vital signs, hemodynamic stability, and need for blood transfusion are important determinant for surgical v/s non-surgical management of patient with splenic trauma.

· Choledocholithiasis symptomatic of biliary colic and without any systemic toxicity is treated with analgesic and spasmolytics and elective surgery is done at a later date.

· Tetanus prophylaxis depends upon whether the patient had his 3 doses or not. If yes, it depends upon when did he have it. For any wound, clean or minor, patients should be administered tetanus toxoid if the last dose was administered 5 years ago. However, if the patient has clean wound & he has previously received 3 or more doses, but received the last dose 10 years ago, then again he should receive the tetanus toxoid.

· Transient submandibular gland swelling may occur during feeding due to partial obastruction of its duct and further evaluation is required if swelling is persistent or recurrent.

· In a young individual who present with a fleshy immobile mass on his hard palate, the most likely Dx is torus palatinus. No medical or surgical therapy is required.

· Technetium pertechnetate scintigraphy is the best diagnostic test for Meckel’s diverticulum.

· Colonoscopy is difficult and rarely performed in settings of active bleeding. If the bleeding stops, however, it should be done.

· Angiodysplasia may be seen as cherry-red spots that may be coagulated.

· Labeled erythrocyte scintigraphy, although not a very precise study, could be helpful to define the site of bleeding.

· The diaphragmatic rupture is more common on the left side, since the right side is protected by the liver. The leakage of intraabdominal contents into the chest causes compression of the lungs and mediastinal deviation. Elevation of the hemidiaphragn on the chest X-ray may be the only abnormal finding. Sometimes, there may be evidence of small bowel in the thoracic cavity.

· Approximately 5-10% of unconscious patients who present to the ED as result of a motor vehicle accident or fall, have a major injury to the cervical spine. One third of injuries occur at the level of C2, and one half of the rest occur at the level of C6 or C7. Most fatal cervical spine injuries occur in upper cervical levels, either at craniocervical junction, C1 or C2.

· It is important to rule out a fracture or dislocation of cervical spine as the first priority because of grave consequences of missing a cervical spine injury.

· Cast immobilization is recommended in the tx of all non-displaced scaphoid fractures (fractures <>10
· ï‚• Neuromuscular scoliosis: secondary to neuromuscular disturbance or muscle disease.
· ï‚• Congenital scoliosis: secondary to structural bony deformities.

· Highest detection rate of prostatic carcinoma in early stages---PSA+digital rectal examination

· Kidney stones:
· ï‚• Oxalate stones: in a patient who undergoes bowel resection and then develops kidney stones, one should always suspect oxalate.
· ï‚• Cystine stones: rare and occurs as part of a rare inherited disorder of defective renal transport resulting in over-excretion of cystine. Sone formation begins in childhood and are a rare cause of staghorn calculi.
· ï‚• Uric acid stones: occur when urine is saturated with uric acid in the presence of an acidic urine and dehydration. Seen in gout, myeloproliferative disorders and diarrhea. Tx: fluid, alkalinization of urine, allopurinol.
· ï‚• Struvite stones: form in the collecting system and become infected with urea splitting organisms. Condicitons required for formation of struvite stones are presence of high urine pH, magnesium, ammonium and carbonate levels.
· ï‚• Calciu phosphate stones: associated with hypercalciuria (sarcoidosis, immobilization, Cushing’s syndrome, renal tubular acidosis.) std Tx: fluid, thiazide.(note Furosemide in CI).

· Acute appendicitis: Rovsing’s sign +. Requires immediate surgery.

· Acute appendicitis may be complicated by pelvic abscess that presents with lower abdominal pain, malaise, low-grade fever and tender pelvic mass on rectal examination. (most of the pelvic abscesses are due to perforation of appendix. Tx. Drainage of the abscess).

· Laxatives should not be given in the setting of intestional obstruction.

· Intestinal obstruction with metabolic acidosis and shock indicates serious disease and it requires laparotomy. (suggesting bowel ischemia or necrosis).

· In case of simple mechanical obstruction, there would be metabolic alkalosis.

· Patients who present more than 5 days after the onset of symptoms of appendicitis, and have localized right lower quadrant findings, should be treated with IV hydration, antibiotic and bowel rest. Antibiotics should cover enteric gram-negative organisms and anaerobes (cefotetan)

· Cefotetan: has a good coverage of gram-negative organisms and anaerobes; therefore, this can be used as monotherapy in complicated appendicitis.

· Erythromycin and vancomycin are effective against gram-positive organisms, they do not cover gram-negative organisms or anaerobes.

· Persistent symptoms (e.g. mechanical symptoms) in patients with probable meniscal injury should be further evaluated by MRI or arthroscopy. Surgery (arthroscopic or open) is often necessary to correct the problem.

· Boerhaave’s syndrome is esophageal perforation due to severe vomiting and it produces pneumomediastinum.

· Saphenous vein cut down or percutaneous femoral vein catheterization are alternatives to have an intravenous access in trauma patients with collapsed veins.

· Interosseous membrane cannulation is an alternative route in children <4>40 yo, one or more additional risk factors, minor/non-major surgery. The risk of DVT is 2-10%.
· ï‚• High risk: patients > 40 yo, additional risk factors, major operation (e.g. orthopedic procedures of the lower extremity). The risk of DVT in these patients is between 10-20%.

· Bucket handle tear of medial meniscus is the MC meniscus injury at knee and leads to locking of the knee joint during terminal extension.

· Lachman’s test is the most sensitive physical test for Dx of anterior cruciate ligament injury. (A popping or snapping sensation is commonly felt at the time of ACL injury, ACL prevents anterior gliding of the tibia under the femoral condyles). Patients complain of instability of the knee. Commonly associated with injury to medial meniscus and medial collateral ligament of the knee (terrible triad). Lachman’s test: is done with knee flexed at 20 degrees, and pulling the proximal tibia with one hand while stabilizing the femur with the other hand.

· Anterior cruciate ligament: prevents anterior glinding of the tibia under the femoral condyles. Isolated injury is seen after hyperextension of the knee. A “popping or sanpping” sensation is commonly felt at the time of injury. Patients complain of instability of the knee (giving out, looseness etc.) It is commonly associated with injury to medial meniscus and medial collateral ligament of the knee. (terrible triad)

· Osgood Schlatter disease: is an apopysitis of tibial tubercle seen in young teenager due to overuse. (swelling and marked tenderness over the tibial tubercle. Pain increases on contraction of quadriceps muscle.)

· Slipped femoral capitis: is an emergency condition and should be promptly corrected with external screws. (Dx is made by a high degree of clinical suspicion in presence of limited range of hip movements. Loss of abduction and internal rotation are very characteristic and external rotation of thigh is seen when hip is flexed. Frog-leg lateral view X-ray of hip joint is the imaging technique of choice for Dx.)

· Lateral collateral ligament injury: tackled while playing football, knee pain, swollen, direct palpation over the lateral aspect of the knee elicit pain. Anterior drawer and posterior drawer test, and Lachman test are all negative.

· Anterior drawer test: is also used for Dx of ACL injury but is less sensitive. It is done in supine position with the knee flexed at 90 degrees and hips flexed at 45 degrees, while tibia is pulled forward over femur to note the degree of displacement.

· Posterior drawer test: is used for Dx of posterior cruciate ligament injury. It is similar to anterior drawer test except that posterior pressure is exerted on tibia to note posterior displacement.

· McMurray’s test: is used for Dx of meniscus injury. In case of meniscus injury a click is heard on forced flexion and rotation of the knee. (popping sound on passive flexion/extenstion of the joint)-specific for meniscal injury.

· Valgus stress test: is used for Dx of medial collateral ligament injury in which case valgus stress leads to marked angulation of knee joint as compared to the normal knee.

· The immediate management of splenic trauma caused by blunt abdominal injury depends on the patient’s hemodynamic status and response to IV fluids. If the patient is initially hemodynamically unstable but improves with fluid administration, the best next step is to obtain an abdominal CT scan. If the patient is initially hemodynamically unstable and is unresponsive to fluid administration, then emergent exploratory laparotomy is required.

· Intermittent claudication is best treated with aspirin and an exercise program.

· MRI is now the investigation of choice for ligamentous injuries of the knee with an accuracy rate of 95%. Surgery is rarely necessary for MCL tear.

· Non-communicating hydrocele disappears spontaneously by 12 months of age and it is therefore managed expectantly.

· CT scan of a diffuse axonal injury shows numerous minute punctuate hemorrhages with blurring of grey-white interface. It is the most significant cause of morbidity in patients with traumatic brain injuries.

· A sternal fracture is very likely to be complicated by myocardial contusion, serial ECG is needed.

· Paget’s disease of the nipple: Dx-mammogram and punch biopsy.

· Tx. of Mitral stenosis: cardiovascular surgeons prefer to repair the patient’s own mitral valve, rather than replacing it. Stenosis is due to fusion at the commissures---commissurotomy can correct.

· As a rule: internal hemorrhoids bleed but do not hurt, wherears external hemorrhoids hurt but do not bleed. (discomfort could be pain, or itchy)

· Brain examinations:
· ï‚• CT scan is our best tool when intracranial bleeding is suspected.
· ï‚• MRI is our choice when brain tumor is suspected..
· ï‚• Duplex scanning is our choice if transient ischemic attack is suspected.

· Fogarty balloon tipped catheters: an embolectomy used in treating embolic occlusion of the artery. Heparin etc anticoagulants are an adjunct to vascular procedures, but are not the primary Tx for a clot that has already traveled from the atrial appendage to the lower extremity. Anticoagulants cannot dissolve existing clots.

· The urinary retention is extremely common in the immediate postoperative period after lower abdominal inguinal or perineal surgery. Tx: in and out bladder catheterization. (don’t use indwelling Foley catheter unless in and out fails twice to resolve the urinary retention.)

· If a scaphoid fracture is suspected, even without a visible fracture on X-ray, it must be treated as if there was a fracture. (long arm cast)---fall on an outstretched hand. Pain with wrist movement, tenderness in the anatomical snuffbox. 10% go on to develop avascular necrosis due to tx error.

· Spinal cord ischemia with lower spastic paraplegia is a rare complication of abdominal aneurism surgery.

· Acute adrenal insufficiency is a potentially lethal postoperative complication. Preoperative steroid use is the main cause. A high index of suspicion is required. Commonly, they present with nausea, vomiting, abdominal pain, hypoglycemia, and hypotension.

· Burns:
· ï‚• 1st degree: superficial burns, confined to the epidermis with minimal skin damage. The skin is mildly erythematous and pain is the chief complaint. (such as sunburn, heals without scaring.)
· ï‚• 2nd degree: partial thickness burns-involves the entire epidermis and various layers of the dermis. Skin is painful, red, edematous and blistered.
· ï‚• 3rd degree: full thickness burns-no dermal appendages remain, all epidermis and dermis is completely destroyed. (flame burn)

· Patients have obvious signs of hemorrhagic shock (loss of about 25-30%, 1500 mL blood), can only occur with intraabdominal bleeding, intrathoracic bleeding, and fracture of femur, pelvic, extremities or bleeding in neck. USG and DPL are the procedure of choice to diagnose intra abdominal bleeding in an unstable trauma patient. (ultrasonogram, diagnostic peritoneal lavage).

· In case of amputation injury, amputated parts should be retrieved and brought to the ED. The amputated part should be wrapped in a saline-moistened gauze sponge placed in a plastic bag. The plastic bag should be sealed and placed on ice.

· Cirrhotic patients with ascites may develop spontaneous primary bacterial peritonitis, which gives a “mild picture of acute abdomen”, Dx: culture of the ascetic fluid.

· Sigmoid volvulus, a common condition in elderly patients. The endoscopic instrument (proctosigmoidoscopy) can untwist the bowel from the inside, relieve the obstruction, and allow placement of a long rectal tube.

· Nerves of the lower extremities:
· Femoral N.:innervated the muscles of the anterior compartment of the thigh, and is therefore responsible for knee extension and hip flexion. It provides sensation to the anterior thigh and medial leg via the saphenous branch.
· Tibial nerve: supplies the muscles of the posterior compartment of the thigh, posterior compartment of the leg, and plantar muscles of the foot. The tibial nerve provides sensation to the leg (except medial side) and plantar foot.
· The obturator nerve: innervated the medial compartment of the thigh (ie, gracilis adductor longus, adductor brevis, anterior portion of adductor magnus), and controls adduction of the thigh. It provides sensation over the medial thigh.
· The common peroneal nerve: gives rise to the superficial and deep peroneal nerves. These two nerves supply the muscle of the anterior and lateral leg. These nerves provide sensation to the anterolateral leg and dorsum of the foot.

· Current Tx. to full thickness burn: immediate excistion, grafting

· DDH:
· Ultrasound is the most sensitive investigation for DDH (developmental dysplasia of the hip) for infants less than 6 months of age.
· X-ray of hip is not useful in young infants, as the cartilage and epiphysis are not ossified.
· However, in older infants and children, plain radiography is the preferred modality of investigation.
· MRI of hip joint though sensitive is reserved for complicated cases
· CT though sensitive is not the first investigation of choice. It is particularly used for evaluating complicated dislocations and for postoperative evaluation of the hip.
· After rhinoplasty, if there is whistling noise during respiration, one should suspect nasal septal perforation.

· Unless strangulation or perforation is suspected, bowel obstruction is treated conservatively with fluids, nasogastric suction and enemas.

· Retrograde cystogram with post void film is the investigation of choice for patients with suspected bladder trauma.

· Retrograde urethrogram should be the first step in management of suspected posterior urethral injury. (inability to void, trauma history, high riding prostate)

· Anterior urethral injury due to injury to urethra anterior to the perineal memebrane. Anterior urethral injuries are most commonly due to blunt trauma to the perimeum (straddle injuries), and many have delayed manifestation.

· Posterior urethra consists of the prostatic urethra and memebranous urethra. Posterior urethral injuries are most commonly associated with pelvic fracture. (presents with blood at meatus, high riding prostate, scrotal hematoma and inability to void in spite of sensation to void).

· When suspecting a urethral injury, do a retrograde urethrogram, inject the dye directly into the urethra. Inserting a Foley catheter is absolutely contraindicated in suspected urethral injury, you may change a partial urethral disruption into a complete transaction.

· Retrograde ejaculation occurs in up to 90% patients undergoing transurethral resection of the prostate (TURP).

· TUIP (transurethral incision of the prostate) involves incision of the periurethral prostate without resection of any tissue. This procedure is minimally invasive and can be performed on an outpatient basis. It frequently results in symptomatic relief without the adverse effects of TRP.

· The disease with the highest incidence of perioperative death or cardiac event is a recent myocardial infarction. (other causes: coronary disease, worsened or poor baseline exercise tolerance, recent infarction)

· Postoperative period, patient has persistent difficulty swallowing solids and even more difficulty swallowing liquids. Any attempts to do so results in violent coughing ans aspiration.Lesion: ----------sensory fibers of the 9th (glossopharyngeal) nerve.

· When a patient presents with a pulsatile abdominal mass and hypotension, a presumptive Dx of ruptured abdominal aortic aneurysm must be entertained and the patient should be taken straight to the operating room.

· Aortic aneurysm rupture, best diagnostic exam: Spiral CT scan or MRI angiogram.

· Ureteropelvic junction obstruction and profuse diuresis: a congenital narrowing at the ureteropelvic junction allows normal passage of urine at a normal flow rate, but the lumen can’t accomadate a suddenly increased flow rate. (remember, beer is a wonderful diuretic.)

· Most common nontraumatic casue for SAH is: berry aneurysm in the anterior portion of the circle of Willis.

· Any gunshot wound of the abdomen requires exploratory laparotomy. Any gunshot wound below the 4th intercostals space (level of nipple) is considered to involve the abdomen.

· Subluxation of radial head is a common condition in preschool children and needs closed reduction by flexion and supination of forearm.

· Small amount of intraperitoneal bleed that is not visible on abdominal ultrasound can be detected by diagnostic peritoneal lavage.

· Consider bowel ischemia and infarction as an early complication of operation on the abdominal aorta.

· Hallmark triad of urethral injury is:
· ï‚• Blood at urethral meatus
· ï‚• Inability to void
· ï‚• Distended bladder

· For carcinoid tumors located at the tip of the appendix, appendectomy is sufficient Tx. Carcinoids do not have the tendency to spread and have a good prognosis. When carcinoid spreads to the liver, it may produce the carcinoid syndrome, which is characterized by flushing, diarrhea, cramping, and valvular heart lesions.

· Rule out vascular injuries in case of penetrating wound near the site of important vessels. (arteriogram)

· Monteggia fracture: an isolated fracture of proximal third of ulna, with anterior dislocation of radial head. May be associated with injury to radial nerve, so careful neurovascular examination at the time of evaluation is mandatory. Tx: open reduction and internal fixation in adults, closed reduction and casting are optimal for children.

· Galeazzi fracture: an isolated radial shaft fracture, associated with disruption of distal radio ulnar joint also need open reduction and internal fixation.

· Osteogenic sarcoma usually presents with painful swelling around the knee without any systemic signs and radiographic findings are osteolytic lesions with periosteal reaction.

· Hyperventilation helps to prevent and treat intracranial hypertension by causing cerebral vasoconstriction and thus decresing cerebral blood flow. (goal: to have pCO2 in the range of 30-35 mmHg.)

· Harvesting team’d evaluate any dying patient as a potential donor.

· Typical history for fracture of the posterior lateral talar tubercle: standing on a chair and falls backward, a cracking sound -develop pain and swelling behind the ankle. Pain is exacerbated by plantar flexion and dorsiflexion of the hallus (big toe).Tx: with immobilization in a cast for 4-6 weeks. Dx: lateral x-ray film of the ankle.

· After rectal surgery, patient experience impotence, cause?-erectile nerve damage.

· In cirrhotic patient with hepaticencephalopathy, porto-systemic shunt may worsen the encephalopathy.

· Patient with cirrhosis may have upper GI bleeding due to:
· ï‚• Erosive gastritis
· ï‚• Varices
· ï‚• PUD (peptic ulcer disease)
· ï‚• Mallory-Weiss tears.

· In cases of bleeding esophageal varices, need for 5 or more units of blood transfusion in a period of 24 hours is considered an indication for surgery and transjugular intrahepatic portosystemic shunt is the best choice in emergency situations.

· When clavicle injuries occur and a bruit is present, an anterial injury must be ruled out with an angiogram.

· Atelectasis on chest X-ray can be confused with pneumonia and pleural effusion. However, it is more common after surgery in smoker and requires bronchoscopy to remove the mucus plug.

· Fever on the first postoperative day is almost invariably from atelectasis, the Tx of which requires active participation and cooperation from the patient. If atelectasis does not resolve, it leads to the development of pneumonia, which can be identified in chest x-ray and confirmed with sputum cultures.

· Sclerotherapy and surgery are indicated after first variceal bleeding, but not prophylactically. (sclerotherapy may have complications such as perforation, stenosis, and bleeding.)

· Pelvic X-ray should be routinely done in all patients with trauma to screen for pelvic injury.

· Fibrocystic disease: (mammary dysplasia) typically seen in women aged 20-40. It is characterized by painful breasts and recurrent formation of cysts.

· Malrotation: 3 week old infant, protracted bilious vomiting. With double bubble sign with a little gas beyong is highly suggestive. Dx must be promptly confirmed by barium enema or contrast study from above. Tx: emergency surgery.

· A patient must be left with at least 800mL in FEV1 to live a semi-decent life.

· Even being left with at least 800 mL in FEV1, a patient with SCC in lung still needs to do a CT scan of the chest and upper abdomen to rule out lymph metastasis before a pneumonectomy can be done.

· The best initial therapy for rhabdomyolysis is infusion of copious amounts of alkalinized saline to assist the kidneys in clearing the myoglobin from the blood. Alkalinizing the urine allows the renal tubules to retain the myoglobin and excrete it in the urine. (saline+bicarbonate)

· Percutaneous lithotomy: used for large renal sontes located within the pelvicaliceal system. Smaller stones located in this position are best treated with ESWL.

· Extracorporeal shock wave lithotripsy (ESWL): particularly effective on stones impacted in the distal ureter that have failed to pass spontaneously with conservative management.

· Testicular torsion needs immediate de-torsion if the testis is to be saved. No time should be wasted doing further studies.

· In patients sustaining trauma, there is a chance of bony cervical spine injury-lateral cervical spine x-ray can rule it out.

· A COPD patient with a 1100 mL in FEV1, suffers from a SCC at the hilar. What to do? ---only radiation + chemotherapy. If surgery and have the bad lung removed, then only leave him 40% FEV1 (440 mL).

· Expectant therapy is a rule for all patients with uncomplicated basilar skull fracture. Clinical signs of basilar skull fracture includes rhinorrhea, raccoon eyes (black eyes), and ecchymosis behind the ears and otorrhea. Patient’s head should be elevated and fluid intake should be restricted to 1200 mL/day. Patient should also be cautioned against the maneuvers that increase the intracranial pressure like blowing the nose.

· Legg calve Perthes disease (avascular necrosis) is serious but self-limiting condition of young children characterized by avascular necrosis of femoral head. Can be painless. But hip pathology can present as referred knee pain. Also named: avascular necrosis of the capital femoral epiphysis.

· The Tx of choice for isolated diaphyseal humeral fracture is by closed methods.

· Scaphoid fracture: nonunion and avascular necrosis are common complications. The proximal third of the scaphoid is prone to avascular necrosis in fractures involving the wrist or proximal pole.

· Gentle traction to attempt alignment of the fragments of a fractured long bone is important to prevent further vascular and neurological damage and it should be attempted immediately.

· Nasopharyngeal cancer usually presents initially as a painless neck mass. (other symptoms: epistaxis, hearing loss, nasal blockage)

· Warfarin treated patients should be given fresh frozen plasma instead of vitamin K when emergency surgical procedure is to be performed.

· Intravenous pyelography is very useful for the Dx of renal stones.

· Open fractures should not be closed primarily because of the associated increased risk of infection and subsequent osteomyelitis.

· Rhabdomyolysis can occur with severe crush injuries and should be managed with IV fluids, osmotic diuretics and alkalinization of urine.

· Hyperkalemia due to crush injuries needs IV calcium gluconate (acts as a membrane-stabilizing agent to balance against the imminent hyperkalemia-induced global depolarization of the myocardium.

· Elderly patients with displaced femoral neck fractures should be treated with primary arthroplasty.

· Tx of choic for intertrochanteric fracture: internal fixation with sliding screw and plate and early mobilization.

· Patients treated with high-dose methylprednisolone within eight hours of spinal cord injury have significant and sustained neurological improvement, thus its use is warranted as the first priority after stabilizing the patient. *important Q.!!!*

· 213. Garden classification for femoral neck fracture:
· ï‚• Type 1: valgus impaction of femoral head commonly seen with stress fracture
· ï‚• Type 2: complete but non-displaced femoral neck fracture.
· ï‚• Type 3: complete fracture with displacement <50%>50%

· Delayed emergency from anesthesia is characterized by hypotension, which is evident by decreased in respiratory rate, HTN progressing to hypotension, tachycardia progressing to bradycardia, restlessness and pallor/cyanosis.

· After blunt trauma to the chest, if an x-ray shows a deviated mediastinum with a mass in the left lower chest, one should suspect a diaphragmatic perforation.(Dx. barium swallow)

· Patient with head injury can never have hemorrhagic shock due to intracranial bleeding.

· Beck’s triad of hypotension, elevated JVP, and muffled heart sounds confirms the Dx of pericardial tamponade.

· Volkmann’s ischemic contracture is the final sequel of compartment syndrome in which the dead muscle has been replaced with fibrous tissue. Tx: immediate fasciotomy.

· Displaced anterior fat pad is a radiographic sign of supracondylar fracture, which may be complicated by Volkmann’s ischemic contracture.

· Presence of brachial pulse on the fracture side can’t rule out the possibility of vascular compromise because of collateral flow.

· Two locations in the body have the highest risk for development of the dreaded compartment syndrome: the forearm and the lower leg.

· Hirschsprung’s disease in neonate presenting with obstruction: diverting ileostomy +appendectomy (for Dx. of the disease). Definite repair can be done when the child is older.

· A known complication of ling-standing use of birth control pills is the development of hepatic adenomas that may rupture and bleed. (acute onset of abmominal pain, followed by a faint)

· The MC site of ulnar nerve entrapment is the elbow where the ulnar nerve lies at the medial epicondylar groove. *extremely HY Q for USMLE* (decreased sensation over the 4th and 5th fingers of the hand and a weaker grip compared to the normal side.) Prolonged, inadvertent compression of the nerve by leaning on the elbows while working at a desk or table is the typical scenario.

· APKD (adult onset polycystic kidney disease) diagnosed, you should order an MRA (magnetic resonance angiogram) of the brain to rule out berry aneurysms. (10%-20% incidence of this in APKD).

· Virtually all solid testicular masses are malignant tumors. The best way to avoid dissemination is to open the inguinal canal, do a high ligation of the cord, and pull the testicle out.(radical inguinal orchiectomy)

· Mixed connective tissue disease represents the over lapping symptoms of SLE, scleroderma and myositis. It is associated with autoantibody to ribonuclear protein.

· The rule is that lymph nodes that progressively enlarge over several months are malignant.

· Lymph nodes which are in the supraclavicular area, typically harbor metastasis from a primary tumor below the clavicles (i.e., not in the head and neck).

· Inhalation injury is common in burns patients and may take several days to manifest. Diagnosis is best done with a bronchoscopy.

· Body surface involved in burn injury is calculated with the rule of 9:
· ï‚• Each arm: 9%
· ï‚• Each lower extremity: 18%
· ï‚• Anteiror torso: 18%
· ï‚• Posterior torso: 18%
· ï‚• Face 9%
· ï‚• Perineum: 1%

· Burns patients need 4 ml/kg/% of the body area involved of fluid in first 24 hours, half of which is given in the first 8 hours. Plus 2000 mL dextrose 5% in water.

· Infection is the MCC of death in burns patients.

· Burns:
· ï‚• Superficial and erythematous burns while painful do not require any special wound care (not even antibiotics)
· ï‚• Early excision therapy is indicated for extensive partial-thickness and full-thickness burns, as they do not heal spontaneously. Also, it allows for early skin grafting and lesser complications.
· ï‚• Prophylactic systemic antibiotic is not indicated in all the patients. However, topical antibiotics should be used for burn wound care.
· ï‚• The most commonly used topical anti bacterial agent: silver sulphadiazine. Mafenide sulphate is only used if deep penetration is required in case of wound with eschar. Mafenide sulfate is associated with severe pain and acidosis.
· ï‚• Eschar is dead rigid tissue formed in burns wounds. The eschar restricts outward expansion of the compartment as edema occurs in the injured extremity following the burns. As a result, interstitial pressure rised to the point that vascular flow is compromised. This can be relieved by performing an escharoctomy.
· ï‚• Tetanus prophylaxis should be considered in all the burns wound patients using std guidelines as burn wounds are prone to tetanus infection.
· Cholesteatoma is an epithelial cyst that contains desquamated keratin. Patients generally present with chronic ear discharge and granulation tissue that are unresponsive to antibiotic treatment. (This is not a tumor)

· Carcinoids are most commonly found on the appendix; however, patients who present with carcinoid syndrome usually have carcinoids located in the small bowel.

· Dog bite:
· ï‚• May result in rabies (fatal disease)
· ï‚• Post exposure prophylaxis: active and passive immunization.
· ï‚• Capture the dog, if fails to do so, the dog is assued to be rabid and post exposure prophylaxis is indicated.
· ï‚• If the dog is available and it does not show any features of rabies, observed it for the development of rabies (10 days). If it shows rabies, it is killed and its brain is examined to confirm the presence of rabies and post exposure prophylaxis is given when rabies in dog is confirmed by FA.(fluorescent antibody)

DERMATOLOGY

DERMATOLOGY
1. Seborrheic Dermatitis Red skin with greasy scales, worse in winter & when under stress, Se or Tar soap

2. Psoriasis HLA-B27, Similiar sx to RA but w/ neg RF, Silvery scaled plaques w/ sharp demarcations, Pitted fingernails

3. Pilonidal Cyst Hair lined tract in sacral area = "Jeep Seat"

4. Actinic Keratoses Firm, yellow scale, Due to sun exposure, can lead to squamous cell CA

5. Skin CA Basal Cell > Squamous; Basal Cell = pearly papule w/ dilated blood vessels and central depression; Squamous Cell: Red papule w/ crusted surface, later nodular and ulcerated, rarely mets; Assoc w/ sun exposure

6. Malignant Melanoma Change in size, shape or color of a mole, Usually superficial spreading, Mets incr. as invasion goes deeper than 0.76 mm; itchy & ulcerated

7. Contact Dermatitis 1o = irritant contact - direct injury, all w/ contact affected, Occurs w/ 1st exposure
8. Allergic = type IV hypersensitivity, T cell medicated, Never 1st exposure

9. Carbuncle Abscess of skin caused by several boils coming together

10. Dermatopytoses TINEA CORPORIS: ring worm of body (round lesion w/ raised borders, spreads peripherally w/ central clearing) TINEA CRURIS: Jock Itch; TINEA PEDIS: Athletes Foot; TINEA UNGUIUM : Toenails; TINEA CAPITIS: ring worm of scalp;

11. NEVI PIGMENTED: (Benign) sun exposed areas in children & adolescents
12. DYSPLASTIC: 2-12 mm, more irregular, unexposed areas, Multiple dysplastic Nevi = familial incr. risk of melanoma

13. Hemangiomas NEVUS FLAMMEUS: Port wine stain - flat, purple, does not fade
14. CAPILLARY: strawberry mark, raised, bright red, regress spontaneously by age 5
15. CAVERNOUS: Raised red or purple, enlarged vascular spaces

16. MUSCULOSKELETAL & CONNECTIVE TISSUE
17. Osteoarthritis incr. morning stiffness, bone spurs, osteophytes, DIP = heberdon's nodes, PIP = Bouchard's nodes, also affects hips, knees, spine

18. Rheumatoid Arthritis Symmetric, PIP & MCP joints NOT DIP, Subcutaneous nodules, 70% +RF

19. Gout Affects big toe (Podagra), pinna of ear; Negatively birefringent crystals; Sodium urate; Colchicine or NASIDS for acute attacks

20. Pseudo Gout Calcium pyrophosphate dihydrate; Knee most affected; Positively birefringent

21. Phocomelia Hands & feet attached to trunk, Thalidomide

22. Slipped Capital Femoral Epiphysis Overweight Teens; stiffness=>weakness=>pain radiating down anteromed thigh to knee, ext rot of leg; avascular necrosis

23. Lyme Disease Borrelia burgdorfi, Ixodes tick, arthralgias, Rash w/ central clearing = erythema chronicum migrans, CNS chgs 1 month after exposure

24. Osteoporosis decr. mass of bone; hip & wrist fx most common; decr. estrogen, Ca & Phos normal; Risk factors = post menopause, Caucasian, Asian, smoking, alcohol, corticosteroids, Cushings, hyperparathyroid, hyperthyroid; Etidronate - inhibits osteoclast activity, used for men & women who can't take estrogen

25. Systemic Lupus Erythematosus Malar (butterfly) rash, arthralgias (raynauds), ANA sensitive; Anti dsDNA specific; Neuro = HA, psychosis, seizures, aseptic meningitis; Check for hemolytic anemia w/ Coombs; Renal = incr. BUN incr. Cr, + protein = immune complex glomerulonephritis

26. Polymyositis & Dermatomyositis inflammation of skeletal muscles; violet discoloration of eyelids (heliotrope rash), elevated muscle enzymes (CPK, SGOT, SGPT, LDH) symetric proximal muscle weakness; hips & shoulders 1st

27. Ankylosing Spondylitis "Bamboo shoots" = vertebral squaring w/ bony outgrowths, paraspinal lig. Calcifications on xray; sacroiliac involvement is diagnostic; HLA-B27; incr. ESR

28. Shoulder Hand Syndrome Pain, stiffness, swelling in hand and shoulder; Occurs 1 month after MI or other acute disease

29. Bone Mets from Primary breast, lung, prostate, kidney, thyroid

30. Paget's Disease Osteolytic => osteoblastic; Frontal "bosing" (enlarged skull with rounded forehead) bow legs and shortened spine; incr. alk phos, Ca & phosphorus levels normal; "Cotton Wool" appearance on skull xray; high output cardiac failure

31. Congenital Hip Femoral head partially or completely dislocated from acetabulum; BARLOWS: dislocates hip when abducted and decr. pressure; ORTOLANI'S: reduces dislocation by abduction and flexion

32. Osteochondritis Inflammation of bone & cartilage; Osgood Schlaters - teens, tibial tubercle, pain& swelling at the insertion of the patellar tendon

33. Osteomyelitis Bone infection; Local or hemtogenous spread; Prepuberty infection is in metaphysis; Salmonella - sicklers; S. aureus; pseudomonas; incr. ESR; incr. WBC; Radionucleotide bone scan w/ in 72 hrs; 4-6 wks organism specific antibiotics

34. Septic Arthritis S, aureus = most common; N. Gon most common sexually active; synovial fluid = incr. WBC and + culture; Ceftriaxone NG infection; Nafcillin for others

35. Degenerative Disk Nucleus Pulposa herniates post or postlat.; Lumbosacral = sciatics = L3L4; + pain on straight leg raise;

36. CaudaEquina Syndrome Lg midline post. Hemorrhage compressing C.E. Urinary and bowel incontinence; bilateral leg weakness

37. Polymyalgia Rheumatica older women; assoc w/ temporal arteritis; Morning stiffness; swelling 1-2 joints; no weakness; incr. ESR; neg. Rheum factor; steroid response immediate

38. Fibromyalgia "Trigger Points" reduce pain, IBS, depression, anxiety

39. Osteosarcoma teenage boys, distal femur & proximal tibia; mets to lungs

40. Eosinophillic Granuloma 20-40; granuloma w/ histiocytes, eosinophilic infiltrate & fibrosis; multifocal = poor prognosis

HEMATOLOGY & ONCOLOGY

HEMATOLOGY & ONCOLOGY


i. Microcytic Anemia MCV < 80; IRON DEFICIENCY = decr. ferritin; CHRONIC DISEASE decr. Fe, decr. Transferrin, incr. Ferritin; LEAD POISONING; THALASSEMIA

ii. Normocytic Anemia MCV 80 - 100; Hemolysis, Chronic disease, Bone marrow suppression (drugs, leukemia) (aplastic)

iii. Macrocytic Anemia MCV > 100; FOLATE DEF. = most common cause, decr. folate normal B12;
iv. B12 DEFICIENCY: B12 absorbed when linked with IF from parietal cells, neuro sx,

v. Alpha Thalassemia Acanthocytes (rounded projections from cells); Poikilocytosis (variable size); target cells, Very low MCV but mild anemia, Hemoglobin H = a chain missing; Asians, Dx by Hb electrophoresis,

vi. Beta Thalassemia Peripheral Smear = basophillic stippling, nucleated RBC, anisocytosis (chgs in size) Mediterranean & African heritage; Minor = heterozygous, Major = homozygous

vii. Sickle Cell Anemia sickled cells, decr. Hct & incr. reticulocyte count, electrophoresis HbS + HbA neg. Salmonella osteomyelitis, S. pneumonia sepsis.

viii. Hemophilia X linked factor VIII (A) or IX (B) deficiency; Prolonged PTT, Joint & soft tissue bleeding; Tx cryoprecipitate & FFP

ix. Von Willebrand's Disease autosomal dominant deficiency of VIII & vWF, epistaxis, menorrhagia, bruising, increased PTT & bleeding time

x. Eosinophilia Allergic Drug Reaction; NAACP = neoplasm, asthma/allergies, Addison's disease, connective tissue disorders, parasites

xi. Thrombotic Thrombocytopenic Pupura adults > kids, women > men; platelets consumed in clotting reactions, Fluctuating neurologic defects, decr. platelets, decr. HCT, incr. retic count, incr. incr. incr. LDH, acute onset not autoimmune

xii. Idiopathic Thrombocytopenic Pupura kids > adults, autoimmune destruction of platelets, Purpurea & Petechia , Platelets<10000, Epistaxis, menorrhagia

xiii. Hemolytic Uremic Syndrome Usually caused by E. coli toxin, RBC fragments on smear, RBC destruction => acute renal failure, 2o thrombocytopenia, abd pain & diarrhea after a flu or URI prodrome; platelets derc, LDH greatly increased

xiv. Hodgkin's Lymphoma Painless cervical lymphadenopathy, Reed Sternberg cells (multinucleated reticular cells), 80% survival

xv. Burkitt's Lymphoma B cell lymphoma, Associated with Epstein-Barr virus, children & young adults

xvi. Hereditary Spherocytosis dominant deficit in RBC membrane proteins, damaged cells get trapped in spleen. Spherical RBC & reticulocytosis on smear. Coombs neg.

xvii. G-6-PDase Deficiency X linked hemoglobin accumulates in RBC (Heinz bodies) hemolysis occurs after ingestion of oxidant

xviii. Agranulocytosis neutrophils = decr production or incr destruction

xix. DIC wide spread activation of coagulation cascade. decr. platelets, fragmented RBC, incr. PT & PTT ; decr. fibrinogen, Pregnancy, malignancy, infections, massive trauma

xx. Acute Lymphocytic Leukemia 80% childhood leukemia, peak age 3 - 7; usually B cell origin; incr. lymphoblasts, few other cells on bone marrow biopsy

xxi. Acute Myelocytic Leukemia affects myeloid cells (N,B,E,erythrocytes, megakarocytes) adults > kids; DIC possible, gram neg and fungal infections, Auer Rods (red staining intracellular inclusions.

xxii. Chronic Myelocytic Leukemia Philadelphia Chromosome (acquired translocation chromosome 9 & 22), tumor cells are more mature, Dx in middle aged, WBC > 150000; incr. uric acid, incr. B12 (B12 carrier protein produced by WBC); leukocyte alkaline phos decr or absent, RBC normal
xxiii. Blast crisis transforms it to acute leukemia

xxiv. Chronic Lymphocytic Leukemia Disorder of mature B cells (rarely T); B cells don't differentiate into plasma cells, men > women; usually > 50; No Blast Crisis

xxv. Hairy Cell Leukemia B cell transformed into tumor cell with fine hair like projections; pancytopenia, red pulp of spleen infiltrated

xxvi. Multiple Myeloma Plasma cell proliferation and monoclonal IG; men = women; peak 50 - 60, 1 - 3 year survival; xrays show osteolytic bone lesions, Increased urine protein (Bence Jones)

xxvii. Waldenstrom's Macroglobulinemia single B cell line = monoclonal IM over production; decr. RBC with normal WBC & platelets; Rouleau Formation = RBC pile up forming cylinders

xxviii. Mycosis Fungoides Clonal proliferation of CD4 T cells; infiltrates dermis & epidermis, thickened & nodular skin lesions

xxix. Polycythemia Vera overproduction of all 3 cell lines; RBC > 1,000,000, Hct > 60%; men & women peak age 60; Bone biopsy- hypercellular with absent Fe stores; R/O spurious polycythemia = incr. RBC due to dehydration; R/O 2o polycythemia = RBC mass incr. due to decr. oxygenation.

xxx. Eaton Lambert 90% assoc w/ small cell CA, decr. presynaptic Ca release = proximal muscle weakness; hyporeflexia, dysautonomia, function incr. w/ stimulation; weakest in AM (opposite MG) Tx Tubocurare

INFECTIOUS DISEASES & IMMUNOLOGY

INFECTIOUS DISEASES & IMMUNOLOGY
1. Fever most common cause immed post op = atelectasis; 3-5 days postop = infection; > 2 wks post op = PE or thrombophlebitis

2. Fever of Unknown Origin > 100F for > 3 weeks despite active search for cause for > 1 week; need to get CBC w/diff, blood cultures; kids = usually infection; adults = infectious, neoplasm, autoimmune

3. Inflamation Rubor, Tumor, Calor, Dolor

4. Types of Immunity Active Acquired= direct exposure - infection or vaccination; Passive Acquired = temporary, serum Ab given (IG, breast milk)

5. Bacteremia bacteria in blood but asymptomatic

6. Septicemia bacteria in blood with symptoms

7. Immunizations in Kids HEP B = mom + HbsAG = HBIG & 1st Hep B vaccine at birth
8. DTP = contraindications => progressive neuro disorder, Hx encephalopathy w/ in 7 days of previous dose; Pertussis not given if > 7 y/o or if currently have pertussis
9. H FLU = not in kids > 5
10. POLIO = IPV if immunocompromised
11. MMR = not effective before age 1; don't give if less than 3 months since transfussion or IG use; ok for HIV +; suppresses TB - give Tine(PPD) & MMR at same time or 4-6 weeks apart.

12. Adult Immunizations TETANUS = booster q10y, No Hx immunization 2 td 1-2 mos apart then booster at 6-12 mos then on normal 10 y cycle
13. FLU = chronic resp problems, metabolic diseases, adults > 65; can cause false positive HIV test

14. HIV/AIDS RNA retro, CD4 cells, Dx based on concurrent related diseases &/or CD4 , 200 cells/mm3; Flu-like illness, antibodies 1 - 6 months after infection

15. AIDS related infections CMV, HSV, VZV, EBV, TB, mycoplasma avium-intracellular, candida coccidioides, histoplasmosis, cryptococcus, Pneumocystic carnii (protozoa) Toxoplasmosis, cryptosporidiosis, Giardiasis

16. DeGeorge's Syndrome Thymic aplasia, Absent T cells, congenital heart disease, craniofacial abnormalities

17. Wiskcott- Aldrich Syndrome X linked, no antibodies against encapsulated bacteria, eczema, decr. platelets,

18. Chronic Granulamatous Disease Autosomal recessive, defect in phagocytic enzymes, recurrent bacterial & fungal infections

19. Chediak-Higashi Syndrome Autosomal recessive, recurrent strep & staph infections

20. Bruton's Disease x-liked, agammaglobulinemia, N B cells or antibodies

21. Ataxia Telangectasia Auto recessive, lymphopenia & IgA deficiency; gait abnormal, telangiectasia

22. Severe Combined Immunodeficiency Deficits of B & T cells, IgA deficiency, recurrent infections esp resp & GI, IG administration contraindicated