USMLE World Step 2 Notes

12/15/09 1. Febrile neutropenia (chemotherapy for tumor patient) is a medical emergency. Admit the patient to the hospital, obtain blood cultures, then start broad-spectrum antibiotics such as IV ceftazidime or cefepime. The most common site of mucositis si the gastrointestinal tract, and the frequently identified organism are G-, Particular P.aeruginosa. 2. In patient with acute ‘mechanical’ back pain (disc herniation) without significant neurologic deficit, conservative approach is preferred for a period of 4-6 weeks. This includes early mobilization, muscle relaxants, and NSAIDs. Best rest and physical therapy has not been shown to be help. If the pain persists after 4-6 weeks of conservative treatment or progressive neurologic deficit evolves, high-resolution diagnosis modalities are usually employed: MRI and CT with or without contrast myelography. 3. Advanced age is probably the single most important risk factor for breast cancer. That is why women of more than 40-50 years of age would need regular annual mammograms. Interestingly, only 10 percent of women diagnosed with breast cancer have a positive family history. 4. When questionable ulcer is visualized by flexible sigmoidoscopy, a biopsy is recommended for two purposes: (1) to rule out possible cancerous lesions, and (2) distinguish ulcerative colitis from Crohn’s disease, since the treatment of each given conditions is different. 5. Mitral valve prolapse (MVP) typically causes a mid-systolic click over the cardiac apex, with a short systolic murmur at the apex after the click if mitral regurgitation is present. Squatting decreases the murmur. MVP is sometimes associated with chest pain, anxiety, palpitations, and/or hayperventilation. 6. The most common cause of overflow incontinence in elderly males is an enlarged prostate, which is usually revealed by rectal examination, and is characterized by a high post-void residual volume. 7. The typical symptoms of aortic stenosis are exertional dyspnea, syncopy, and angina. The physical exam will reveal a systolic ejection murmur radiating to the apex and carotid arteries. 8. A prolonged QRS interval (i.e., typically bundle branch block) suggests a bradyarrhythmia, whereas a prolonged QT interval suggests a tachyarrhythmia. When the heart rate is lower than 30bmp, cerebral perfusion is impaired, even if there is a compensatory increase in stroke volume. A patient with a disease of the sinus node (SSS) or conduction system can have intermittent bradycardia and typically manifest with recurrent syncopy episodes. Ventrical beats, by themselves, are not associated with syncope. The most important differential diagnosis of syncope is generalized seizures. Distinguishing features of a seizure include the presence of sustained clonic-tonic movement, tongue biting, and postictal confusion. 9. Palliate radiation, along with anti-androgen therapy, is the treatment of choice for metastatic prostate cancer. Anti-androgen therapy consists of Leuprolide (LHRH analogue). Flutamide is considered inferior to LHRH analogues. 10. While effective in the treatment of many bacterial infections, aminoglycosides can also cause nephrotoxicity and ototoxicity. Gentamicin sometimes causes severe vestibulotoxicity, resulting in potentially permanent vertigo and ataxia. Benign positional vertigo occurs when calcium crystals within the inner ear shift position. 1

Patients present with recurrent, acute-onset vertigo that is precipitated by head movement. Nystagmus, nausea and vomiting are common associated findings. 11. Suspect alpha-a antitrypsin (AAT) deficiency in non-smoking adults 150% of ideal body weight) and alveolar hypoventilation during wakefulness. The ABG will demonstrate hypercapnia, hypoxemia and respiratory acidosis (pH 7.3, pO2 60mmHg, pCO2 69 mmHg) as a consequence of decreased lung compliance. Weight loss, ventilator support, oxygen therapy, and progestins (a respiratory stimulant) are all potential therapies for these patients. 29. The basic pathology in myasthenia gravis lies at the neuromuscular junction (that’s why it’s called myasthenia) and is mediated by auto-antibodies against the acetylcholine receptor. 30. HIV patients are at high risk for tuberculosis. A positive PPD test (>5mm in HIV) require prophylaxis with isoniazid (+pyridoxine) for 9 months. Alternatives to the use of isoniazid include the use of pyrazinamide with rifamipin or rifabutin for 2 months. If a patients if intolerant ot pyrazinamide, rifampin is given alone for 4 months. A combination of 3 or 4 drugs is used to treat active tuberculosis infection. 31. Situational syncope should be considered in the differential diagnosis of syncopal episodes. The typical scenario would include a middle age or older male, who loses his consciousness immediately after urination, or a man who loses his consciousness during coughing fits. 32. Hypertension in patients with thyrotoxicosis is predominantly systolic and caused by hyperdynamic circulation. 33. False negative 34. Lymphogranuloma venereum (LGV) is a sexually transmitted disease caused by Chlamydia thrachomatis serotypes L1,2 and 3. The disease starts to 1 to 4 weeks after initial contact and manifests with generalized malaise, headaches and fever. A papule appears and subsequently transforms into an ulcer, typically located in the vulvovaginal region. The ulcer is painless and the disease may go unnoticed until inguinal adenitis develops about a month later. In women, however, the lymphadenopathy involves more commonly the deep nodes around the rectum and anus. If untreated at this stage, LGV progresses into a severe and chronic disease causing ulceration, proctocolitis, rectal stricture, rectovaginal fistulas and elephantiasis. Granuloma inguinale (GI) is a distinct condition that presents similarly but is due to Donovania granulomatis. Unlike LGV, the ulcer and lymphadenopathy of granuloma inguinale present at the same time. Moreover, the ulcer of GI has irregular borders and is characterized by a beefy red granular base. 35. Once the specific causative bacterium responsible for native valve bacterial endocarditis is identified, the antibiotic coverage can be narrowed from empiric to specific. Native valve bacterial endocarditis due to Strep viridans highly susceptible to penicillin is well-treated with IV penicillin G or IV ceftriaxone. 36. While most live vaccines (BCG, varicella, anthrax, oral typhoid, intranasal influenze, oral polio, and yellow fever) are C/I in patients with HIV, the MMR vaccine is an exception and can be given to patients who have CD4 counts greater than 200/mL and not evidence or history of an AIDS-defining illness. 37. Hyperparathyroidism predisposes to the development of pseudogout. Pseudo tends to present as an acute onset, painful monoarthritis affecting the knee. Rhomboid shaped, positively 4

birefringent crystals are diagnosic. Struvite crystals have the shape of coffin lids and are seen in nephrolithiasis causes by chronic urinary tract infection with urease-producing organisms. 38. The null hypothesis is always the statement of no relationship between the exposure and the outcome. To state the null hypothesis correctly, you should recognize the study design first. Cross-section: no association; cohort study: the same 39. The most important causes of thyrotoxicosis with low radioactive iodine uptake include: 1. subacute painless thyroiditis; 2. subacute granulomatous thyroiditis—De Quervain’s, intense pain; 3.iodine-induced thyroid toxicosis; 4.levothyroxine overdose; 5. Struma ovarii 40. Leydig cell tumors, the estrogen production can be increased with secondary inhitibition of LH and FSH. High testosterone, high estrogen 41. Howell-Jolly bodies (single round, blue inclusions on Wright stain) are nuclear remnants within RBC typically removed by the spleen. Their presence strongly suggests physical or functional hyposplenism. 42. Hypertrophic cardiomyopathy is inherited in an autosomal dominat pattern. 43. Hypertension can be one of the presentating signs of polycythemia (know the various presentations). 44. Steroid-induced myopathy is a well described result of long-term corticosteroid use. It is characterized by painless proximal muscle weakness. Steroid myopathy will improve slowly once the offending medication is discontinued. Serum Ck and ESR are normal. Insidious, acute and chronic. 12/16/09 1. Lead-time bias should always be considered while evaluating any screening test. This bias occurs when there is an incorrect assumption or conclusion of prolonged apparent survival and better prognosis due to a screening test. What actually happens is that detection of the disease was made at an earlier point in time, but the disease course itself or the prognosis didn’t change. So the screened patients appeared to live longer from the time of diagnosis to the time of death. (USMLE tip: think of lead-time bias when you see ‘a new screening test’ for poor prognosis diseased like lung or pancreatic cancer.) 2. The main causes of metabolic alkalosis include exogenous administration of alkali, removal of acidic gastric secretions due to vomiting or NG tube aspiration, renal hydrogen ion loss due to mineralocorticoid excess and contraction alkalosis. 3. Hyperemesis gravidarum typically causes metabolic alkalosis with respiratory compensation via hypercapnia. PE causes a primary respiratory alkalosis due to hyperventilation. 4. Blood PH 7.43, PaO2 100mmHg, PaCO2 25mmHg, HCO3- 16 mEq/L. Aspirin intoxication causes a mixed respiratory alkalosis and metabolic acidosis. Respiratory alkalosis results from increased respiratory drive, while metabolic acidosis results from the accumulation of salicylate and organic acids. 5. Memorize! Lesion Manifestation posterior limb of the unilateral motor hemiparesis of the face, arm and leg without any internal capsule (lacunar higher cortical dysfunction and visual field abnormalities. infact) Middle cerebral artery contralateral hemiplegia, conjugate eye deviation toward the side 5

occlusion Anterior cerebral occlusion

artery

vertebrobasilar system lesion (*supplying the brain stem)

of the infarct, hemianesthesia and homonymous hemianopia. *aphasia (dominant hemisphere), *hemineglect (non-dominant hemisphere lesions). contralateral weakness that predominantly affects the lower extremity. Associated findings include abulia, akinetic mutism, emotional disturbances, deviation of the head and eyes toward the lesion, and sphincter incontinence. ‘alternate’ syndromes, with contralateral hemiplegia and ipsilateral cranial nerve involvement.

6. Toxic adenoma presents as symptoms suggestive of thyroid toxicosis. There is radioactive iodine uptake in the nodule, and suppression of uptake in the rest of the thyroid gland. Patients with toxic nodule do not have infiltrative ophalmopathy. Patients with Hashimoto’s thyroiditis are hypothyroid or euthyroid. The thyroid scan shows heteogenous pattern. Grave’s –diffusely increased radioactive iodine uptake + infiltrative ophalmopathy+pretibial myxoedema. The radioactive iodine uptake in patients with painless thyroiditis is markedly reduced. 7. Esophagoscopy is indicated when a patient with GERD fails to repond to empiric treatment, or when a patient had features of complicated disease. 8. Nephritic syndrome is characterized by dependent edema, hypertension, and hematuria (dysmorphic red blood cells or red blood cell cast). Rash, low-grade fevers and proteinuria may also be present. 9. Agioedema is characterized by the rapid onset non-inflammatory edema of the face, acral extremities, genitals, trachea and abdominal organs. It is due to a deficiency in C1 esterase inhibitor, which results in elevated levels of the edema-producing factors, C2b and bradykinin. Low C1q levels are associated with familial systemic lupus erythematous. 10. Fluphenazine is a high potency ‘typical’ antipsychotic medication that occasionally causes hypothermia by disrupting thermoregulation and the body’s shivering mechanism. Patients taking antipsychotics should be advised to avoid prolonged exposure to extreme temperatures. 11. Any male adolescent who presents with epistaxis (nosebleeds), a localized mass, and a bony erosion on the back of the nose had an angiofibroma until proven otherwise. This is typically found in the back of the nose or upper throat (nasopharynx). Reactive nasal polyps normally do not cause bony erosions. These are usually associated with chronic infections or allergies, and the main complaint is obstruction rather than bleeding. 12. Osteoarthritis is a non-inflammatory arthritis presenting with pain that is worse with activity and improved with rest. X-ray findings include joint space narrowing and osteophytes. Synovial fluid analysis will reveal fewer than 2000 WBC/ml, no organisms, and no crystals. Gouty arthritis—punched out erosions with a rim of cortical bone. 2,000-50,000 WBC/ml, negative birefringent crystals. RA—periarticular osteopenia and joint margin erosions. 2,000-50,000 WBC/ml Infectious arthritis—normal joint space with soft tissue swelling, >50,000 cells/ml Gram staining Psudogout, or calcium pyrophosphate dyhydrate (CPPD) deposition—calsification of cartilaginous structures (chondrocalcinosis).

6

13. indications for upper endoscopy in the management of GERD: 1-Nausea/vomiting; 2-Weight loss, anemia or melena/blood in the stool; 3-Long duration of symptoms (>1-2 years), esp in Caucasian males >45 years old; 4-Failure to respond to proton pump inhibitors. 14. Vitiligo is an autoimmune condition characterized by area of depigmentation lacking melanocytes. Vitiligo is sometimes associated with other autoimmune conditions such as pernicious anemia, autoimmune thyroid disease, type I diabetes mellitus, primary adrenal insufficiency, hypopituitarism, and alopecia areata. 15. hemochromatosis is an autosomal recessive disorder characterized by increased skin pigmentation, diabetes, cirrhosis and arthralgia in the later stages. 16. CDC vaccination schedules on a yearly basis: Tetanus and diphtheria (Td): every 10 years after 18. A single tetanus, diphtheria, and acellular pertussis (Tdap) booster between 19-64. Influenze: all adults agen 50 years and older. It should also be given to all adults with chronic cardiovascular, pulmonary, hepatic, renal, or metabolic (e.g.diabetes) disease, immunosupprssion, or pregnancy. Healthcare workers, close contact of children aged 0-59 months, and those in nursing homes should also be vaccinated. Healthy, non-pregnant persons aged 5-49 years may receive the intranasal influenza vaccine. Pneumococcal vaccine (PCV): all adults aged 65 years and older. It should also be given to all adults with chronic cardiovascular, pulmonary, hepatic, renal, or metabolic (e.g. diatetes) disease, or immunosuppression. Persons vaccinated before age 65 need a booster in 5 years. 17. Dubin-Johnson and Rotor syndrome are two familial disorders of hepatic bile secretion that result in conjugated hyperbilirubinemia. A dark granular pigment is present in the hepatocytes of patients with Dubin-Johanson, but not Rotor. For diagnosis of Dubin-Johnsom, conjugated hyperbilirubinemia with a direct bilirubin fraction of at least 50% and an otherwise normal liver function profile must be present. Confirmation can be obtained by evaluating the urinary coproporphyrin for usually high levels of coproporphyrin I80% (normal 80% III) . 18. Fresh frozen plasma is the therapeutic agent of choice for the coagulopathy in patients with liver failure. 19. Primary HIV infection causes a febrile illness that can closely resemble infectious mononucleosis. The key distinctions: rash (unless antibiotics have been administered), diarrhea—HIV; a tonsillar exudates –EBV 20. The sudden onset of vertigo, vomiting and occipital headache in a hypertensive patient is strongly suggestive of cerebellar hemorrhage. Other manifestation are 6th nerve paralysis, conjugate deviation, blepharospasm and coma. Heat stroke—failure of body thermoregulation upon exposure to high environmental temperatures. High core body temperature (>105F), dehydration, confusion, coma, and dry, flushed skin. “heat exhaustion” less severe. Vestibular neuronitis—acute onset of vertigo and nystagmus without any other neurological deficit Meiiere disease—increase pressure of the endolymph, vertigo, tinnitus, hearing problem. Vomiting is not prominent. 21. V/Q scan is a useful tool in diagnosis pulmonary thromboembolism. Mismatched perfusion defect is characteristic, but it is found in less than 50% of the patients. 22. Actinic keratoses—sun –exposed, erythemarous papules with a central scale and a ‘sand paper-like’ texture, squamous cell carcinoma. 7

Atopic dermatitis –light microscopy—spongiosis (edema of the epidermis) 23. The typical VitK deficiency –NPO for a prolonged period of time + broad spectrum antibiotics. PT is elevated more than PTT. Similar in newborn who had not received prophylactic vitK (home born) 24. Hypercalcemia and intractable ulceration –MEN syndromes 25. ARDS-acute onset, bilateral patchy airspace disease on CXR, PCWP6.5 with oral sodium bicarbonate or sodium citrate is indicated. In general, immunosuppressed pts and those with immunodeficiencies should receive an extensive panel of vaccinations, but should not receive live vaccines: BCG, varicella (chickpox), varicella zoster (shingles), anthrax, oral typhoid, intranasal influenza, oral polio, and yellow fever vaccines. The only exception is the MMR, which may be used in pts without evidence of immunity if their CD4+ count is >200/mm3 and they have no history or evidence of an AIDS-defining illness. Acute inflammatory arthritis caused by CPPD (calcium pyrophosphate dehydrate) crystals is called pseudogout. It often occurs in the setting of recent surgery or medical illness. Pseudogout is diagnosis by the presence of rhomboid-shaped, positively birefringent crystals on joint aspiration microscopy and radiographic evidence of chondrocalcinosis (calcified articular cartilage). receiver-operating characteristic curve (ROC) Suspect acute glaucoma in a pt with a sudden onset of eye pain, photophobia, and a middilated pupil. Tonometry is the best diagnostic test. The concept of latent period is an important issue in chronic disease epidemiology. Exposure must be continuously present for a centain peroid to time (called latent period) to influence 129

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40. 41.

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the outcome. Exercise EKG testing is recommended for pts with an intermediate pre-test probability of angina based on clinical features and risk factors. Medications that should be withheld prior to testing include anti-ischemic medications, digoxin and medications that slow the heart (eg. beta-blockers). Cholesterol embolization usually follows surgical or interventional manipulation of the arterial tree. Renal failure, livedo reticularis, systemic eosinophilia, and low complement levels should make you think of cholesterol embolism. Renal failure in the presenct of systemic eosinophilia should make you think of cholesterol embolism, allegic interstitial nephritis, or polyarteritis nodosa. Acute allergic interstitial nephropathy is a drug-induced hypersensitivity reaction characterized by rash, renal failure, eosinophilia, and eosinophiluria (Hansel stain). The common medications that you should remember of the exam are: 1) antibiotics (most common is methicillin group). 2) NSAIDs (often cause heavy proteinuria). 3) Thiazides 4) phenytoin 5) allopurinol * Extremely high yield!! Acute otitis media should be considered in any pt with symptoms of ear drainage and difficulty hearing. Ear pain is also common, but may be absent in young pts. Nonspecific systemic symptoms including fever, irritability, and diarrhea can sometimes be present as well. Cholesteatoma can present with hearing loss and ear drainage, but fever and systemic symptoms are not usually present. Succinylcholine is a depolarizing neuromuscular blocker that can cause life-threatening hyperkalemia. It should not be used in pts with or at high risk for hyperkalemia, such as burn and cruch injury pts and pts with prolonged demyelination. The classic findings in pts with amyloidosis are renal amyloid deposits that show apple-green birefrigence under polarized light after staining with Congo red. Clues—RA pt with enlarged kidney and hepatomegaly. Many expert group including the US Preventative Services Task Force recommended a onetime screening of all women who are 65 years and older with a DEXA scan—ostepporosis. “Soap bubble appearance in the epiphyseal end of long bone”—giant cell tumor of bone. The classical pt is 20-40 yr old female with knee pain and some mass. The tumor cells are oval or spindle shaped intermingled with numerous multinuclear giant cells in fibrous stroma. It is benign but locally aggressive. It frequently recurs even after local currettage. The best way to handle this tumor is to recognize it and leave it for experts. The most feared complication of a retropharyngeal abscess is spread of infection into the mediastinum, which can lead to acute necrotizing mediastinitis. The major complication of an infection in the parapharyngeal space is involvement of the carotid sheathm which may lead to erosion of the carotid artery and jugular thrombophlebitis. Crystal-induced nephropathy is a well-know side effect of indinavir (a protease inhitibor) therapy. Remember: 1) didanosine-induced pancreatitis. 2) abacavir—related hypersensitivity synrome. 3) Lactic acidosis sencondary to the use of any of the NRTIs. 4) Stevens-Johnson syndrome secondary to the use of any of the NNRTIs. 5) nevirapine—associated liver failure. Alcoholism is the most common cause of cirrhosis in the US. Infection with HCV is the second MCC of cirrhosis in the US.

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1. IgA nephropathy is the most common cause of glomerulonephritis in adults. Pts have recurrent episodes of gross hematuria, beginning 1-3 days after an upper respiratory infection. Serum complement levels are normal. The latent peroid from infection to hematuria in poststreptococcal glomerulonepharitis averages 10 days for pharyngitis and 21 days for impetigo, while it is less than 5 days for IgA nephropathy. Serum complement levels are low in cases in post-streptococcal glomerulonepharitis. 2. In chronic tophaceous gout, urate crystals can be deposited in the skin resulting in the formation of tumor with a chalky white appearance. 3. Viridans group strepcocci are the most likely cause of endocarditis in native valves following dental procedure. 4 members of the viridans group cause infective endocarditis: Streptococcus mitis, S. sanguis, S. Mutans and S. salivarius. S. mutans also causes dental caries. S. bovis is a normal inhabitant of the GI tract, and S. bovis bacteria is associated with colon cancer. Colonscopy should be perfomed when this organism is isolated from blood culture. S.epidermidis is an important cause of prosthetic valve endocarditis. It is also seen in infants with IE sencondary to umbilical venous catheter infection in neonatal intensive care units. Enterococci are normal inhabitants of the GI tract and also occasionally colonize the anterior urethra. Enterococcal endocarditis generally affects older men after genitourinary manipulation or young women after obstetric procedures. 4. Guillain-Barre syndrome is an acute or subacute ascending papalysis, CSF analysis reveals an elevated protein level with normal glucose levels, WBC and RBC counts. 5. Gallbladder carcinoma (GBC) is a rare malignancy that most often arises in Hispanic and Southwestern Native American females who have a history of gallstones. It is typically diagnosed during or after cholecystectomy. Because the symptoms of gallbladder carcinoma are vague and nonspecific (eg. pain, anorexia, nausea, vomiting, malaise) and the gallbladder is nestled among other organs, GBC tends to be late-presenting and to have spread by the time of diagnosis. Radical surgical interventio for pts with advanced disease includes cholecystectomy and removal of the gallbladder bed, pancreatic head, LN, and sometimes portions of the liver or biliary tree. If the GBC is discovered while still confined to the lamina propria of the gallbladder, however, simple cholecystectomy results in a cure rate of 73%100% and is considered sufficient tx. Chronic choledochoithiasis is a risk factor for GBC because if causes inflammation and irritation of the gallbladder epithelium, thereby inviting malignant change. 6. Hawthorne effect is the tendency of the study population to affect the outcome since they are aware they are being studied. Sample distotion is seen when the estimate of exposure and outcome association is biased b/c the study sample is not representative of the target populationn with respect to the joint distribution of exposure and outcome. Information bias occurs due to the imperfect assessment of association between the exposure and outcome as a result of errors in the measurement of exposure and outcome status. It can be minimized by using standardized techniques for surveillance and measurement of outcomes, as well as trained observers to measure the exposure and outcome. Confounding bias occurs due to the presence of one or more variables associated independently with both the exposure and the outcome. For example, cigarette smoking can be a confounding factor in studying the association between maternal alcohol drinking and low birth weight babies, 131

as cigarette smoking is independently associated with both alcohol consumption and low birth weight babies. 7. The most common site of ulnar nerve entrapment is the elbow where the ulnar nerve lies at the medial epicondylar groove. Prolonged, inadvertent compression of the nerve by leaning on the lebows while working at a desk or table is the typical scenario. * Extremely high yield!! 8. 70% of cases with interstitial nephritis are caused by drugs such as cephalosporines, penicillins, sulfonamide containing diuretics, NSAIDs, rifampin, phenytoin, and allopurinol. Discontinuing the offending agent is the tx of drug-induced interstitial nephritis. Steroids may hasten recovery in cases of drug-induced interstitial nephritis, but they may aggrevate the underlying infection. 9. Otimally, the first step in treating a pt with a witnessed cardiac arrest is defibrillation. When a cardiac arrest is unwitnessed or when there is a greater than 4-5 minute lapse between arrest and arrival of the defibrillator, a trial of cardiopulmonary resuscitation (CPR) should precede defibrillation. 10. Hodgkin’s disease is a curable lymphoma that tends to affect young pts. Unfortunately, pts can develop secondary malignancies form chemotherapy and/or radiation, especially those treated before the age of 30. The risk of secondary malignancy is highest when chemotherapy is combined with radiation, reaching up to 3.2% within 20 years of tx. Lung and breast cancers are among the most common secondary malignancies affecting pts previously treated for Hodgkin’s disease. 11. Wafarin is a vit K antagonist used for anticoagulation in numerous clinical settings. Foods rich in vits K (eg. dark green vegetables: brussels sprouts, green tea, spinach) will decrease its efficacy whereas numerous other foods, supplements, and medications will increase its activity. Examples of agents that increase warfarin activity include alcohol, vit E, garlic, ginkgo biloba, ginseng, St. John’s wort, and several types of antibioticss. 12. IgA deficiency significantly increases the risk of developing an anaphylactic reaction to transfused blooc products. The risk of anaphylaxia may be reduced in susceptible pts by providing IgA-deficient blood products or by preforming additional washes on RBC or platelet products. 13. Clear lung fields, hypotension, and jugular venous distension in the setting of an inferior wall MI are suggestive of an RV infarct. Fluid resuscitation is the appropriate mx, and nitrates should be avoided. Nitrates are not indicated in the setting of aortic stenosis, recent phosphodiesterase inhibitor use, or right ventricular infarction. 14. It is important to distiguish between the different patterns of muscle weakness. The hallmark of myasthenia gravis is decreasing muscular strength with continued contraction. While this can affect any skeletal muscle, extraocular symptoms (eg. diplopia) are most common. 15. Normally, more than 95% of circulating bilirubin is the unconjugated fraction, which is highly insoluble in water and is tightly bound to albumin. When bound, this unconjugated bilirubin cannot be filtered by the glomerulus and is therefore not excreted in the urine. In the contrast, the conjugated bilirubin is water soluble, loosely bound to albumin, and excreted in urine when presnt in excess. Therefore, the presence of bilirubin in urine is indicative of a conjugated hyperbilirubinemia (urine dipstick)—eg. Rotor syndrome. 16. Leukoplakia presents as hard to remove white patches in the oral mucosa and may lead to squamous cell carcinoma. It is usually caused by chronic irritation to the oral mucosa due to 132

smoking, alcohol, or ill-fitting dentures. 17. First generation H1-antihistamines (diphenhydramine, chlorpheniramine, doxepine and hydroxyzine) have potent anticholinergic effects and may cause eye and oropharyngeal dryness as well as urinary retention, especially in older males who may have some underlying BPH. Urine retention caused by anticholinergic agents results from failure of detrusor contraction. 18. Pts at average risk of developing colon cancer should begin screening at age 50 with fecal occult blood testing (FOBT), flexible sigmoudoscopy, a combination of the two, colonoscopy, or double-contrast barium enema. Pts with an affected first-degree relative should begin screening 10 years before the age of relative was diagnosed. 19. Facial nerve palsy and classical erythema migrans (EM) indicate Lyme disease, which is a tick-bite disease. 20. The first step in the evaluation of a pt with a thyroid nodule is measurement of the TSH level. If the TSH level is elevated, the levels of thyroid antibodies and thyroxine (T4) are measured b/c pts with Hashimoto’s thyroiditis can have thyroid nodule formation. Since thyroid cancer can occur with Hashimoto’s thyroiditis, FNAB is usually done if the nodule is larger than 1-1.5cm. There is no real pathognomic sign that can conclusively differentiate benign form malignant thyroid nodules; however, a rapid decrease in nodule size with levothyroxine tx is very reassuring for a bening process. If the TSH level is suppressed or below normal, radioiodine uptake and scan are typically performed. If the scan shows a hot nodule (increased uptake of the tracer in the nodule with decreased uptake in rest of the tryroid gland), FNAB is not performed b/c the chances of malignancy in a hot nodule are extremely low. If the TSH level is normal, FNAB is the next step. 21. Muscle weakness in paraneoplastic syndrome can be due to a variety of processes at different levels. A good history and physical exam can help localize the process in most cases. Myopathy association with lung cancer--The muscle involvement may be due to inflammation, necrosis, fiber atrophy, and antibody-mendiated damage. Proximal muscles are typically affected, and muscle strength is diminished symmetrically. Reflexes are normal, and no sensation abnormality is present. Elevated CK level and myopathic electromyograph help to confirm the dx. The pathologic precess in localized in muscle membrane. 22. The dx of cystic fibrosis is made on the basis of compatible clinical findings with laboratory comfirmation. Sweat chloride test ( >60 mEq/L) is the gold standard test for the diagnosis of cystic fibrosis and preferred over direct mutation analysis as more than 1,250 mutations in CFTR can lead to cystic fibrosis. 23. There is no evidence that regular abdominal ultrasounds can help decrease mortality from ovarian cancer. 24. The body compensates for chronic hypercarpnia by increasing renal bicarbonate retention. Typically 0.1 mEq/L of bicarbonate is retained for every 1 mmHg increase in pCO2. 25. Senile purpura is characterized by ecchymoses that occur on elderly pts’ extensor surfaces due to perivascular connective tissue atrophy. The lesions develop rapidly and resolve over several days. Typically leaving a brownish discoloration from hemosiderin deposition. Senile purpura is not a dangerous condition and requires no further investigation. 26. Psudogout cannot be reliably distinguished from gout and septic arthritis based on history and 133

physical alone. It is diagnosed by the presence of rhomboid, positively birefringent crystals on synovial fluid analysis, and radiographic evidence of chondrocalcinosis. 27. It is important to recognize that oral contraceptives can be a potential cause of hypertension (an estrogen-mediated increase in the synthesis of angiotensinogen in the liver), and simply discontinuing its use can correct the problem. 28. Chronic pancreatitis is a serious disease and often leads to severe disability. Surgical interventions in the case of chronic pancreatitis are indicated in case of chronic pseudocyst, debilitating pain or to treat other complications. This pt has severe debilitating pain affecting her work and daily life. She is an ideal candidate for ERCP and stone removal with stent insertion, which would relieve the pain in 80% of such pts. 29. Turcot’s syndrome refers to an association between brain tumor (primarily medulloblastomas and gliomas) and FAP (Familiar Adenomatous polypsis) or HNPCC (Hereditary nonpolyposis colorectal cancer). The majority of FAP-associated brain tumors are medulloblastomas, but gliomas have also been described. Pts with HNPCC are prone to high-grade gliomas. It is autosomal recessive and mainly occurs in teens. Gardner’s syndrome is autosomal dominant where colonic polyps are seen with prominent extraintestinal lesions. These include desmoid tumors, sebaceous or epidermoid cysts, lipomas, osteomas (especially of the mandible), supernumerary teeth, gastric polyps, and juvenile nasopharyngeal angiofibromas. Peutz-Jeghers syndrome is an autosomal dominant inherited disorder characterized by intestinal hamatomatous polyps in association with mucocutaneous melanocytic macules. Multiple hamartoma syndrome (Cowden syndrome) is associated of GI tract hamartomas with breast Ca, thyroid Ca, and nodular gingival hyperplasia. Cronkhite-Canada syndrome is association of juvenile-type polyps and ectodermal abnormalities like alopecia, hyperpigmentation, and nail loss (onycholysis). 30. Malignant otitis externa (MOE) is a potentially serious infection of the external ear that is usually caused by Pseudomonas aeruginosa. It is typically seen in elderly pts with poorly controlled diabetes and presents with ear pain, drainage, and granulation tissue within the ear canal on otoscopic exam. IV ciprofloxacin is the most effective tx. 31. Opioid intoxication does not always present with miosis. Coingestions can lead to normal pupil size or even mydriasis and certain opioids (meperidine, propoxyphene) do not reliably cause miosis even when taken alone. As a result, pupil examination is not as reliable as the recognition of bradypnea in opioid intoxication. Tx—naloxone. Buprenorphine is an alternative opioid agonist used in long-term mx of opioid addiction. However, it is not helpful in cases of acute intoxication. 32. In a normal (bell-shaped) distribution: 68% --within 1 SD from the mean 95% --within 2 SD from the mean 99.7% --within 3 SD from the mean 33. Cryptosporidium parvum is a major cause of chronic diarrhea in HIV-infected pts with CD4 counts less than 180 cells/mm3. A modified acid-fast stain showing oocysts in the stool is very suggestive. 34. Parkinsonism is caused by overactivity of cholinergic neurons and underactivity of dopaminergic neurons in the substanta nigra. A shuffling gait (ie. The pt appears as if he was 134

chasing his center of gravity) is characteristic of the disease. –hypokinetic gait * Extremely high yield!! Other syndroms—multiple system atrophy, spinocerebellar atrophies, and multiple-infarct gait disorder. Wide-based gait is also seen in sensory ataxia, some cerebellar disorders and muscular dystrophies. Cerebellar ataxia is usually ipsilateral (ie. The pt tends to fall towards the side of the lesion). Other features of cerebellar disorders include nystagmus, hypotonia, dysarthria, loss of coordination, and the inability to perform rapid, alternating movements. Muscular dystrophy results in a waddling gait 蹒 跚 而 行 owing to weakness of the gluteal muscles. Spastic gait is seen with lesion of the upper motor neuron (eg. spinal cord injury or cerebral palsy). The movements of the affected extremities are slow, stiff, and effortful. Gait disequilibrium results from disorders of the frontal lobe and multiple sensory systems. Sensory ataxia is seen with lesions involving the peripheral nerves, dorsal roots or posterior columns. Loss of proprioception results in a wide-based, high-stepping gait. Romberg’s sign may be positive (the pt sway on standing with his feet together and eyes closed). Vestibular ataxia results in an en-bloc gait, with minimal movements of the head during walking. It is typically a staggering gait 蹒跚 and accompanied by vertigo and nystagmus. 35. Petit mal (absence) seizures are characterized by a sudden cessation of mental activity. An episode is very short, but may occur repeatedly throughout the day. There are no associated complex automatisms or tonic-clonic activity. The diagnosis is best confirmed by EEG studies (activation procedures—hyperventilation, photic stimulation, sleep). 36. ARP (arributable risk percent) represents the excess risk in the exposed population that can be attributed to the risk factor. ARP= (risk in exposed –risk in unexposed)/risk in exposed. It can be easily derived from the relative risk: ARP = (RR-1)/RR 37. Fluid replacement is the most important step in the mx of non-ketotic hyperglycemic coma. 5% dextrose is given once blood glucose level has been lowered to 250 mg/dl by insulin therapy. It prevents the development of cerebral edema. Regular insulin should be administrated in all cases of nonketonic hyperglycemic coma, but fluid replacement alone can reduce hyperglycemia significantly. 38. Abdominal ultrasound is the best tool for the initial investigation of gallbladder pathology. While asymptomatic pts typically do not require tx, laparoscopic cholecystectomy (not open cholecystectomy) is the tx of choice of those with symptomatic gallbladder disease. 39. Renal artery stenosis is a common cause of resistant hypertension in a pt with advanced atherosclerosis. Carefully auscultate the periumbilical area of such a pt to reveal continuous (or systolic with diastolic component) murmur characteristic of renal artery stenosis. 40. Syncope in a young pt with a crescendo-decrescendo murmur at the lower left sternal border without carotid radiation is most likely due to hypertropic cardiomyopathy. Syncope in hypertrophic cardiomyopathy is often multifactorial and inappropriately causes vasodilation. 41. Cholesteatomas in children can either be congenital or acquired secondary to chronic middle ear disease. New-onset hearing loss or chronic ear drainage despite antibiotic therapy are typically presenting symptoms of cholesteatomas, and granulation tissue and skin debris may be seen within retraction pockets of the tympanic membrane on otoscopy. 42. Volume resuscitation with normal saline will correct contraction alkalosis (loss of gastric fluid and activation of the renin-angiotensin-aldosterone system). Hypokalemia shound be treated 135

well. 43. Opioid withdrawal presents with symptoms of nausea, vomiting, abdominal pain, diarrhea, restlessness, arthralgias and myalgias. Signs of opioid withdrawal on exam can include increased bowl sounds, mydriasis and piloerection. Unlike ethanol and sedative withdrawal, opioid withdrawal does not cause seizures. Methadone is proven effective for tx of opioid withdrawal (not iv morphine). 44. Sjogren syndrome is diagnosed when subjective and objective evidence of dry eyes (xerophthalmia) and mouth (xerostomia) exists in the presence of either histologic evidence of lymphocytic infiltration of the salivary glands or serum autoantibodies against SSA (Ro) and /or SSB (La). 1/10/10 1. Neurocardiogenic, or vasovagal, syncope occurs due to excessive vagal tone. Episodes are preceded by nausea, diaphoresis, tachycardia, and pallor. Pain, stress, and situations like medical needles and urination can all precipitate vasovagal syncope. 2. All pt with chronic liver disease should be immunized against HAV and HBV. 3. The correlation coefficient shows the strength and direction (positive, negative) of linear association between two variables. It does not necessarily imply causality. 4. Lateral epicondylitis (tennis elbow) manifests as pain with supination or extension of the wrist and point tenderness just distal to the lateral epicondyle. 5. Pts with infectious mononucleosis are at risk for splenic rupture. All pts with splenomegaly should avoid excessive physical activity, particularly contact sports, until their spleen regresses in size and is no longer palpable (usually after one to three months). 6. Viridans group streptococci are a frequent cause of subacute bacterial endocarditis (SBE) in pts with preexisting valvular disease. Staphylococcus aureus is the major cause of acute infective endocarditis and if often seen in IV drug abusers. 7. Allergic conjunctivitis is an acute hypersensitivity reaction that is caused by enviromental exposure to allergens. It is characterized by intense itching, hyperemia, tearing, conjunctival edema and eyelid edema. 8. In a pt with an MI who develops a cold leg, one has to get an ECHO to rule out a thrombus in the left ventricle. Venous duplex study is an error. The leg is cold and without pulses which indicates an arterial occlusion. Venous obstruction will present with a swollen leg and the pulses will be present. In the setting of an MI and administration of heparin, the chances of a DVT are low. 9. PCP is an important cause of progressive dyspnea and hypoxia in pts with HIV/AIDS. Hypoxia results from an increased alveolar-arterial oxygen gradient. 10. 100% oxygen (tx of chioce) is an effective and rapid method used to abort an acute attack of cluster headache. Verapamil is used to prophylaxis of cluster headache. * Extremely high yield!! 11. The extent of a malignancy determined the most appropriate, timely, and individualized pt care. CT is a standard diagnostic tool employed in pts with newly diagnosed gastric cancer to evaluate the extent of the disease. Surgical removal of the affected tissues remains as the mainstay of therapy. * Extremely high yield!! 12. Always suspect infectious mononucleosis (IM) in a young pt with a sore throat and 136

nonspecific symptoms. Pts with IM can develop autoimmune hemolytic anemia and thrombocytopenia. 13. The characteristic lab findings of iron deficiency anemia are decreased serum iron level, decreased percent saturation (serum iron/TIBC), and increased TIBC. Sideroblastic anemia is characterized by increased serum iron levels and normal TIBC. 14. A thiazide diuretic such as hydrochlorothiazide is the first-line pharmacologic agent for mx of hypertension in a pt without significant comorbidities. ACEIs are the first-line agent for mx of hypertension in pts with DM, chronic kidneu disease and CHF. Beta-blockers such as altenolol are indicated as a first-line antihypertension in pts with angina, low ejection fraction, or status post-MI. 15. Lacunar strokes are due to microatheroma and lipohyalinosis in small penetrating arteries of the brain. They often affect the internal capsule and result in pure motor dysfunction. Lacunes comprise 25% of ischemic strokes. Hypertension and diabetes are two major risk factors. Because of their small size, lacunes are often not appreciated on non-contrast CT scans obtained during or shortly after the event. Todd’s palsy is transient paralysis that occurs during the post-ictal state. 16. Warfarin doding should be adjusted to maintain a goal INR appropriate for the condition being treated. For pts with idiopathic VTE (venous thromboembolism) or AF, a target INR of 2.0-3.0 provides adequate anticoagulation without an excessive risk of bleeding. 17. Hyperthyroidism is characterized by numerous symptoms including weight change, tremor, fatigue, anxiety, and weakness. Hyperthyriod myopathy presents as progressive proximal muscle weakness. It is slowly progressive but reverses quickly when the underlying hyperthyroidism is treated. Inflammatory muscle diseases include polymyositis, dermatomyositis, and inclusion body myositis. Tremor is not seen in these conditions. 18. CHF causes decreased cardiac output, which in turn lead to increased hydrostatic pressue in the pulmonary vasculature. This results in transudation of fluid into the air spaces of the lungs, which can lead to pulmonary edema and pleural effusion. A pleural effusion presents with absence of lung sounds and dullness to percussion at the involved lung bases. 19. Most pts will require pharmacotherapy for blood pressure control, but life style changes can make a difference. Weight control is the most important intervention, followed by physical activity, salt restriction, and moderation of alcohol consumption. Every 10 kg reduction in weight can decrease the systolic blood pressure by 5-20 mmHg. For all pts, the goal BMI is 18.5-24.9 kg/m2. 20. COPD, in general, is characterized by reduced FEV1 and repid decline in FEV1. FEV1/FVC is decreased in COPD as opposed to normal in restrictive lung disease. DLCO is decreased in emphysema and normal in chronic bronchitis. 21. Paroxysmal, lightning-like pain on the face is usually due to trigeminal neuralgia. Carbamazepine is the drug of choice. Carotidynia is a neurological condition caused by inflammation of the carotids and the vagus. The pain is sharp and localized to the carotid artery distribution in the neck. Usually, the intensity of pain is much less. The dx is clinical, although an MRI is sometimes required. Burning mouth syndrome is a rare cause of facial pain. It is caused by a virus and the individual has reddened mucosa and has significant pain. The condition is aggravated by dryness. It is treated by supportive care. 137

22. Suspect hepato-renal syndrome in a pt with severe liver disease, hypotension, hyponatremia, azotemia, and oliguria with normal urinalysis. Take measures to withhold all possible precipitating factors. Initial mx includes careful volume loading and discontinuation of furosemide and spironolactone. 23. Acute, symptomatic hyponatremia is a medical emergency requiring a prompt increase in the serum sodium concentration (3% saline). In contrast, chronic hyponatremia requires slow correction of the serum sodium concentration (1.5cm, usually unilateral), oral changes (erythema, fissured lips, or a strawberry tongue), and a rash. Supporting lab evidence include sterile pyuria, a CRP >3, an erythrocyte sedimentation rate >40, and albumin level 12,000). Other clinical findings may include urethritis, orchitis, arthritis, or hepatitis. Scarlet fever has a similar presentation to Kawasaki disease. Symptoms may include fever, a strawberry tongue, a red sandpaper-like rash over the trunk and extremities, and cervical lymphadenopathy. However, scarlet fever has a shorter duration than Kawasaki disease. Its fever usually remits by day 3-5, and the rash begins to fade by day 5-6. Rocky Mountain spotted fever presents with fever and constitutional symptoms followed by a centripetal rash (starts on the extremities and spreads inward). Arthralgias, myalgias, and headache may also be present. 20. Coronary artery aneurysms are the most serious complication of Kawasaki disease. 21. Jaudice within the first 24 hours of life requires immediate attention and may be due to erythroblastosis fetalis, concealed hemorrhage, sepsis or congenital infections. Jaundice that 172

first appears on the 2nd or 3rd day of life is usually “physiologic”, but sometimes may represent a more severe disorder. Jaundice appearing after the 3rd day and within the 1st week of life suggests bacterial sepsis or UTI, and requires prompt and aggressive evaluation. Sepsis in the neonate rarely causes classic findings such as neck stiffness, buldging fontanel or shock. The susal clues are history of poor feeding, lethargy, vomiting, or alteration of usual activity. All pts with a suspected dx of sepsis should be investigated with blood cultures and lumbar puncture. 22. Suspect Beckwith-Wiedemann syndrome in an infant with macrosomia, macroglossia, visceromegaly, omphalocele, hypoglycemia and hyperinsulinemia. Additional features include prominent eyes, prominent occiput, ear creases and hyperplasia of the pancreas. It is usually sporadic, but there are occasional cases involving familiar inheritance. The exact cause is unknown, although it is sometimes associated with duplication of chromosome 11p. This region contains the gene encoding for IGF-2, which may explain the macrosomia, Sometimes, the hypoglycemia may be severe and intractable, and subtotal pancreatectomy may be needed. Pts have an increased risk of neoplasms such as Wilm’s tumor, hepatoblastoma, and gonagoblastoma. Congenital hypothyroidism also presents with hypotonia and an enlarged tongue, and may easily be confused with Beckwith-Wiedemann syndrome; however, an umbilical hernia (instead of omphalocele) is another typical finding of hypothyroidism. Furthermore, the head circumference of pts with congenital hypothyroidism may be increased, whereas pts with Beckwith-Wiedemann syndrome have microcephaly. There is no hypoglycemia and hyperinsulinemia in pts with congenital hypothyroidism. Macrosomia secondary to maternal diabetes is an important differential diagnosis of BeckwithWiedemann syndrome; however, infants with this condition do not present with dysmorphic features such as omphalocele, prominent occiput and macroglossia. Moreover, the prenatal and birth histories of the pt in the case were unremarkable. The common congenital problems that you should remember in an ‘infant of diabetic mother’ are: 1) caudal regression syndrome; 2) transposition of great vessels; 3) duodenal atredia and small left colon; 4) anencephaly and neural tube defects. WAGR syndrome is characterized by Wilm’s tumor, aniridia, genitourinary anomaly and mental retardation. It is related to a deletion in chromosome 11 involving the gene WT1 and aniridia gene PAX6. Denys-Drash syndrome is also associated with an increased rish of Wilm’s tumor, but its clinical features are totally different from those of Bechwith syndrome. It includes male pseudohermaphrodism and early onset renal failure characterized by mesangial sclerosis. The symptoms of galactosemia manifest a few days or weeks after the infant starts taking formula or breast milk. These include liver failure (hepatomegaly, direct hyperbilirubinemia, disorders of coagulation), abnormal renal function, emesis, anorexia, acidosis and glycosuria. Von-Gierke disease is secondary to a deficiency of glucose-6-phosphatase, It also affects the kidney and liver, and cause severe hypoglycemia; however, the hypoglycemia characteristically occurs with fasting, since it occurs secondarily to a failure to release glucose from the liver into the circulation, rather than to hyperinsulinemia. 23. No investigations are needed in the case of migraine headache, unless the neurological exam is abnormal and/or fever is present. Migraine is a clinical dx, and the initial tx is 173

24.

25.

26.

27. 28.

29.

30. 31. 32. 33.

34. 35. 36. 37. 38.

acetaminophen or NSAIDs. Laryngomalacia or congenital flaccid larynx is the MCC of chronic inspiratory noise in infants. Larygoscopy shows flaccidity of the larynx, and collapses during inspiration (epiglottis rolling in from side to side). It is a self-limiting condition in most cases, and generally subsides by 18 months of age. The mother should be instructed to hold the child in an upright position for half an hour after feeding, and to never feed the child when he is lying down. Neuroblastoma is the third most common cancer in the pediatric population (after leukemia and CNS tumors). The tumor arise form neural crest cells, which are also the precursor cells of the sympathetic chains and adrenal medulla. The most common site is the abdomen. Calcifications and hemorrhages are seen on plain x-ray and CT scan. The levels of serum and urine catecholamines and their metabolites (ie HVA and VMA) are usually elevated. Risperidone is a dopamine and serotonin antagonist that can cause weight gain or hyperprolactinemia, the latter of which can lead to amenorrhea and galactorrhea. Lamotrigine is used in the tx of epilepsy and bipolar disorder. The major side effect of lamotrigine is a rash, although severe skin reactions can develop including Steven-Johnson syndrome or toxic epidermal necrolysis. Salicylates are C/I in young children with viral infections. Recognize the clinical presentation of Reye syndrome. Suspect vit A deficiency in a 2 or 3 year old child with impaied adaption to darkness, photophobia, dry scaly skin, xerosis conjunctiva, xerosis cornea, keratomalacia, Bitot spots and follicular hyperkeratosis of the shoulders, buttocks and extensor surfaces. Four clinical criteria have been shown useful in differentiating septic arthritis from transient synovitis: white blood cell count >12,000/mm3, temperature >39C (102F), ESR>40mm/h, and refusal to bear weight. If at least 3 of these 4 criteria are met, further work-up is indicated to rule out septic arthritis. Transient synovitis is treated with rest and NSAIDs. Suspect choanal atresia in an infant who presents cyanosis that is aggravated by feeding and relieved by crying. Acute, unilateral cervical lymphadenitis in children is usually caused by bacterial infection, and the most common pathogen is Staph aureus. Vaginal discharge in the newborn is due to the effects of maternal estrogens. In such cases, reassurance of the mother is all that is required. Early neonatal care in an uncomplicated pregnancy include initial physical assessment, removal of airway secretions, drying the infant and keeping him/her warm, and early preventive measures (gonococcal ophthalmia prevention, vit K supplementation). Always suspect pyloric stenosis in a neonate who presents with non-bilious, projectile and persistent vomiting. In such cases, order an abdominal ultrasound to establish the dx. Medulloblastoma is the second most common (after cerebellar astrocytoma) infratentorial tumor in children and arised form vermis. Recognize posterior vermis syndrome. A large thymic shadow (sail sign) is a normal finding on chest radiographs in children less than 2 years old. Painless rectal bleeding in a young child often presents a Meckel’s diverticulum (fecal occult blood test positive), which is diagnosed by performing a technetium-99m pertechnetate scan. A 2-year-old child can build a tower of 6 blocks, obey two-step commands, and use 2- to 3174

words phrases. 2 months

Language Social smile

3 months 4 months 6 months

Babbles

12 months

2 words; obeys 1-step command

Gross Motor Holds head Rolls back-tofront and frontto-back Sits well upsupported Walks alone

15 months

Fine Motor

Social Recognizes parents

Raking grasp

Recognizes stangers (stranger anxiety) Imitates action

Throw objects Build tower of 2 blocks

18 months 24 months

2-3 words; obeys 2-step command

Walks up- and downstairs without help

Build tower of 6 blocks; Turn pages of books

Plays with other children Parallel play

39. Conduct disorder is characterized by disruptive behavior patterns that violate basic social norms for at least one year in pts less than 18 years old. 40. Chlamydia is the MCC agent of infectious neonatal conjunctivitis. Chlamydial pneumonia can develop in infected infants. Gonococcal conjunctivitis is extremely purulent and presents between the 2nd and 5th day after birth. 41. Osteogenesis imperfecta is an autosomal dominant disease characterized by mutations in type I collagen. Pts with the severe type II form of this disease typically expire in utero due to multiple ntrauterine and/or perinatal fractures. Clinical findings include limb deformities, growth retardation, multiple fractures and blue sclerae. 42. Pts with genetic B-cell deficiencies begin to develop recurrent infections after passing 6 months of age. The deficient humoral immune response in these pts impairs the body’s ability to destroy encapsulated organisms. Hence, recurrent sinopulmonary infections with H. influenzae and S. pneumoniae are common. Lack of IgA also predisposes to Giardia infection. Chronic granulomatous disease (CGD) is a condition of impaired oxidative metabolism. In CGD, a defect in the NADPH-oxidase system of phagocytic cells results in defective intracellular killing. Pts are therefore prone to abscesses secondary to catalse-producing organisms like Aspergillus and Staphylococcus. Gonococcal and meningococcal infections are common in pts with complement deficiency. S.Pneumoniae and H.influenzae infections do occur in this pt population as well, but infections with Giadia are not typically seen. Thymic hypoplasia is one element of DiGeorge syndrome. The resultant T-cell deficiency puts pts at high risk for viral and fungal infections. Adenosine deaminase deficiency is commonly the genetic defect underlying severe combined immunodeficiency (SCID). Pts with SCID have a deficiency of both B- and T- cells. The T-cell deficiency predisposes to viral and fungal infections and the B-cell deficiency predisposes to infection by bacteria. 43. A 12-month-old child walks alone, speaks two words, throws objects, and comes when called.

175

44. Apgar score

Heart rate Reaction to nasal stimulatoin Tone/Activity

0 Body and extremities are blue/pale No activity No response limp 柔软的

Respirations

absent

Color

1 Body is pink and extremities are blue 100 beats/min Active cough active flexion of extremities Good respiratory effort

1/19/10 1. Most small ventricle septal defects close paontaneously and require no tx, as long as there are no signs of pulmonary vascular disease. Reassurance, surveillance (via EKG and echocardiograph), and infective endocarditis prophylaxis are all that are needed for mx. VSD murmur: harsh and holosystolic heard at the left, lower sternal border. Surgical repair si indicated in large or symptomatic defects. 2. Primary amenorrhea, Tanner stage 2 development, and aortic coarctation in a teenager strongly suggest Turner syndrome (45, XO). Turner syndrome is the MCC of primary amenorrhea. Dx is confirmed by karyotype analysis. 17-hydroxyprogesterone measurement is indicated when congenital adrenal hyperplasia is suspected as a possible cause of primary amenrrhea. Serum 17-OH progesterone is elevated in 21and 11 hydroxylase deficiencies and is decreased in 17-hydroxylase deficiency. 3. Cystic fibrosis is an autosomal recessive disorder. If one of the parents has the disease (is homozygous), you cannot predict whether a child would be likely to have the disease without knowing the other parent’s carrier status. 4. Mongolian spots are most commonly found in dark-skinned populations, present at birth, and usually fade or disappear in several years. 5. The most common causative organism of acute otitis media is Streptococcus pneumoniae (40% of cases), followed by non-typable Haemophilus influenzae (25-30%), and Moraxella catarrhalis (10-15%). The first-line tx is a ten-day course of amoxicillin. 6. Hand-foot syndrome or dactylitis is the earliest manifestation of vasoocclusion in sickle cell anemia, thereby warranting a complete workup for previously asymptomatic sickle cell pts. 7. Rubella is characterized by low-grade fever, lymphadenopathy (sub-occipital and posterior auricular) and rash. The rash is erythematous, maculopapular and classically begins on the face, spreading subsequently down the body. Erythema infectiosum or Fifth disease is caused by human parvovirus B19. Childre have different presentations and develop a rash with a “slapped cheeks” appearance. Fever is not present or very mild in this disease. The clinical manifestation of chickenpox in healthy children generally develop within fifteen days after the exposure and typically include a predrome of fever, malaise, or pharyngitis, followed by the development of a generalized vesicular rash, usually within 24 hours. The lesions are commonly prutitic and appear as successive crops of vesicles over a three to four day period. Pts typically have lesions in different stages of development on the dace, trunk and extremities. New 176

lesions formation generally stops within 4 days, and most lesions are fully crusted by the 6 th day in normal hosts. Roseola infantum is caused by herpes virus 6, and is characterized by the abrupt onset of highgrade fever, which is then followed by a maculopapular rash, appearing on the trunk and then spreading peripherally. The pt is no longer febrile when the rash develops. There are no positive physical signs such as sore throat or lymphadenopathy during the febrile stage. 8. Friedreich ataxia is the most common type of spinocerebellar ataxias. Remember the combination of neurologic (ataxia, hysarthrial), skeletal (scoliosis, feet deformities), and cardiac (concentric hypertrophy cardiomyopathy) manifestations of the disease. The MCC of death are cardiomyopathy and respiratory complications. * Very high yield!! 9. Reactive pericarditis with a pericardial effusion can present after surgery for congenital heart disease and is called postpericardiotomy syndrome. Symptoms usually occur 1-6 weeks after surgery. Although the cause is no known, postpericardiotomy syndrome is thought to be an autoimmune response, possibly to a viral infection. Most children develop mild symptoms which are self limited. In infants, pericardial effusion can present with abdominal pain, vomiting, and decreased appetite. Older children may complain of chest pain. Fever is often present. On exam, findings are consistent with pericardial and/or pleural inflammation, including tachycardia, poor perfusion, pulses paradoxus, distant heart tones, and jugular venous distention. If the effusion is large enough to affect the function of the heart, pericardial tamponade can occur. 10. In an infant with meningococcemia, watch out for Waterhouse-Friderichsen syndrome, which is characterized by a sudden vasomotor collapse and skin rash due to adrenal hemorrhage. 11. The differential diagnosis of a solitary, painful, lytic long bone with overlying swelling and hypercalcemia in a child should include Langerhans cell histiocytosis (histoobtosis X, eosinophilic granuloma—the least severe form) as well as other neoplastic processes like Ewing sarcoma. 12. Remember the classic triad of congenital rubella syndrome (CRS)sensorineural deafness, cardiac malformation (eg. PDA and ASD), and cataracts. CRS occurs most commonly when transmission occurs in the first 4 weeks of pregnancy. Struge-Weber syndrome is a neurocutaneous disease characterized by a port-wine stain on trigeminal nerve distribution, mental retardation, seizures and glaucoma. 13. Microcytic anemia caused by iron deficiency can often be differentiated from thalassemia by an elevated RDW, which is typically greater than 20% in iron deficiency. The reticulocyte count is low in pts with iron deficiency due to decreased erythropoiesis. 14. A typically presentation of Tetralogy of Fallot (TOF) individuals is squatting, which increases the systemic vascular resistance and forces blood into the lungs, thus improving cyanosis. Other manifestations include “tet” spells, which are hypoxic episodes that are characterized by paroxysms of deep, rapid breathing, and are caused by an increased pulmonary vascular resistance. Crying, infection, and exercise can lead to tet spells. Severe spells may precipitate seizures and loss of consciousness. The immediate tx is asministration of oxygen and placing the child in a knee-chest position, following by the administration of fluids, morphine and propranolol. 177

15.

The MCC of viral meninigitis are the non-polio enteroviruses, such as echoviruses and coxsachievirus. 16. Marfan’s syndrome (MFS) is an autosomal dominant disorder that results from the mutations of the fibrillin-1 (FBN1) gene. It presents with tall stature, long and emaciated extremities, arachnodactyly, hypermobility of the joints, upward lens dislocation, and aortic root dilation. Homocystinuria is an autosomal recessive disorder that results from cystathinine synthase deficiency, an enzyme involved in the metabolism of methionine. These pts share many features of Marfan’s syndrome but they usually have a fair complexion 肤 色 , thromboembolic events and osteoporosis. The other main differentiating feature is the type of lens dislocation. In Marfan’s syndrome, the lens is typically dislocated upward, whereas in homocystinurea it is dislocated downward. Congenital contractural arachnodactyly (CCA) is an autosomal dominant condition that presents with tall stature, arachnodactyly, and multiple contractures involving large joints. Marfan’s pts do not have joint contractures. Furthermore, ocular and cardiovascular symptoms are not present in CCA. Ehlers-Danlos syndrome is a disorder of collagen structure, which may also have hypermobile joints; however, it also results in easy bruising, poor wound healing and soft, velvety, and hyperelastic skin. Severe complications such as organ rupture and severe hemorrhage may occur. 17. Internal carotid artery dissection is a potential cause of stroke in children. The history of a fall on a pencil or on a stick in a child’s mouth within 24 hours of the onset of symptoms is typical. 18. In pts with sickle cell disease, acute severe anemia with absent reticulocytes in the peripheral blood smear is due to aplastic crisis. 19. Recurrent hemarthroses in pts with coagulopathies lead to a joint injury called ‘hemaphilic arthropathy’. 20. Transposition of the great vessels (a normal S1, single and a loud S2, and no murmur) is the most common cysnotic heart disease which presents with cyanosis in the first 24 hours of life. It is commonly seen in infants of diabetic mothers and in males. Echocardiography confirms the dx. Maintaining the patency of the ductus arteriosus is important for survival. Surgical tx is definitive. 21. Deficiency of sphingomyelinasae causes Niemann-Pick’s disease, which is characterized by cherry red macula, protruding abdomen, hepatosplenomegaly, lymphagenopathy, and regression of development milestones. Sphingolipidosis due to a deficiency in hexosaminidase A is known as Tay-Sachs’ disease. It is characterized by hyperacusis, mental retardation, seizure, cherry red macula, but not hepatosplenomegaly or cervical lymphadenopathy. Sphingolipidosis due to a deficiency in glucocerebrosidase is known as Gaucher’s disease. It is characterized by hepatosplenomegaly, anemia, leucopoenia, and thrombocytopenia, but not cherry res macule. Sphingolipidosis due to a deficiency in galactocerebrosidase is known as Krabbe’s disease. It is characterized by hyperacusis 听觉过敏, irritability and seizure. Mucopolysaccharidoses are characterized by coarse facial features, hydrocephalus and umbilical hernia. 178

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Turner syndrome should be considered in newborns with a webbed neck, high palate, short fourth metacarpal, and nail dysplasia. Lymphedema frequently occurs due to abnormal development of the lymphatic system. 23. The most common predisposing factor for acute bacterial sinusitis is a viral upper respiratory infection. 24. Bedwetting is considered normal until the age 4-5 years. If nocturnal enuresis perisists, DDAVP (drug of choice) or imipramine may be used. 25. Post-exposure rabies prophylaxis can be lifesaving and should be initiated after exposure to saliva or neural tissue from bats, wild carnivores, or other animals suspected of being rabid. People bitten by domestic animals suspected of being rabid or not available for observation, or by wild carnivores like raccoons, skunks, and foxed should also receive prophylaxis. 26. Aplastic anemia should be suspected in any pt with pancytopenia following drug use, exposure to toxins or viral infections. A bone marrow biopsy is essential to make the dx, it typically shows profound hypocellularity with a decrease in all cell lines and fatty infiltration of the marrow. Classically, pts with Fanconi’s anemia have pancyotpenia and characteristic congenital anomalies, such as hyperpigmentation on the trunk, neck and intertriginous areas and/or café-au-lait spots, short stature, upper limb abnormalities, hypogonadism, skeletal anomalies, eye or eyelid changes, and renal malformations. Blood counts start to decrease between 4 and 12 years of age, and the initial manifestation is usually thrombocytopenia, followed by neutropenia, then anemia. Diamond-Blackfan anemia (DBA), or congenital pure red cell aplasia, presents in the first 3 months of life with pallor and poor feeding. CBC reveals a normocytic or macrocytic anemia with reticulocytopenia. WBC and platelet counts are normal. Transient erythroblastopenia of childhood (TEC) is an acquired red cell aplasia which occurs in healthy children between 6 months and 5 years old. There is a gradual onset of symptoms such as pallor and decreased activity. The physical exam is unremarkable except for pallor and tachycardia. The typical lab findings ar normocytic normochromic anemia, with hemoglobin levels ranging from 3 to 8 g/dL, and extremely low reticulocyte count. Bone marrow infiltration due to leukemia results in pancytopenia by crowding out the normal bone marrow element. 27. Suspect necrotizing enterocolitis in a newborn with abdominal distention, bloody diarrhea, and leukocytosis. These symptoms usually occur after the introduction of formula feeding. The radiologic finding of pneumatosis intestinalis (ie intramural air) in infants is diagnostic. 28. Undetected hearing impairment can earsily be confused with certain pervasive and behavioral disorders of childhood. Therefore, hearing tests should be conducted in all such children. 29. Compartement syndrome can be a complication of supracondylar humerus fractures (X-ray picture). It is characterized by severe pain, pallor, poikilothermia, paresthesias, and the late finding of pulselessness and paralysis. Initial tx incudes removal of any bandages, measurement of compartment pressures, and emergent orthopedic evaluation for possible fasciotomy. 30. Intussusception is the most common cause of intestinal obstruction in the first 179

two years of life. In addition to the signs of interstinal obstruction (eg. severe, sudden-onset abdominal pain and vomiting), pts present with red currant jelly stool containing blood and mucus. 31. Fetal alcohol syndrome is characterized by irritability, mild to moderate mental retardation, hypoplastic maxilla, long philtrum, thin upper lip border, and microcephaly. Fetal hydantoin syndrome is characterized by hypoplasic nails, cleft palate, and vitK deficiency, which may result in bleeding. 32. Nursemaid’s elbow occurs when infants or children are lifted or pulled by the hand or arm. The mechanism of the injury involves radial head subluxation. The child typically keeps the hand in a pronated position, and refuses (cries out in pain) attempted forearm supination. Panner disease is osteochondrosis of the capitellum 小头. The typical pt is an adolescent who is actively engaged in sport activities that involve throwing, and the common complaints include pain, crpitation and loss of motion of the arm (particularly pronation and supination). The most common elbow dislocation is posterior dislocation, with is caused by falling backward onto the outstretched arm with the elbow extended. An obvious deformity is noted, with the olecranon process displaced prominently behind the distal humerus. 33. Colic presents by 3 weeks of age with excessive crying for more than 3 hours a day, more than 3 days a week, and more than 3 weeks a month, usually resolving by 4 months of age. 34. Anemia of prematurity is the most common anemia in premature and low birth weight infants. The pathology involves a combination of diminished RBC production, shortened RBC life span, and blood loss. Iron supplementation does not prevent falling hemoglobin levels, and iron deficiency is not the cause of anemia of prematurity. The tx involves iron supplementation, periodic hemoglobin checking and blood transfusion, if needed. Erythropoietin is not routinely used. Lab studies: 1) Peripheral smear shows normocytic and normochromic anemia. No other abnormal forms are seen. 2) the reticulocyte count is low, and RBC precursors in the bone marrow are decreased. 3) Normal WBC and platelet counts. 4) Normal total bilirubin level. 35. ADHD should be considered as the most probable dx in any pts with symptoms of short attention span, impulsivity, and hyperactivity for more than 6 months in more than one setting. 36. Vaginal foreign bodies should be suspected in children with purulent, foulsmelling vaginal discharge and bleeding. If a foreign body is seen, irrigation with warmed fluid should be performed in an attempt to flush the foreign body. If irrigation is unsuccessful, exam and foreign body removal should be done with sedation or general anesthesia. 37. The body derives vit K from the diet and from gut flora synthesis. Deficiency in newborn babies is the result of poor placenta transfer, absent gut flora, and inadequate levels in breast milk. To prevent hemorrhagic disease of the newborn, it is recommended that all newborn babies receive a vit K injection. 38. Racemic epinephrine decreases the need for intubation in pts with croup and should always be tried before any invasive procedure. 39. Painless melena in a 2 to 3-year-old child is most likely due to Mechel’s 180

diverticulum. It results from the failure of the vitelline duct to obliterate during the fetal development. The dx of a Meckel’s diverticulum is best made with technetium-99m pertechnetate scanning (uptake by heterotopic gastric mucosa). 40. The tx of Kawasaki’s disease consists of aspirin and IV immunoglobulins. 41. Suspect Duchenne muscular dystrophy in a child with proximal muscle weakness, positive Gower’s sign, depressed reflexes, and pseudohypertrophy of the calf muscles. Dystrophin is usually absent. EMG shows myopathic pattern. Serum CK levels are very high (4000-5000IU). The dx is confirmed by muscle biopsy. 42. Human milk is the ideal form of nutrition for term infants. The major protein source is whey 乳清, which is more easily digested than casein 酪蛋白 and helps to improve gastric emptying. 43. Infectious mononucleosis is an infection caused by the EB virus, and is sometimes detected only when the pt develops a characteristric polymorphous rash after taking ampicillin for an apparent upper respiratory tract infection. 44. Severe dehydration in a neonate in the presence of hyponatremia, hyperkalemia, hypoglycemia, and metabolic acidosis suggests a diagnosis of congenital hyperplasia or salt wasting 21-hydroxylase deficiency. There are 2 main abnormalities involving the galactose metabolic pathways. Galactose-1phosphate uridyl tranferase deficiency is a sever condition that can lead to shock if untreated. Clinical features include vomiting, diarrhea, hepatomegaly, catatect, mental retardation, and hypoglycemia. Galactokinase deficiency is a milder condition which generally presents with catatact if untreated. Both conditions are inherited as autosomal recessive. 1/20/10 1. Subarachnoid hemorrhage (SAH) can be caused by by an intraventricular hemorrhage, which is common in premature infants. Accumulation of the blood in the subarachnoid space may lead to destruction of the arachnoid villi and cisterns, thereby blocking the flow or decreasing the absorption of CSF, and leading to communicating hydrocephalus (CT scan shows dilation of the entire ventricular system with distinct enlargement of the subarachnoid space over the cerebral cotex). SAH is the most common cause of communicating hydrocephalus. DandyWalker anomaly and Chiari malformation will both reveal CT findings consistent with obstructive or noncommunicating hydrocephalus. Dandy-Walker Anomaly will demonstrate a cystic expansion of the 4th ventricle, and Chiari malformation will reveal protrusion of the structures of the posterior fossa through the foramen magnum. 2. Intussusceptin is best diagnosed and treated by an air contrast enema. 3. Suspect meningococcemia in a neonate with signs of meningitis and a petechial rash. 75% of pts with Meningococcus meningitis present with a petechial rash that is prominent on the axilla, wrist, flanks and ankles. It appears with 24 hours of the infection, and the pt generally appears sick. 4. Sturge-Weber syndrome is a neurocutaneous syndrome that is characterized by a congenital unilateral cavernous hemangioma along the trigeminal nerve distribution and radiographic evidence of intra-cranial calcifications that resemble a tramline. 5. Increasing head circumference and signs of increased intracranial pressure in children should 181

6.

7. 8.

9.

10.

11.

12. 13.

14. 15. 16.

be evaluated with a CT scan of the brain. Symptoms of hydrocephalus in infants include poor feeding, irritability, vomiting, and decreased activity. On exam, the fontanelle may be tense and buldgig, the scalp veins may appear prominent with shiny, tight skin overlying the vessels, and the cranial sutures may be widely spaced. On review of the growth charts, the head circumference may be rapidly increasing in size to greater than the 97th percentile. Tx consists of a shunt that is placed form the ventricle to the peritoneum, pleura, or right atrium, which allow the excess CSF to drain rather than continue to collect in the ventricles. With suprachondylar fracture, the brachial artery can be compromised, resulting in the loss of the radial artery pulse; therefore, the radial artery pulse must be assessed when the fracture is reduced. To prevent SIDS (sudden infant death syndrome), infants should be placed on their backs (supine position) while sleeping. Home monitors do not decrease the risk of SIDS. A positive Coomb’s test points towards autoimmune hemolytic anemia, and a positive osmotic fragility test points towards hereditary spherocytosis. Hereditary elliptocytosis is a rare disorder that is characterized by elongated RBC. Microcytes, spherocytes, and other poikilocytes may also be seen. Recognize fetal alcohol syndrome and know that it is the most common cause of mental retardation in children. Remember the midfacial abnormalities (short palpebral fissures, epicanthal folds, ling philtrum, thin upper lip). Suspect ITP in children who develop isolated thrombocytopenia after a viral infection. ITP is a relatively benign condition. There is some controversy regarding the tx, but in general, corticosteroids are the drugs of choice in all age groups for thrombocytopenia less than 30,000/mm3, and/or for sever symptoms. Pts with a platelet count of more than 30,000/mm3 usually have very few symptoms and do not require tx. An immediate anaphylactic reaction, an encephalopathy, or any CNS complication within 7 days of administration of the vaccine is a C/I for further administration of DTaP. In these instrance, DT should be substitute for DTaP since the adverse reactions are susally attribute to the pertussis compoment of the vaccine. * Extremely high yield!! RSV infection may increase the risk of asthma later in life. Children with a parental history of elevated total cholesterol levels (>240mg/dL), or risk factors for coromary artery disease should get a screening test for total cholesterol level. A fast lipid profile is recommended if the total cholesterol level is greater than 200mg/dl. It is usually not the first step in evaluating an asymptomatic pt. Henoch-Schonlein purpura (HSP) is characterized by palpable purpura, scrotal swelling, hematuria and abdominal pain. Children with HSP are susceptible to intussusception. Simple febrile seizures do not typically require an extensive work-up, and these pts can usually be discharged home from the emergency department. Slipped capital femoral epiphysis is a common hip disorder seen in overnight adolescents. On exam, affected pts tend to hold the hip in passive exernal rotation and exhibit decrased internal rotation, abduction, and flexion. Dx is made with plain radiographs of the hip (Ap and frog leg lateral view), which show the posteriorly and inferiorly displaced femoral head. Tx consists of emergent orthopedia consultation and surgical fixation at the current degree of slippage to avoud the risk of avascular necrosis. Avascular necrosis can also occur in LeggCalve-Perthes disease, which is most commonly seen in younger children (age 5-7) with 182

idiopathic infarction of the femoral head. 17. Turner’s syndrome with 46 XY karyotype is associated with a higher incidence of gonadoblastoma, hence, prophylactic bilateral gonadectomy is indicated in the mx of such pts. 18. Renal tubular acidosis (RTA) is a normal anion gap metabolic acidosis caused by a defect in the ability of the renal tubules to reabsorb bicarbonate or excrete hydrogen. There are 3 types of RTA: 1) Type 1 RTA or distal RTA occurs due to a defect in hydrogen ion secretion. These pts are acidotic, hypokalemic, and have an elevated urinary PH. In children, Type 1 RTA is often a genetic disorder. Pts commonly develop nephrolithiasis. 2) Type 2 RTA is caused by decreased bicarbonate reabsorption in the proximal tubule. Fanconi syndrome is a common cause in children. 3) Type 4 RTA is caused by a defect in the sodium/potassium exchange in the distal tubule which results in hyperkalemia, hyperchloremic acidosis. In children, obstructive uropathy, renal disease, or multicystic dysplastic kidney are common causes. RTA can present as growth failure and should be considered in the differential dx for failure to thrive. Screening labs will show a low bicarbonate level with an increase in chloride, producing a normal anion gap metabolic acidosis. 19. Down syndrome pts are prone to endocardial cushion defects which can rapidly cause pulmonary hypertension. 20. Mammary gland enlargement and non-purulent vaginal discharge are common findings in newborn infants. These are transitory physiologic events; therefore, such infants only require observation and routine care. * Extremely high yield!! 21. Pts with functional asplenia are at risk of infection with capsulated organisms, and the most common cause of sepsis in such pts is pneumococcus. Pts with sickle cell disease encounter constant clumping of sickle cells, which leads to repeated microinfarctions in the spleen. By 2-3 years of age, most such children have functional asplenia. Since one of the spleen’s important immunologic functions is the removal of capsulated organisms such as pneumococci and H. influenza, pts with functional asplenia are at risk of infection with these organisms. For this reason, antibiotic prophylaxis and vaccination against pneumococci and H. influenza are standardly given to pts with functional asplenia. 22. Ventrical septal defects can cause failure to thrive, easy fatigability, and heart failure. On exam they characteristically cause a pansystolic murmur loudest at the left lower sternal border, plus a rumbling diastolic flow murmur at the apex. 23. X-linked agammaglobulinemia is an inherited immune deficiency characterized by recurrent bacterial infections early in life. Suggestive lab data includes a normal amount of T lymphocytes with a low or absent concentration of B lymphocytes. It is treated with regular infusions of iv Ig. 24. Painless gross hematuria is the most common presentation of sickle cell trait. The pathophysiology involves a defect in the renal tubular function, thereby leading to the inability to properly concentrate urine. 25. The long-term neurologic sequelae associated with bacterial meningitis are: 1) hearing loss, 2) loss of cognitive functions (due to the neuronal loss in the dentate gyrus of the hippocampus). 3) seizures, 4) mental retardation. 5) spasticity or paresis. 26. 21-hydroxylase defeiciency is the most common form of CAH. It presents with virilism, salt 183

wasting, and increased 17-alpha-hydroxyprogesterone level. Other deficiencies leading to CAH include (1) 11-alpha-hydroxylase deficiency, which results in androgen and mineralocorticoid excess, and (2) 3-beta-hydroxysteroid dehydrogenase deficiency, which results in DHEA-S excess and decreased testosterone and mineralocorticoids. In 21hydroxylase defeiciency, all other metabolites are decreased. 27. Chronic pyelonephritis is characterized by focal parenchymal scarring and blunting of calices on IVP. Hydronephrosis is seen on IVP as dilation of the collecting system including the calyces, pelvis and ureter, depending on the level of obstruction. 28. All children with recurrent episodes of nocturnal vulvar itching should be examined for pinworms (Scotch tape test) and treated empirically with mebendazole. 29. Pts with Down’s syndrome are more likely to develop duodenal atresia, Hirschsprung’s disease, endocardial cushion defects and acute leukemia. 30. Food, esp peanut, allergies are the major cause fo outpatient anaphylaxis in children. Signs include bronchoconstriction, hypotension and urticaria. Subcutaneous injection of epinephrine is the first-line tx for anaphylaxis in a pt with a patent airway. 31. In pts with apparent subcutaneous emphysema secondary to severe coughing paroxysms, CXR must be obtained first ot rule out pneumothorax. 32. Vit A can be of benefit in the tx of measles infection. 33. Pts present with precocious pubarchem, it is very important to differentiate between precocious puberty that is caused by premature activation of the hypothalamus-pituitarygonad (HPG) axis and precocious pseudo-puberty that is casued by a gonagotropinindependent process, typically an excess of sex steroids. Precocious pubarche with signs of severe androgen excess is suggestive of precocious pseudo-puberty that is caused by a gonadotropin-independent process (typically an excess of sex steroids). It can be caused by late-onset congenital adrenal hyperplasia. Hypothalamic dysfunction leading to precocious puberty is usually less dramatic in presentation. Sequential development of testicular enlargement, penis enlargement, pubic hair growth, and then growth spurt is typically present. 34. Displacement anterior fat pad is a radiographic sign of supracondylar fracture, which may be complicated by Volkmann’s ischemic contracture. 35. Minimal change disease is a highly steroid-sensitive condition and is the MCC of nephritic syndrome in children. For these reason, empiric steroid therapy is indicated in any child with a clinical presentation and findings that are suggestive of nephritic syndrome. 36. Edward’s syndrome is characterized by micrognathia, microcephaly, rocker bottom feet, overlapping fingers, and absent palmar creases. Ventricular septal defect is common in pt with this disease. ASD and endocardial cushion defects –trisomy 21 Supravalvular aortic sternosis—William’s syndrome Conotruncal abnormalities (Truncus arteriosus, Tetralogy of Fallot, interrupted aortic arch)— CARCH-22 syndromes, including DiGrorge and velocardiofacial syndromes Congenital heart block—neonatal lupus Paten ductus arteriosus—congenital rubella Coronary artery aneurysm—Kawasaki disease 37. Henoch-Schonlein purpura is an IgA-mediated vasculitis of small vessels, which results in 184

rashes, arthralgias, abdominal pain and renal disease. Immunofluorescence microscopy reveals IgA deposition in the kidney. 38. Anabolic steroids are used to improve physique and athletic performance but they are associated with numerous adverse effects, including acne, baldness, gynecomastia, hepatic dysfunction, altered lipid profiles, virilization, testicular failure, and mood and behavior changes. 39. Neonatal tetanus is generally seen in infants born to unimmunized mothers, frequently following umbilical stump infection. Affected infants initially present in the first 2 weeks of life with poor suckling and fatigue, following by rigidity, spasms and opisthotonus. 40. Rheumatic fever is a complication of streptococcal pharyngitis and is diagnosed clinically using the Jones criteria. The major criteria include carditis, migratory polyarthritis, Sydenham chorea, subcutaneous nodules, and erythema marginatum. Juvenile RA is diagnosed by arthritis that is present for greater than 6 weeks. Systemic symptoms including a rash can be seen in children with JRA, but the arthritis is usually not migratory as described in this pt. 41. Stranger anxiety is the normal anxiety experienced by infants when they are exposed to unfamiliar individuals. It peaks at 12-15 months. 42. Isotonic solutions such as normal saline are the fluid of choice for initial resuscitation in severe hypovolemic hypernatremia. 43. Although adequate hydration is very important in the mx of diarrhea, replacement of electrolytes is also essential to prevent complications such as water intoxication and hypomatremia. Water intoxication, hyponatremia, and seizure may result if diarrhea is treated with large amounts of hypotonic or low-solute fluids (eg. water). 44. The vaccination schedule for preterm infants should be conformed to the child’s chronologic age, not the gestational age. The exception is that children should be 2kg prior to receiving the first HBV vaccine. 1/21/10 1. IVH is most commonly seen in premature and LBW infants. Pts may present with pallor, cyanosis, hypotension, seizurem focal neuologic signs, bulging or tense fontanel, apnea, and bradycardia; however, many cases remain asymptomatic, thus mandating transfontanel ultrasound for all newborns with predisposing risk factors. 2. In the pediatric population, infratentorial tumors are more common than supratentorial tumors, and benign astrocytomas are the most common histology type in both groups. Medulloblastoma is the second most common. 3. Bedwetting is a normal phenomenon until the age of 5. 4. Umbilical hernia is due to an imperfect closure or weakness of the umbilical ring. It is especially common in low birth weight, female, and black infants. It appears as a soft swelling, covered by skin that protrudes during crying, coughing, or straining, and can be reduced earsily through the fibrous ring at the umbilicus. The hernia consists of ometum or portions of the small intestine. Most umbilical hernias disappear spontaneously by 1 year of age. Surgery is advised if the hernia persists to the age of 3-4 years, exceed 2cm in diameter, causes symptoms, becomes strangulated, or progressively enlarge after the age of 1-2 years. An omphalocels is a herniation or protrusion of abdominal contents into the base of the umbilical 185

cord, and it usually diagnosed at birth. In contrast to the more common umbilical hernia, the sac is covered with peritoneum without overlying skin. Immediated surgical repair before infections take place is essential for survival. Gastroschisis is diagnosed at birth by protrusion of bright red intestines to the right side of the umbilicus. There is no covering of the intestines, and the umbilicus is normal. It is a surgical emergency. 5. The features of Prader-Willi syndrome (obesity hypogonadism syndrome) include hypotonia, hypogonadism and obesity. Remember mental retardation, and dysmorphic craniofacial features (ie., narrow bifrontal diameter, diamond-shaped eyes and a small, down-turned mouth). 6. Breastfeeding jaundice is an exaggeration of physiologic jaundice commonly seen in exclusively breastfed infants who are not getting enough breast milk. When effective breastfeeding is not established in the first few days of life, the inadequate enteral intake prolongs the intestine transit time, resulting in an increased enterohepatic circulation. In addition, the infant becomes relatively dehydrated from the limited fluid intake. The increased enterohepatic circulation and relative dehydration together cause an elevated unconjugated bilirubin level in the first few days after birth. 7. The initial mx of breastfeeding jaundice is to stimulate milk production by increasing the nursing frequency. The infant should be monitored closely (repeat bilirubin level 12-24 hours) to ensure that the feeding problems are resoved and the bilirubin decreases. If the infant’s bilirubin continues to rise, then interventions such phototherapy (bilirubin levels >1725mg/dL), exchange transfusion (bilirubin levels > 25mg/dL), or formula supplementation may become necessary to prevent the complication known as nernicterus. Breastfeeding jaundice that occurs in the first few days of life must be distinguished form breast milk jaundice, which usually starts after the first 3 -5 days of life, peaks 1-2 weeks after birth, and can lasat several months. An otherwise thriving infant will present with jaundice and elevated unconjugated hyperbilirubinemia. The etiolgoyc is not completely understood, but it is thought that a substance in breast milk may inhibit UDPGA or that the increased beta glucuronidase activity in breast milk may increase the enterohepatic circulation of bilirubin. ABO incompability is caused by maternal antibodies against fetal erythrocytes. Most commonly, ABO incompatibility is seen when the mother’s blood type is O and the infant’s blood type is A , B, or AB. The jaundice of ABO incompatibility tends to manifest in the first 24 hours of life. 8. Urinalysis is a preliminary inverstigation that should be performed first in all pts with suspected renal disease. 9. Wiskott-Aldrich syndrome is an X-linked disorder characterized by the triad of thrombocytopenia, eczema (there are dry, scaly patches on his cheeks and lower extremities), and recurrent bacterial infections. The thrombocytopenia is caused by decreased platelet production, and the few platelets that exist are typically quite small. 10. Coarctation of the aorta (COA) is characterized by hypertension in the upper part of the body and relative hypoperfusion in the lower part of the body. A mild, continuous murmur heard all over the chest is due to the development of collaterals between the hypertensive and hypoperfused vessels. Rb notching, caused by the dialatation of the collateral chest wall vessels, is specific for coarctation. 11. The most common esophageal anomaly is esophageal atresia with a tracheoesophageal fistula. 186

12. 13. 14. 15. 16.

17. 18. 19.

20. 21. 22. 23.

24.

This is charaterzied by an atretic esphoageal pouch that communicates diatally with the trachea just above the carina. This anatomic arrangement allows air to enter the stomach, and this leads to gastric distention. The discontinuous esophagus prevents the infant from completely swallowing, thereby resulting in drooling or regurgitation during feeding. In addition, gastric fluid ascends into the distal esophagus through the fistula, into the trachea and lungs, thereby producing aspiration pneumonia. Pneumonitis and atelectasis occur frequently, and rattles are heard during breathing. The inability to pass a feeding tube into the stomach is suggestive of esophageal atresia with or without tracheoesophageal fistula. Congenital syphilis presents early on with hepatomegaly, cutaneous lesions, jaundice, anemia, and rhinorrhea. Metaphyeal dystrophy and periostitis may be seen on radiography. The classic triad of Kartegener’s syndrome is recurrent sinusitis, bronchiectasis, and dextrocardia. The cause is primary ciliary dyskinesia. Pneumococcal vaccination plus penicillin prophylaxis can prevent almost all cases of pneumococcal sepsis in pts with sickle cell anemia. Arteriovenous malformation (AVM) is the most common of the subarachnoid hemorrhage in children. The history of seizure and migraine-like headaches is characteristic. Aseptic necrosis of the femoral head is a common complication of sickle cell disease. It involves occlusion of end arteries supplying the femoral head, bone necrosis, and eventual collapse of the periarticular bone and cartilage. * Extremely high yield!! Prostaglandin E1 infusions may be used to keek the ductus arteriosus patent in pts with ductus-dependent congenital heart disease until definitive therapy can be pursued. Those with sickle cell trait have some protection against malaria. Chronic garnulomatous disease is an inherited immunodeficiency disorder marked by an inability to oxidize pathogens within phagocytes. Pts experience recurrent infections starting early in life. Pneumonia and suppurative adenitis are especially common infections in these pts. Acute bacterial sinusitis for children 2mg/dL); 2) jaundice that appears in the first 24-36 hours of life. 3) serum bilirubin rising at a rate faster tham 5 mg/dl/24 hours . 4) Serum bilirubin greater than 12mg/dl in full-term (esp n the absence of risk factors) or 10-14 mg/dl in preterm infants. 5) Jaundice persists after 10-14 days. 6) The presence of signs or symptoms. 33. Tetralogy of Fallot, the most common cyanotic congenital disease in children less than 4 years of age, presents with cyanotic spells and pansystolic murmur on exam (a harsh pansystolic murmur is noted at the left sternal border, along with a single S2). 34. Suspect duodenal atresia when the pt has bile-stained vomitus, no abdominal distension, dehydration, double bubble sign, and Down syndrome. Vomiting usually begins in the first 188

35. 36.

37.

38.

39. 40. 41.

42. 43.

44.

24-48 hours after birth. Hydroxyurea is indicated in sickle cell pts with frequent, acute, painful episodes, as it tends to increase the HbF levels. Iron poisoning presents as nausea, vomiting, diarrhea, abdominal pain, gastrointestinal bleeding and metabolic acidosis. Since iron is radio-opaque, the tablets can be seen in the stomach on abdominal x-ray. The dx is confirmed by measuring serum iron levels. Iv deferoxamina, an iron chelator, is used in moderate to severe cases of intoxication. Capillary blood specimens (using a finger stick) are widely used in childhood screening for lead poisoning. Since false positive results are common, the first step after an abnormal fingerstick lead level is to confirm the dx with a serum (venous blood) lead level. If the serum lead level is > 10ug/dl, then intervention is needed. Recurrent self-limiting episodes of vomiting and nausea in children, in the absent of any apparent casue, suggest the dx of cyclical vomiting. The etiology of this condition is unclear, however, its incidence is high in children whose parents have a history of migraine headaches. Complications that may arise from the condition are anemia and dehydration. Tx consists of anti-emetics and reassuranve of the parents. A minor who is a parent can consent to treatments or procedures for his/her child. A retropharyngeal abscess should be suspected in pts who present with pharyngitis, moderate fever, dysphagia, neck stiffness, a muffled voice, a posterior pharyngeal bulge. Inflammed, fluctuant cervical LN are typically caused by streptococcal or staphylococcal infection. The antibiotic of choice is dicloxacillin 二氯苯甲异恶唑青霉素钠. Other effective antibiotics include cephalexin or clindamycin. Night terrors occur during non-REM sleep and are characterized by fear, crying or screaming, decreased level of consciousness, and amnesia of the event. Bordetella pertussis causes whooping cough, which are severe paroxysms of cough that can last up to two weeks. The coughing spells are so severe that rectal prolapse and pneumothoraces can ensue. The TORCH infections (toxoplasmosis, rubella, CMV, HSV and syphilis) cause a syndrome characterized by microcephaly, hepatosplenomegaly, deafness, chorioretinitis, and thrombocytopenia.

1/22/10 1. Language development: 12-month: “mama”, “dada”, and one other word. Be able to follow simple commands with a gesture 15-month: “mama”, “dada”, and 3-5 other word. Understand simple commands even without a gesture. 18-month: a vocabulary of 5-20 words. 2-year: a vocabulary of 150-300 words and be able to combine words into short sentences. In addition, half of their speech should be understandable to a stranger. 3-year: vocabulary has increased ti close to 1000 words, and about 75% of the children’s speech can be understood by a stranger. In addition, they speak in 3-4 word sentences and use pronouns correctly. 2. Suspect growing bone pain in a child with nocturnal pain and no obvious physical or lab 189

finding. The tx is reassurance. Common in age 2-12 year, is usually poorly localized and common in the legs (usually below the knees and bilateral). In all cases, it resolves in the morning. The dx of growing pain is a diagnosis of exclusion. 3. Pts with classic PKU present with fair skin, blue eyes, musty body odor and eczema. Dx of PKU: 1) plasma phenylalanine level greater than 20mg/dl. 2) normal to low-normal plasma tyrosine level. 3) increased urinary levels of phenylalanine metabolites (phenylpyruvic and ohydroxyphenylacetic acids). 4) normal tetrahydrobiopterin level. Pts with benign hyperphenylalaninemia also have a deficiency in phenylalanine hydroxylase, but some residual enzyme activity is preserved; therefore, the serum phenylalanine blood levels are only slightly elevated (less than 20mg/dl). Pts who undergo PKU screening may be identified during the neonatal period, but they are otherwise asymptomatic and may develop normally without tx. Pts with transient hyperphenylalaninemia are asymptomatic. Tyrosinemia is caused by a deficiency of fumarylacetoacetate hydrolase. Affected infants may become symptomatic as early as the 2nd week of life. Common manifestations include fever, irritability, vomiting, hemorrhage, hepatomegaly, jaundice, elevated levels of serum transaminases, episodes of acute peripheral neuropathy, Fancon-like syndrome, and hypoglycemia. Pts may smell like boiled cabbage. 4. Sickle cell anemia can cause childhood atroke. 5. This pt with recurrent bacterial infections and necrotic periodontal infection is most likely suffering from congenital immunodeficiency cause by a leukocyte adhesion defect. Delayed separation of the umbilical cord (>3 weeks) is characteristic and presents an important clue to the correct dx. The leukocytes fail to express some adhesion molecules on their surface. The leukocyte number is increased, but the interleukocyte communication is defective; therefore, chemotaxis and cytotoxicity are impaired. Normal lymphocyte count and gamma globulin concentration help to differentiate this condition from a variety of cell and/or humoral immune defects. The classic example of opsonization defect is asplenia. Infections with encapsulated bacteria (like S. pneumoniae) are typical. Complement deficiencies manifest as recurrent generalized infections with encapsulated bacteria, typically Neisseria and autoimmune disorders. Defective intracellular killing is due to impaired oxidative burst within the phagocytes and a positive NBT test is characteristic. 6. Positive anti-Smith antibodies and/or anti-double stranded DNA antibodies is specific and comfirmatory for the diagnosis of systemic lupus erythematosus. 7. The USPSTF recommends screening for atrabismus, amblyopia, and refractive errors in children aged 0-5 years. 8. Batteries lodged in the esophagus on x-ray should be removed immediately under endoscopic guidance to prevent mucosal damage and esophageal ulceration. Batteries located distal to esophagus pass unevenfully in most cases and need only to be observed with stool examination and/or follow up x-rays to confirm excretion. 9. Scarlet fever is characterized by fever, toxicity, pharyngtis, sandpaper-like rash, circumoral pallor and strawberry tongue. It is caused by strains of Group A streptococcus that produce erythrogenic exotoxins. Penicillin V is the drug of choice. 190

10. 11. 12.

Vit A has been shown to reduce the morbidity and mortality rates of pts with measles. Thyroid dysgenesis is the MCC of congenital hypothyroidism in US. Infants with congenital hypothyroidism initially appear normal at birth, but gradually develop apathy, weakness, hypotonia, large tongue, sluggish movement, abdominal bloating, and an umbilical hernia. For this reason, screening newborns for hypothyroidism, along with phenylketonuria and galactosemia, is standardly performed in all states. 13. Severe combined immune deficiency is a life-threatening syndrome presenting with recurrent bacterial, viral and fungal infections. Its diagnostic features are: absent LN and tonsils, lymphopenia, absent thymic shadow on CXR, and abnormal T, B and natural killer cell enumeration by flow cytometric analysis. 14. Osteogenesis imperfecta can be associated with blue sclera, hearing loss, joint hypermobility, and dentinogenesis imperfecta (opalescent teeth). 15. Milk protein intolerance may present with vomiting and bloody diarrhea. Stools may show RBCs and eosinophils, and there may be a family history of an atopic disorder. It is a hypersensitivity reaction to cow’s milk proteins, and therefore usually occurs in babies who are fed with cow’s milk, however, it may occur in breastfed babies, as the mother’s milk may contain proteins from ingested cow’s milk. 16. Topical mupirocin or oral erythromycin is the tx of choice for local impetigo. 17. Watch out for the infant or newborn with failure to thrive, bilateral cataracts, jaundice and hypoglycemia. Such an infant most likely has galactosemia, which is a metabolic disorder caused by galatose-1-phosphate uridyl transferase deficiency, thereby leading to elevated blood level of galatose. The pt presented in this case has the typical presentation: vomiting, poor weight gain, jaundice, hepatomegaly, convulsions and cataracts. Other common manifestations include aminoaciduria, hepatic cirrhosis, hypoglycemia, and mental retardation. Such pts are at increased risk for E.coli neonatal sepsis. Early dx and tx by elimination of galactose from the diet are mandatory. Pts with galactokinase deficiency present with cataracts only, and are otherwise asymptomatic. Uridyl diphosphate galactose-4-epimerase deficiency is a rare diseses compared to uridyltransferase deficiency. In addition to the manifestations of transfrease deficiency, pts with epimerase deficiency have hypotonia and deafness. 18. Meconium aspiration syndrome occurs most commonly in low birthweight and postmature infants. It is characterized by respiratory distress at birth, rales, rhonchi, hyperinflation, and coarse streaking and patchy opacities on CXR. 19. Septic joint in a child is a true surgical emergency and needs immediate surgical drainage. A delay of even 4-6 hours can lead to avascular necrosis of the femoral head. 20. Hypocomplementemia (low C3, CH50) in post-streptococcal glomerulonephritis resolves in 8-12 weeks. Hematuria may persist for up to 6 months. Persistent microscopic hematuria is suggestive of IgA nephropathy. Proteinuria resolves much slower than hematuria. Up to 15% of pts may have proteinuria for a period of 3 years. Antibody titers tend to rise after 7 days, peak after one month, and return to normal in 3-4 months. 21. Respiratory distress syndrome is caused by surfactant deficiency and is more common in premature infants and infants of diabetic mothers. 22. Parinaud’s syndrome and Collier’s sign (paralysis of vertical gaze that may be associated with papillary disturbances and eyelid retraction) usually indicate a lesion in the 191

rostral midbrain, most likely pinealoma or germinoma. 23. The 3 most common organisms that cause pneumonia in pts with cystic firbrosis are Haemophilus, Pseudomonas, and Staphylococcus. It is essential to memorize: G+ diplococci – Streptococcus pneumoniae G+ cocci in clusters – Staphylococcus G- cocci – Neisseria G+ rods – Listeria and Bacillus G- rodes – Pseudomonas, Haemophilus, Klebsiella, Legionella 24. Pts wiht cystic fibrosis may initially present with meconium ileus, which is characterized by bilious vomiting, failure to pass meconium at birth, and ground glass appearance on abdominal x-rays. 25. By the first birthday, a child should triple his birth weight and increase his height by 50%. The rate of growth slows towards the end of the first year of life. When compared to birth weight, a child’s weight should double by 5 months and triple by 1 year. Height increases by 50% in the first year, bouble by 4 years, and triple by 13 yeas. 26. Painful crises (vasoocclusion in connective tissue and muscle) are the most common manifestation of sickle cell anemia. Sickle cells and reticulocytes will be seen on the peripheral smear. Burr cell are speculated RBC of similar size and with regularly spaced profections. They are seen most commonly in uremia or as an artifact of preparation. 27. Osteonecrosis is a common complication of sickle cell anemia due to vaso-occlusion of the bone. It causes significant joint pain and functional limitation. The humerus and femur are the most frequently affected bones. 28. Physiological jaundice usually presents after 24 hours of birth. Jaundice in the first 24 hours of birth or with direct hyperbilirubinemia requires a detailed evaluation to identify its cause. 29. Howell-Jolly bodies are nuclear remnants of the RBC which are generally removed by a functional spleen; therefore, their presence in a peripheral smear suggests functional asplenia in sickle cell pts. Heinz body-G6PD Helmet cells are fragmented RBC—traumatic hemolytic conditions such as DIC, HUS and TTP Basophilic stippling are ribosomal precipitates whichi appear as blue granules of various sizes dispersed throughout the cytoplasm of the red cell—thalassemias, hevey metal poisoning 30. Acquired torticollis is a relatively common condition in children. The most common causes include upper respiratory infections, minor trauma, cervical lymphadenitis, and retropharyngeal abscess. Cervical spine radiographs should be obtained in children with acquired torticollis to ensure there is no cervical spine fracture or dislocation. 31. Pts with Turner syndrome have a higher risk of osteoporosis due to lower estrogen levels and only having one copy of X chromosome genes involves in bone metabolism. 32. A unilateral flank mass in a child >3 years of age is most likely due to Wilm’s tumor, which arises form the metanephros. A unilateral flank mass in a child 35 with DUB, endometrial biopsy is indicated. 32. In a complete abortion, the whole conceptus passes through the cervix. The cervix then closes, an the associated pain and uterine contractions subside. 33. Symptoms of menopause include irregular or absent menses, heat intolerance, flushing, insomnia, and night sweats. Hyperthyroidism and menopause can have similar presentations, and serum TSH and FSH levels should be checked in pts with these symptoms. 34. In the immediate postpartum period, a low-grade fever, leukocytosis and vaginal discharge are normal findings. The vaginal discharge (lochia) is initially bloody, then serous (3-4 days) and finally white to yellow in color days following delivery. Culture of the vaginal discharge would be required if there is foul smelling discharge or if the pt’s fever and leukocytosis persists or worsens. 35. Levonorgestrel (“Plan B”) is the recommended method of emergency contraception. This progestin-only method is considered effective up to 120 hours after intercourse, although effectiveness is greater the earlier the medication is administered. There are no contraindications to the use of levonorgestrel, and no physical exam or lab testing is required. It has the lowest incidence of side effects amongst emergency contraceptives, although nausea (20%) and vomiting (5%) may occur. Individuals 18 years of age or older can obtain levonorgestrel over-the-counter, whereas individuals under 18 must obtain a prescription in most states. Levonorgestrel prevents pregnancy in approximately 7 out of 8 women who would have otherwise become pregnant form intercourse. Intramuscular medroxyprogesterone (Depo-provera) is a primary method of birth control, with shots administered every 3 months. Prosraglandin E2 suppositories may be used as a second trimester abortifacient. Neither is recommended as a form of emergency contraception. 36. Endometrial biopsy is indicated in cases of DUB affecting women>35 years old. It is also indicated in cases of DUB if hypertension, diabetes, or obesity are present. 37. One of the effects of preeclampsia is damage to the liver that can cause right upper quadrant pain due to stretching of the hepatic (Glisson’s) capsule. 206

38. Magnesium sulfate is given to women with eclampsia and severe preeclampsia in order to prevent the further development of seizures while delivery of the fetus is accomplished. Delivery is the most important overall tx for eclampsia. 39. Metformin is indicated in polycystic ovarian syndrome pts with impaired glucose tolerance. It helps in preventing type 2 diabetes mellitus as well as improving obesity, hirsutism, menstrual irregularity, and infertility. 40. Pseudocyesis is a rare psychiatric condition in which a woman presents with nearly all signs and symptoms of pregnancy, however, ultrasound reveals a normal endometrial stripe and negative pregnancy test. Pseudocyesisi is usually seen in women who have a strong desire to become pregnant. It has been suggested that the depression caused by this need is behind the occurrence of some hormonal changes mimicking those of pregnancy. This is a form os conversion disorder, and management requires psychiatric evaluation and tx. 41. In false labor, progressive cervical changes are absent, contractions are irregular and discomfort is readily relieved by sedation. All such pts need reassurance. 42. Systemic and topical corticosteroids can induce an acneiform eruption characterized by monomorphous, erythematous follicular papules distributed on the face, trunk and extremities. Comedones are characteristically absent. 43. Precocious puberty has both central and peripheral causes. Central precocious puberty presents with increased FSH and LH, while peripheral causes present with low FSH and LH. All pts with central precocious puberty should receive brain imaging with CT and MRI. Tx is with GnRH analog therapy. 44. Hormone replacement therapy is now only recommended for the short-term use of controlling menopausal symptoms. Large studies, such as the WHI, have shown that the longterm use of combined HRT can slightly increase the risk of coronary heart disease and stroke. Conclusions from the WHI (Women’s health initiative) trial: 1) there is no cardiovascular benefit with either unopposed estrogen or combined estrogen-progestin therapy. 2) there is an increased risk of stroke with long-term use of both unopposed estrogen or combined estrogenprogestin therapy. 3) There is an increased risk of breast cancer with combined estrogenprogestin therapy, but not with unopposed estrogen. The benefits of HRT are that it helps relieve the symptoms of vaginal dryness, hot flashes and some of the mental changes seen in menopause. It also protects against osteoporosis, and to a minor degree against colon cancer. The risks of HRT include an associated increased incidence of venous thromboembolism and endometrial hyperplasia/cancer (only with unopposed estrogen). This risk can be largely reduced by the addition of progestin therapy. 1/24/10 1. A reactive NST is reassuring and it should be repeated weekly. 2. This pt has a female phenotype but lacks a normal vaginal and uterus, which narrows the etiology of her primary amenorrhea to mullerian agenesis, androgen insensitivity, or 5reductase deficiency. The karyotype is the determinig test, with both androgen insensitivity and 5-alpha-reductase deficiency being seen in pts with a XY genotype. This pt’s genotype is XX, which leaves mullerian agenesis as the best explanation for her condition. The mullerian duct normally leads to the development of the proximal vagina and the uterus; therefore pts with mullerian agenesis normally have a blind ended vagina with little to no uterine tissue. 207

Androgen insensitivity pts have a male XY genotype but there is an abnormality in the androgen receptor. The external genitalia develop as female, but mullerian inhibiting factor is still secreted by the testes which prevents the development of internal female organs. 5-alpha-reductase deficiency cannot convert testosterone to the more potent DHT. They hava a male XY genotype and female external genitalia, but typically show virilization at puberty. 3. Eclampsia is diagnosed when unexplained convulsion occur in the setting of preeclampsia. 4. The most effective agent used for tx and prevention of seizure in eclampsia is magnesium sulfate. 5. Abdominal circumference is the most effective parameter for estimation of fetal weight in cases of suspected FGR, b/c it is affected in both symmetric and asymmetric fetal growth restriction. 6. Prolactin production is stimulated by serotonin and TRH and inhibited by dopamine. Hypothyroidism may result in amenorrhea and galactorrhea. 7. Serum BUN and creatinine are usually decreased in pregnant pts due to an increase in renal plasma flow and glomerular filtration rate. 8. Elevated prolactin levels suppress GnRH release thereby suppressing LH and FSH production and ovulation. This is the reason for anovulation and amenorrhea in lactating mothers. 9. The superficial femoral vein is a deep vein of the thigh and a thrombus of this vein requires anticoagulation. Pregnancy is a major risk factor for deep venous vein thrombosis, especially during the peripartum period. 10. There is no role for medications in the suppression of breast milk production. Pts are advised to wear a tigh-fitting bra, avoid nipple manipulation and use ice packs and analgesics to relieve associated pain. 11. Weight gain has not been associated with the use of combination oral contraceptive pills in controlled studies. Pap smear screening should be initiated in all women 3 years after initiation of sexual intercourse but no later than 21 years of age. 12. Radiation levels used for most diagnostic exams are not associated with teratogenicity. Exposure to ionizing radiation doses below 5 rad (5cGy) is not associated with known fetal abnormalities. Therapeutic abortion is advised when the radiation level is between 5-10 cGy. 13. Pts with androgen resistance present with amenorrhea, normally developed breasts, absent pubic and axillary hair, absent reproductive organs, and a 46 XY karyotype. Serum testosterone levels are in a range typical for males. The internal reproductive organs do not develop because the testes are still present and secret mullerian inhibiting factor. 14. Early decelerations are depressions in fetal heart rate that resolve by the end of the uterine contraction. Early decelerations are not considered a nonreassuring heart rate pattern, and are the result of fetal head compression. Fetal sleep presents with decreased long-term variability. Fetal cord compression presents with variable decelerations. Uteroplacental insufficiency presents wht late decelerations. Intrauterine infections may present with fetal tachycardia (HR>160). 15. In adolescent females, ASCUS or LSIS (low grade squamous intraepithelial lesions) are most likely due to HPV infection. Because frank cervical cancer in this population is uncommon, the best mx strategy is a follow-up Pap smear in 1 year. LSIL (mild dysplasia or CIN 1) 208

------------------------------------------------------------------------------------------------------↓ ↓ ↓ Adolescents ↓

Premenopausal woman Postmenopausal woman ↓ ↓-------------------------↓

Repeat Pap in 12 months

Colposcopy ↓

Reflex HPV resting Colposcopy ↑

If ‘positive’-------------------↑ 16. Mx of placenta previa depends on the severity of bleeding and the age of the pregnancy. Complete placenta previa requires delivery by cesarean section as the placenta completely covers the os cervix and the fetus cannot be delivered vaginally. At 36 weeks gestation, amniocentesis should be done in order to assess lung maturity. If the fetal lungs are mature, elective cesarean section can be performed. 17. Congenital aromatase deficiency is a rare genetic disorder marked by either total absence or poor functioning of the enzyme that converts androgens into estrogens. Its consequences are numerous. In utero the placenta will not be able to make estrogens, leading to masculinization of the mother that resolves after delivery. The high levels of gestational androgens result in virilized XX child with normal internal genitalia but ambiguous external genitalia. Clitoromegaly is often seen when excessive androgens are present in utero. Later in life pts will have delayed puberty, osteoporosis, undetectable circulating estrogens, high concentrations of gonadotropins and polycystic ovaries. McCune-Albright syndrome (aromatase)↑ is marked by the triad of café-au-lait spots, polyostotic fibrous dysplasia, and autonomous endocrine hyperfunction. The most common endocrine feature is gonadotropin independent precocious puberty. Thus, pts have early puberty. 18. Both general and spinal anesthesia as well as sedation may reduce uterine activity if administered in the latent phase (95 mg/dl, 1-hour >180, 2-hour > 155, 3 hour > 140. Arrest disorder of dilation has not progressed for more than 2 hours. It can also be of descent when the descent has not progressed for more than 1 hour. It can be caused by hypotonic contractions, conduction anesthesia, excessive sedation, cephlopelvic disproportion or malpresentation. In the present case, the arrest is resulting from a midpelvic contraction indicated by the prominence of the ischial spines. 210

35. In the case of amenorrhea-hypoprolactinemia, first rule out hypothyroidism by measuring serum TSH. 36. Mild preeclampsia is defined clinically by hypertension greater than 140/90mmHg and proteinuria greater than 0.3/24h (300mg/24h) after the 20th week of gestation. 37. Methyldopa is a pregnancy category B agent and is the first-line medication for tx for hypertension in pregnancy. 38. Lichen sclerosus most commonly affects postmenopausal women and manifests with vulvar prutitus and discomfort. Exam shows porcelain-white atrophy. Biopsy should be considered to rule out valvar SCC. Lichen sclerosus is considered a premalignant lesion of the vulva as vulvar SCC occurs with greater frequency in these pts as compared to the general population. 39. High-potency topical steroids are considered first-line therapy for lichen sclerosus. 40. Premature ovarian failure is characterize by amenorrhea, hypoestrogenism, and elevated serum gonadotropin levels in women younger than 40 years of age. It may be secondary to accelerated follicle atresia or a low initial number of primodial follicles. It is most commonly idiopathic but may also be due to mumps, oophoritis, irradiation or chemotherapy. It can be associated with autoimmune disorders such as Hashimoto thyroiditis, Addison disease, type I DM, and pernicious anemia, which supports wht hypothesis that at least some cases of idiopathic premature ovarian failure are of autoimmune origin. Women present with signs and symptoms that are similar to those seen in menopause. The dx is confirmed by demonstrating increased serum FSH and LH levels and secreased estrogen levels. Pts with premature ovarian failure lack viable oocytes, so the only option available ot allow pregnancy in such pts is invitro fertilization. 41. Infertility in women with irregular menstrual cycles is often due to anovulation. Ovulation can be tested for by measuring a midluteal phase progestone level. 42. Hypothalamic-pituitary-gonadal axis immaturity is a cause of irregular menstrual cycles in women shortly following menarche. 43. In any woman of childbearing age with secondary amenorrhea, first rule out pregnancy. 44. Physician can refuse to perform elective abortions for personal or professional reasons. If you refuse to perform any procedure then you should attempt to refer the pt to another physician who can and will. 1/25/10 1. Granulosa cell tumors produce excessive amounts of estrogen, and can present with precocious puberty in younger children and postmenopausal bleeding in elderly pts. This has to be differentiated from heterosexual precocious puberty or virilizing symptoms which are usully produced by excessive androgens. 2. Epidural anesthesia may cause overflow incontinence as a transient side effect. It is best treated with intermittent catheterization. Oxybutynin has anticholinergic properties and inhibits smooth muscle contraction. This drug is used for urge incontinence. 3. This is a case of hypergonadotropic hypogonadism, b/c the pt has a primary amenorrhea with absent secondary sexual characteristics and increased FSH level. A differential dx of hypergonadotropic hypogonadism includes conditions that present with primary amenorrhea and either a male or female karyotype, making karyotype determination the most appropriated next step in the work up. These conditions include Turner syndrome (45, XO), Savage 211

syndrome, or ovarian resistance syndrome (46, XX), male gonadal agenesis (46, XY), and defects in testosterone production, such as in deficiency of 17-alpha-hydroxylase and 17, 20desmolase (46, XY). Prolactin and TSH levels are indicated in secondary amenorrhea after ruling out pregnancy. They usually do not have problems with secondary sexual characteristics. 4. An increase in blood pressure that appears before 20 weeks gestations is due to either chronic hypertension or a hydatiform mole. 5. Risk factors for placental abruption include prior placental abruption, chronic hypertension, pregnancy-induced hypertension, cocaine, alcohol or tobacco use and vascular diseases such as diabetes and SLE. The most significant risk factor is hypertension of any kind. Sustained maternal blood pressure in excess of 160/110 should be treated pharmacologically. 6. Idiopathic central precocious puberty, which is the most common type in females, results from the premature activation of the hypothalamic-pituitary-gonadal axis. Pts with central precocious puberty have pubertal levels of basal LH that increase with GnRH stimulation, whereas pts with a peripheral source of precocious puberty, such as in certain ovarian pathologies, have low LH levels with no response to GnRH. All pts with central precocious puberty should have brain imaging to rule out an underlying CNS lesion. This pt has had a fairly rapid progression of pubertal maturation, and should be treated with GnRH agonist therapy in order to prevent premature epiphyseal plate fusion. 7. Kallmann’s syndrome consists of a congenital absence of GnRH secretion (ie. Hypogonadotropic hypogonadism) associated with anosmia. Pts have a normal XX genotype and normal female internal reproductive organs. They present with amenorrhea and absent secondary sexual characteristics such as breast development and pubic hair; the addition of anosmia to the presentation may suggest the dx. Abnormal development of the olfactory bulbs and tracts result in hyposmia or anosmia (decreased sense of smell). The FSH and LH levels are low, in contrast to the levels in primary ovarian failure which are usually elevated. 8. Galactorrhea presents as guaiac negative bilateral nipple discharge. Prolactonoma, hypothyroidism, overstimulation of the nipple, oral contraceptive pills, and medications which lower dopamine levels are common cause. Workup includes ruling out pregnancy, measuring serum prolactin and TSH levels, and possible MRI of the brain to rule out prolactinoma. 9. Penicillin is considered to be the tx of choice for pregnant pts with syphilis. If a pt is allergic to penicillin, the allergic shoud be confirmed with skin testing and the pt should then undergo desensitization so that she can safely take the medication. It is typically accomplished using incremental doses of oral penicillin V. 10. Postterm pregnancies are at an increased risk for oligohydramnios, which itself is associated with increased fetal morbidity. Postterm pregnancies should be monitored for oligohydramnios twice weekly. Oligohydramnios in these cases is defined as no vertical pocket of amniotic fluid greater than 2cm or an amniotic fluid index of 5cm or less. 11. Hypertension in a pregnant female in the setting of massive proteinuria, a malar rash, and a strongly positive ANA titer is most likely due to SLE. Glomerulonephritis in general will cause proteinuria, hematuria and RBC casts. 12. The CDC recommends that all pregnant women without contraindications be vaccinated against influenza. 13. It is strongly recommended that asymptomatic bacteriuria in pregnant women be treated, 212

especially women at 12-16 weeks’ gestation. Recommended antibiotics include amoxicillin, nitrofurantoin, and oral cephalosporins. Trimethoprim-sulfamethoxazole is a class C mediation in pregnancy. It may be used during the second trimester but is not recommended for use during the first trimester because it interferes with folic acid metabolism or during the 3rd trimester b/c it increases the risk of kernicterus in the newborn. 14. The combination of primary amenorrhea, bilateral inguinal masses, and breast development without pubic or axillary hair is strongly suggestive of androgen insensitivity syndrome(a mutation of the androgen receptor gene). A blind vaginal pouch and karyocype of 46XY are other clues. A gonadectomy should be performed to avoid the risk of testicular carcinoma. 15. Sudden onset abdominal pain, fetal heart rate abnormalities, and recession of the presenting part during active labor indicated uterine rupture. Rish factors include a preexisting uterine scar or abdominal trauma. 16. The requirement for L-thyroxine in pts receiving estrogen replacement therapy increases. The potential causes may include induction of liver enzyme, increased level of TBG, and an increased volume of the distribution of thyroid hormones. In pregnancy, also, thyroid hormone requirements will be increased, and the pt should be monitored every 4-6 weeks for dose adjustment. 17. Secondary amenorrhea is relatively common in elite female athelets and results from estrogen deficiency (due to decrased LH and GnRH). These amenorrheic women are therefore at increased risk for all conditions associated with estrogen deficiency, including infertility, vaginal atrophy, vaginal atrophy, breast atrophy, and osteopenia. 18. Lithium is associated with congenital heart disease, classically Ebstein’s anomaly, and should be weaned in pregnant women with stable bipolar disorder. When a woman is treated with isotretinoin, she should receive strict contraception. Inhaled steroids can be used during pregnancy. 19. Laparoscopy is the gold standard for the dx of endometriosis. 20. Pts with endometriosis are at an increased risk of decreased fertility or infertility. Up to 30% of females being evaluated for infertility are found to have endometriosis. 21. Ovulation can be induced in pts with PCOS with clomiphene citrate tx as well as with metformin tx. 22. Anabolic steroid use by a male can produce infertility by suppressing the productin of GnRH, LH and FSH. Klinefelter syndrome (XXY seminoiferous tubule dysgenesis) in an inherited disorder characterized by resticular fibrosis (primary hypogonadism), azoospermia, gynecomastia, decreased intelligence and decreased axial skeletal growth. FSH and LH will be high. 23. If maternal serum AFP levels are abnormal in a pregnant pt, the next step is ultrasonography to confirm gestational age, detect fetal structural anomalies, detect multiple gestation and confirm a viable prennancy. Amniocentesis is indicated in cases where the MSAFP pr triple/quadruple screen is abnormal but only after ultrasonography has ascertained gestational age accuracy and ruled out nonviable pregnancy or multiple gestation. It is best performed between 16-20 weeks gestation. Chorionic villus sampling is indicated for early screening in women with known genetic diseases, or who have had children affected by a genetic condition. It is performed between 10-12 weeks gestation, and therefore offers the advantage of a first trimester termination of pregnancy if the 213

fetus is affected. Cordocentesis is used for rapid karyotype analysis, or when fetal blood dyscrasias 恶液质, such as fetal anemia and Rhesus isoimmunization, are suspected. In the present case, ultrasound should be performed first to rule out causes of MSAFP elevation other than genetic anomalies. 24. Abdominal pain in a young female in the middle of her cycle with a benign history and clinical examination is most likely mittleschmerz (midcycle pain). Ovarian torsion is a medical emergency. Pts present with sudden-onset lower quardrant abdominal pain that radiates to the groin or back and it accompanied by nausea and vomiting. An adnexal mass is usually present. 25. Female offsping of women who ingested diethylstilbestrol during their pregnancy are at increased risk of developing clear cell adenocarcinoma of the vagina and cervix as well as cervical anomalies and uterine malformations. 26. Lupus anticoagulant can sometimes be seen in pts with SLE and is a potential cause of recurrent pregnancy loss due to thrombus development within the placenta. 27. Painful third trimester vaginal bleeding with normal ultrasound is most likely due to placental abruption. 28. Women shoudn be screened for group B strep colonization with vaginal and rectal cultures obtained between 35-37 weeks gestation. Women colonized with GBS receive prophylactic antibiotics (penicillin or ampicillin) at the time of delivery. Women who have had GBS bacteriuria during pregnancy or who have previously delivered a child that developed an early-onset GBS infection are automatically given prophylactic antibiotics regardless of the results of a rectovaginal culture. 29. A biophysical profile score of 2 or less is consistent with severe fetal asphyxia. In this setting, the baby should be delivered immediately. 30. Primary ovarian failure results in decreased estrogen levels and increased FSH and LH levels (the elevation of FSH is generally greater than that of LH due to slower clearance of FSH from the circulation). FSH elevation in the setting of >=3 months of amenorrhea in a woman inder age 40 confirms the diagnosis of premature ovarian failure. 31. OCPs offer both risks and benefits as outlined below. The risks and benefits should be weighed carefully for each individual pts. Serious side effect Protective against Venous throboembolism Ovarian cysts and cancer Cardiovascular events/stroke Endometrial cancer Elevation of triglyceride levels Benign breast disease Cholestasis or cholecystitis Dysmenorrhea (anemia) DM Hypertension 32. Fetal distress (repetitive late decelerations) is an indication for emergent cesarean section. 33. Gestational diabetes is most commonly first treated with a low suger diet, but if diet fails to produce euglycemia, insulin is the tx of choice. 34. Gestational diabetes carries numerous risks for the fetus including macrosomia, hypocalcemia (due to parathyroid hormone suppression), hypoglycemia (due to high baseline insulin production), hyperviscosity due to polycythemia (increased erythropoietin), respiratory

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36. 37.

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41. 42.

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difficulties, cardiomyopathy and congestive heart failure. The most important complication of PPROM is pulmonary hypoplasia (immaturity). Steroids are used to enhance fetal lung maturity when premature rupture of membranes occurs at less than 34-weeks of gestation. Hypotension is a common side effect of epidural anesthesia. The cause of hypotension is blood redistribution to the lower extremities and venous pooling. Septic abortion is managed with cervical and blood cultures follows by IV antibiotics and gentle suction curettage. Vigorous suction curettage may cause perforation of the uterus and should be avoid. Intersitial cystitis (painful bladder syndrome) is a chronic condition associated with pelvic pain worsened by bladder filling or intercourse accompanied by urinary frequency, urgency, and nocturia. The negative urinalysis excludes a urinary tract infection. Stress incontinence refers to involuntary leakage of urine with effort, exertion, sneezing or coughing. Pain is typically not a symptom of stress incontinence. Transvaginal ultrasonogram is more accurate than transabdominal ultrasonogram in diagnosing ectopic pregnancy, and should be performed when beta-hCG levels are between 1500-6500 IU/L. Pts with PPROM whose GBS status is unknown should receive antibiotic prophylaxis. Corticosteroids are indicated if the gestational age is 4.5. 3) A positive “whiff” test upon addition of KOH to the vaginal discharge. 4) “clue cells” (vaginal epithelial cells with adherent coccobacilli) on wet mount. External cephalic version (ECV) can be attempt in women with breech pregnancies at greater than 37 weeks gestational age if there are no contraindications to vaginal delivery and fetal well-being has been established. EVC has been shown to reduce the rate of cesarean sections, but the maneuver has the potential to result in fetal distress, so it should only be performed when arrangements have been made to allow for an emergent caesarian delivery. The most appropriate first steps in the mx of variable decelerations (due to umbilical cord compression) are oxygen administration and change in maternal position. If the variable decerlerations persist, the pt should be placed in the Trendelenburg position and the presenting fetal part should be elevated. Persist variable decelerations may require amnioinfusion, which consists of the infusion of fluid into the amniotic cavity. Fetal scalp pH testing should be performed to assess for fetal hypoxia if the abnormal FHR pattern persists after the initial measures of position change, oxygen administration, and discontinuation of oxytocin have been tried. Cesarean section is indicated when fetal distress is confirmed. For acute preterm labor bed rest and tocolysis are continued as long as possible with a longterm goal of reaching 34-36 weeks gestational age. In otherwise normal pregnancies, systemic corticosteroids are administered when gestational age is between 24-34 weeks. Tocolysis should then be attempt with the goal being to maintain the pregnancy for at least 48 hours in order to realize maximum benefit from the steroids. In the ovulatory phase of the menstrual cycle, cervical mucus is profuse, clear and thin (pH 6.5 or greater, more basic than at other pahses). It will stretch to approximately 6 cm and exhibit ferning on a microscope slide smear preparation. In early follicular phase is thick, scant and acidic. In the mid- and late-luteal phase, the cervical mucus becomes progressively thicker and exhibits less stretching ability. 217

21. Suspect atrophic vaginitis in post-menopausal females with symptoms of vaginal dryness and dysuria, and physical exam findings of pale, dry vaginal mucosa, diminished labial fat pad, and scarce pubic hair. Moderate and severe cases require local estrogen therapy. 22. Bilateral edema of the lower extremities in pregnancy is most commonly a benign problem. Preeclampsia and DVT should also be considered, but are unlikely in the absence of other classic symptoms of these conditions. 23. Raloxifene is a mixed agonist/antagonist of estrogen receptors. In breast and vaginal tissue, it is an antagonist, whereas in bone tissue, it is an agonist. It is a first-line agent for the prevention of osteoporosis, and it decreses breast cancer risk. It increases the risk of thromboembolism. 24. BPP includes the NST in addition to four parameters assessed by ultrasonography: 1/fetal tone; 2/fetal movements (3/10min); 3/fetal breathing (30/10min); 4/amniotic fluid index, (520). A total score of 8-10 is considered normal, and should only be repeated once or twice weekly until term for high risk pregnancies. 1) If the presence of oligohydramnios (AFI100bpm) and leukocytosis, fetal tachycardia (>160bpm), uterine tenderness and a foul uterine discharge indicate this dx. Subclinial infection is confirmed by amniotic fluid analysis (amniocentesis for gram staining, culture and sensitivities and other studies). Fetal complications of intraamniotic infection include preterm labor and an increased risk of neurodevelopmental delay and cerebral palsy. 4. All pts who take metronidazole shoud abstain from drinking alcohol, as it is associated with a disulfiram-like reaction. 5. Adenomyosis occurs most frequently in multiparous women above 40 years of age and typically presents with dysmenorrheal and menorrhagia. The physical exam reveals an enlarged and generally symmetrically uterus. In contrastm a fibroid uterus is usually irregularly shaped. 6. Given the high rate of co-infection with Gonorrhea and Chlamydia and the poor sensitivity of gram stain for Chlamydia, antibiotic mx must be aimed at eradiction of both organisms when gram stain confirms cervical Gonorrhea infection (Ceftriaxone and azithromycin). Amipicllin and gentamicin is indicated if there is a suspicion for polymicrobial infection such as post partum endometritis. 7. Inevitable abortion is characterized by vaginal bleeding and fluid discharge, low abdominal cramps and a dilated cervix through which the products of conception can occasionally be visualized. 8. Thichomonas infection usually causes vaginal discharge, prutitus, dysuria, and dyspareunia, though it can also be asymptomatic. Regardless of the presence of symptoms, both partners should be treated with oral metronidazole to prevent recurrent infections. 9. The increased incidence of urinary tract infections in women is due to the shorter length of the female urethra compared to males. Other predisposing factors for UTI’s include sexual intercourse, recent antibiotic use, the use of spermicidal contraceptives, and a close proximity of the urethra to the anus. 10. Fetal hydantoin syndrome presents with small body size, microcephaly, digital hypoplasia, nail hypoplasia, midfacial hypoplasia, hirsutism, cleft palate and rib anomalies. 11. Cesarean delivery should be performed on women with active genital herpetic lesions 220

12.

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16. 17. 18.

(primary or secondary) in order to reduce the risk of neonatal HSV, a severely morbid and potentially fatal illness. Ureine rupture presents with intense abdominal pain associated with vaginal bleeding which can range from spotting to massive hemorrhage. Pts also typically exhibit vital signs consistent with hypovolemia, retraction of presenting parts one pelvic exam, and palpability of fetal extremities on abdominal exam. A breech presentation diagnosed before the 37th week of gestation does not require any intervention, as breech presentations often convert to vertex before the 37th week. External cephalic version is indicated if breech presentation is persistent after 37 weeks, and if this fails, then planned cesarean delivery is indicated. The best mx of intrauterine fetal demise is delivery of the fetus to reduce the risk of infection and coagulopathy. Tx options should be discussed with any pt prior to embarking on a plan so the pt can make an informed decision about therapy with knowledge of the risks and benefits of all options. A hysterosalpingogram is a radiographic test used to identify structural abnormalities in the uterus or fallopian tubes that may contribute to infertility. The pt has regular menstrual cycles accompanied by midcycle pelvic pain (mittelschmerz) and breast tenderness. These facts indicate that the pt is most likely ovulating, so testing for ovulation is not likely to identify the cause of infertility. Cigarret smoking is the most common preventable cause of fetal growth restriction in the US. Fetal alcohol syndrome is characterized by growth restriction, midfacial hypoplasia, a smooth philtrum, short palpebral fissure, a thin upper lip and CNS abnormalities. Bilateral solid ovarian masses discovered incidentally in a multiparous African-American pregnant woman most likely signify a pregnancy luteoma. This is a benign self-limited condition and requires no tx. Sudden onset hirsutism or virulization during pregnancy ↓

Physical examination Pelvic ultrasonogram ↓------------------------------↓------------------------------↓---------------------------↓ No ovarian mass Bilateral cystic Bilateral solid Unilateral solid ↓ ↓ ↓ ↓ Abdominal CT scan to Theca Lutein cysts Mostly pregnancy Laparptomy or rule out adrenal mass (Rule out high-β -HCG states) luteoma Lapaoscopic biopsy to rule out malignancy Solid ovarian tumors (viewed by ultrasonography) are almost malignant and demand immediate and aggressive evaluation and treatment in all age groups, except in pregnancy. 19. Hypogonaotropic hypoganadism is a decrease in circulating sec hormones due to decreased concentrations of LH and FSH. This condition increases a pt’s risk of osteoporosis. Common causes include steneous exercise, anorexia nervosa, marijuana use, starvation, stress, depression, and chronic illness. 20. A menstrual diary for at least 3 cycles is useful aid for comfirning the dx in suspected cases of PMS. Confirmation of the dx must be made before initiating tx. There is no universally accepted tx. Reduction of caffeine intake may reduce breast symptoms. An exercise program 221

21. 22. 23.

24. 25.

26. 27.

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may be effective in improving the general well being of the pt. In women whose symptoms are more severe and cause socioeconomic dysfunction, SSRIs are the drug of choice. When SSRI fail to alleviate symptoms in such pts despite therapy over multiple cycyles, low dose alprazolam is indicated. Relaxation techniques and bright light therapy have some proven effect in mx of PMS, but cognitive behavior therapy and insight oriented and supportive psychotherapy do not play a role. Tx should not be initiated until the dx is made. The tx of choice for bacterial vaginosis in both pregnant and non pregnant pts is oral metronidazole. Vaginal metronidazole and clindamycin are alternatives. RhoGAM is indicated in unsensitized, Rh-negative women at 28 weeks gestation and withn 72 hours of any procedure or incident such as abortion, ectopic pregnancy and delivery. Asymptomatic pts with Chlamydia detected by screening should be treated with azithromycin or doxycycline, but concurrent tx for Gonorrhea is not needed if screening for Gonorrhea is negative. ACEIs and ARBs are C/I in pregnancy. The first-line agents for mx of essential hypertension during pregnancy are labetalol and methyldopa. Low back pain is a very common complaint in the 3rd trimester of pregnancy. It is believed to be caued by the increase in lumbar lordosis 脊柱前弯症 and the relaxation of the ligaments supporting the joints of the pelvic gridle. PCOS is characterized by anovulation or oligo-ovulation, signs of androgen excess, such as male-pattern hair growth and acne, and ovarian cysts. Mx of placenta previa depends on the severity of bleeding and the age the pregnancy. Regardless of gestational age, pts with active, uncontrolled antepartum hemorrhage, who also typically exhibit unstable vital signs and unreassuring fetal heart rates, should undergo emergent caesarian section delivery. Voiding after intercourse has been shown to decrease the risk of urinary tract infection in sexually-active females.

1/28/10 1. Acute bacterial parotitis presents with painful swelling of the paroid gland that is aggravated by chewing. High fever and a tender, swollen and erythematous paroid gland are common. This post-operative complication can prevented with adequate fluid hydration and oral hygiene. The most common infectious agent is Stapylococcus aureus. 2. The rotator cuff is formed by the tendons of the supraspinatus, infraspinatus, teres minor and subscapularis muscles. The supraspinatus is most commonly injured, due to repeated bouts of ischemia near its insertion on the humerus induced by compression between the humerus and acromion. A common cause of acute rotator cuff tears is a fall on outstretched hands. Pts usually have severe shoulder pain and edema following the traumatic event and are unable to abduct the arm past 90 degrees. The drop arm test is a maneuver that can help to dx a rotator cuff tear. Here, the pt’s arm is abducted passively to greater than 90 degrees, and the pts is then asked to lower the arm slowly. With a complete rotator cuff tear, the pt will unable to lower the arm smoothly and it will appear to drop rapidly from near the 90 degree position. Rupture of the tendon of the long head to the biceps produces a positive “Popeye sign” where the biceps muscle belly becomes prominent in the mid upper arm. Weakness with supination is prominent, and forarm flexion is typically preserved. 222

Injury to the long thoracic nerve causes a winged scapula due to paralsis of the serratus anterior muscle. The most common cause is iatrogenic injury during axillary lymphadenectomy. The low (inferior) trunk of the brachial plexus originates from the C8 and T1 cervical roots. Injury to this trunk, which typically results from sudden upward pulling on the arm, produces Klumpke’s palsy. This palsy primarily affects muscles innervated by the ulnar nerve, which supplies most of the intrinsic muscles of the hand. Weakness and atrophy of the pothenar and interosseous muscles characterize this palsy, and a “claw hand” deformity may also result. A humeral neck fracture would be more likely to present with swelling, acchymosis and crepitus over the fracture. Axillary nerve injury may present. 3. Atelectasis is a common post-surgical complication that results from shallow breathing and weak cough due to pain. It is most common on post-op day 2 and 3 following abdominal or thoracoabdominal surgery. Adequate pain control and incentive spirometry decrease the incidence of post-operative atelectasis. Diaphragmatic paralysis may occur as a consequence of phrenic nerve injury from thoracic surgery, cervical manipulation, or tumor compression but is less likely during abdominal surgery. Unilateral diaphragmatic paralysis is often asymptomatic, while bilateral diaphragmatic paralysis causes hypoxemia, repid shallow breathing, orthopnea, and even respiratory failure. 4. Radial nerve is the most commonly injured nerve in association with fracture of midshaft humerus. 5. When there is an intimal flap of the carotid artery, surgery is recommended to repair the vessel. Intimal flap injury can lead to vessel occlusion and symptoms and signs of ischemia. Today, with the availability of stenting, this may be an alternative option to surgery. 6. The femoral nerve innervates the muscles of the anterior compartment of the thigh, and is therefore responsible for knee extension and hip flexion. The femoral never provides sensation to the anterior thigh and medial leg via the saphenous branch. 7. Inflammatory breast cancer is an uncommon form of breast cancer that presents with an erythematous and edematous cutaneous plaque overlying a mass on the breast commonly with axillary lymphadenopathy. 1/4 of pts with this condition will have metastatic disease at the time of presentation. Clinically, inflammatory breast cancer can not be differentiated from infectious process, such as a breast abscess, with 100% certainty. Therefore, a biopsy for histology should be done first to exclude or confirm that dx. 8. Extremities subjected to at least 4-6 hours of ischemia can suffer from both intracellular and interstitial edema upon reperfusion (eg. removal of an embolus). When edema causes the pressure within a muscular fascial compartment to rise above 30mmHg, compartment syndrome occurs leading to further ischemic injury to the confined tissues. The clinical findings are 5 “P’s”: Pain, Paresthesias, Pallor, Pulselessness, Paresis/Paralysis. 9. A pt, who is hypotensive with abdominal pain and has a CT scan showing an enlarged aortic silhouette, has a dx of a ruptured abdominal aortic aneurysm. This pt needs immediate surgery. 10. Peripheral artery aneurysms manifests as a pulsatile mass that can compress adjacent structures (nerves, veins), and can result in thrombosis and ischemia. Popliteal and femoral artery aneurysms are the most common peripheral artery aneurysms. They are frequently associated with abdominal aortic aneurysms. 11. Pts who present more than five days after the onset of symptoms of appendicitis, and have 223

localized right lower quadrant findings, should be treated with IV hydration, antibiotics and bowel rest. Antibiotics should cover enteric gram-negative organisms and anaerobes. A second/third generation cephslosporin or a fluoquinolone plus metronidazole are usually used. Cefotetan had a good coverage of gram-negative oraganisms and anaerobes. 12. Biliary colic occurs when the gallbladder becomes distended as it contracts against an obstructed cystic duct. The pain is typically exacerbated by fatty meals and resolves completely between episodes. Fever and leukocytosis are not present. 13. A breast mass that produces a non-bloody aspirtate and disappears completely on aspiration does not need any further evalution other than observation for recurrence. 14. Fat necrosis shows clinical and radiographic findings similar to those seen in breast cancer including skin or nipple retraction and calcification on mammography. Biopsy of the mass in fat necrosis will reveal fat globules and foamy histocytes. No tx is indicated for this selflimted condition. The calcification seen in breast malignancy tend, however, to microcalcification wihile the clacifications seen in benign conditions such as fat necrosis tend ot be coarse. 15. Pulmonary contusion represents parenchymal bruising of the lung, which may or may not be associated with rib fractures. The clinical manifestations develop usually in the first 24 hours (often with in few minutes); tychypnea, tachycardia, and hypoxia are characteristic. Physical examination typically reveals chest wall bruising and decreased breath sounds on the side of pulmonary contusion. Chest x-ray reveals patchy irregular alveolar infiltrate and a CT scan may be employed to make an early dx. ABG typically shows hypoxemia and, itself, is an indiction to suspect pulmonary contusion in trauma pts. 16. Acute shoulder pain after forceful abduction and external rotation at the glenohumeral joint suggests an anterior dislocation, which may cause injury to the axillary nerve or artery. 17. Pts with Paget disease of bone are typically asymptomatic; the dx is made when an increased bone-specific alkaline phosphatase is discovered on rountine laboratory testing. Pts who do become symptomatic typically present with pain associated with fractures or with arthritis resulting from bone deformity (hearing loss). 18. Osteogenic sarcoma (osteosarcoma) is the most common primary malignancy of bone. It most commonly affects males in their second decade preferentially in the metaphyses of long bones. Pts present with bone pain but do not have systemic symptoms (x-ray film shows an osteolytic lesion of the distal femur along with periosteal inflammation). Osteoclastoma (giant cell tumor of bone), is a tumor of adults that often involves the epiphysis of the distal femur or proximal tibia. Radiology characteristically shows a soap-bubble appearance due to the osteolytic quality of the tumor. Ewing’s sarcoma is also most common in the second decade of life. It is s small, round, blue cell (neuroectodermal) malignancy classically associated with systemic features such as fever, malaise and weight loss. It typically affects the diaphyses of long bones as well as the spine and pelvis. Xray shows an osteolytic lesion with onion-skin appearance. Chronic osteromyelitis may present with painful swelling, fever and laboratory abnormalities including an elevated ESR and leukocytosis. Chronic osteomyelitis most commonly results form contiguous spread of infection from an adjacent site, such as the skin. This is commonly seen in diabetic foot ulces. 19. Spinal cord ischemia with lower spastic paraplegia is a rare complication of abdominal aortic 224

aneurysm surgery. The artery of Adamkiewicz arises from the aorta and supplies the anterior circulation of the middle and lower spine cord. Diminished flow through this artery may results from its thrombosis, ligation, or systemic hypotension. Resultant neurologic dysfunction is due to ischemia of antero-lateral structures of the spinal cord. It includes lower apastic paraplegia, pelvic organ dysfunction, and loss of temperature and pain sensation over the lower extremities. Vibrotory and proprioceptive sensation is preserved because posterior circulation of the spinal cord is not affected. 20. In cases of suspected child abuse, physicians are required to thoroughly examine the child for documentation of all potential signs of abuse. This includes a complete skeletal survey. Child protective services should be notified of all suspected cases immediately, and the pt should be admitted. 21. Bowel ischemia may complicate up to 7% of procedures on the aortoiliac vessles and most commonly affects the distal left colon. Pts report dull pain over the ischemic bowel as well as hematochezia. Colonscopy shows a discrete segment of cyanotic and ulcrated bowel. 22. A retrograde urethrogram should be the first step in mx of a suspected urethral injury. Foley catheterization in the presence of a urethral injury will predispose the pt to abscess formation and worsening of the urethral damage. Classic signs of posterior urethral injury include blood at the urethral meatus, inability to void and a high-riding porstate on digital rectral exam. 23. Pancreatic cancer classically presents insidiously with a combination of constant visceral epigestric pain radiating to the back, jaundice due to extrahepatic biliary obstruction, and anorexia with weight loss. A peptic duodenal ulcer typically causes periodic epigastric pain relieve by meals. 24. The central cord syndrome classically occurs hyperextension injuries in elderly pts with degenerative changes in the cervical spine. Such a traumatic injury causes selectively damage to the central portion of the anterior spinal cord, specifically the central portions of the corticospinal tracts and the decussating fibers of the lateral spinothalamic tract. Central cord syndrome is characterized by weakness that is more pronounced in the upper extremities than in the lower extremities. This unique motor deficit occurs because the motor fibers serving the arms are nearer to the central part of the cortisospinal tract. Rarely, a pt may also have a selective loss of pain and temperature sensation in the arms due to damage to the spinalthalamic tract. The anterior cord syndrome should be suspected when there is bilateral spastic motor paresis distal to the lesion. It usually occurs secondary to occlusion of the vertebral artery. Posterior cord syndrome is associated with bilateral loss of vibratory and propioceptive sensation. 25. Tachypnea, tachycardia, jugular venous distension and tracheal deviation following blunt chest trauma all suggest tension pneumothorax. This life-threatening emergency requires immediate decompression with needle thoracostomy. Subsequent tube thoracostomy may be performed to maintain lung expansion. In a pt who remains hemodynamically unstable following decompression of a pneumothorax, pericardial tamponade shoud be suspected. 26. Gastric outlet obstruction is a clinical syndrome characterized by early satiety, nausea, nonbilious vomiting, and weight loss, all of which can be the result of many difference disease processes. In a pt with a history of acid ingestion, pyloric stricture is the most likely cause. Esophageal stricture/dysmotility tends to present with dysphagia, which is not a presenting symptoms of this pt. In addition, abdominal succession splash 液波震颤 is not a finding in those 225

with esophageal stricture/dysmotility. 27. In frail chest, multiple contiguous ribs are fractured resulting in an isolated segment of the thoracic wall that exhibits paradoxical motion during normal respirtation. Pain control and supplemental oxygen pressure ventilation is required in many pts with this injury. The institution of positive pressure mechanical ventilation causes the flail segment to move normally. 28. When a wound fails to heal after a prolonged period, biopsies should be obtained to ensure that the ulcer has not degenerated into a squamous cell carcinoma. When SCC arises within a burn wound, these unclers are known as Marjolin ulcers. 29. In a young individual who presents with a fleshy immobile mass on the midline hard palate, the most likely dx is torus palatinus. No medical or surgical therapy is required unless the growth becomes symptomatic or interferes with speech or eating. A pt with torus palatinus will usually give a history that the lesion has been present for some time and will deny tenderness. The thin epithelium overlying the bony growth will tend to ulcerate and be slow to heal due to poor vascularity. 30. Aortoilliac occlusion (Leriche syndrome) is characterized by the triad of bilateral hip, thigh and buttock claudication, impotence and symmetric atrophy of the bilateral lower extremities due to chronic ischemia. Impotence is almost always present in men with this condition, in the absence of impotence, an alternate dx should be sought. The pulse is soft or absent bilaterally from the groin distally in this condition. Men with a predisposition for atherosclerosis, such as smokers, are at the greatest risk of this condition. Because impotence is not uncommon in this age group, and the complaints of hip and thigh pain with walking may also be attributed to osteroarthritis, there is a risk of missing this dx if a thorough vascular exam is not performed. 31. Injury to a number of different structures within the knee, including ligaments and cartilaginous menisci, can cause a popping or snapping sensation. Most meniscal tears in the knee jount occur during a distinctly recalled acute knee injury, often associated with a popping sensation. Subsequent joint swelling develops gradually, and is often not noticed until the following day. This is in contrast to ligamentous tears, which may also be associated with a popping sensation, but which cause rapid joint swelling due to hemarthrosis. An anterior cruciate ligment (ACL) tear wound cause immediate swelling due to rapid development of hemarthorosis. Moreover, pts typically experience immediated inability to weihtbear and then lasting knee instability following such an injury. Chronic overuse, typically related to strenuous athletic activities, can cause patellar tendonitis, or “jumper’s knee”. Physical exam typically reveals point tenderness over the proximal patellar tendon. The anserine bursa underline the conjoined tendons of the gracilis and semitendinosus muscles and separtates them from the head of the tibia. Anserine bursitis causes tenderness over the medial aspect of the knee, and typically affects athletes and obese middle-aged to elderly women. A popping sensation is not typically reported. Stress fractures do not result from discrete injuries such as falls or other trauma. Instead, they arise insidiously secondary to repeat stress. Athletes, especially long-distance runners, are most commonly affected. The tibia and fibula are most vulnerable. 32. Nasopharyngeal cancer (NPC, undifferentiated carcinoma of squamous cell origin) is most common in pts of Mediterranean and Far Eastern descent. It is strongly associated with 226

Epstein-Barr virus infection. Pts with NPC often present with recurrent otitis media (resulting from Eustachian tube obstruction by tumor), recurrent epistaxia, and/or nasal obstruction. 33. The tibia is the most common bone is the body to be affected by stress fractures, and the pts affected by ths condition are most commonly competitive athelets. A stress fracture can occur even in conditioned athletes after only four to six weeks of intense training. Pts who participte in running sports classically obtain stress fractures in the distal third of the tibia on the posteromedial border while pts involved in jumping sports, such as dancing, classically abtain stress fractures in the middle third of the tibia on the anterior side of the bone. Pts typically complain of pain with activity that improves with rest. If activity is continued, the pain may persist during rest. Point tenderness to palpation over the fracture is present on exam. X-rays are usually normal, but they may reveal periosteal reaction in the site of the fracture. The injury is best defined radiographically using CT or bone scan. Epiphysitis of the tibial tubercle would cause pain in the proximal tibia, near the knee, where the iliotibila tract inserts. 34. Urinary calculi present as the flank or abdominal pain radiating to the groin, along with nausea and vomiting. A non-contrast spiral CT of the abdomen and pelvis is the imaging modality of choice (best!) for diagnosis. IVP was the test of choice in the past for diagnosing urinary stones but, because of the risk of contrast-related reactions with IVP, non-contrast CT is now the preferred test. 35. Scaphoid is the most commonly fractured bone among all the carpals. It is commonly seen in young adults following a fall on the outstretched hand. Pt generally complaints of pain at wrist joint. Tenderness in anatomical snuffbox is a very sensitive marker of scaphoid fracture. Fracure is most commonly located across the waist of scaphoid bone. Initial X rays may be normal or may show fine radiolucent line in non-displaced scaphoid fractures. Scaphoid views are necessary to avoid missing the scaphoid fractures. Cast immobilization is recommended in the tx of all non-displaced scaphoid fractures (fractures 20:1 in the post-operative state most likely indicate acute pre-renal failure from hypovolemia, though urinary catherter obstruction should be first be ruled out. The next step in the dx/mx of acute renal failure manifesting as oliguria or anuria is an IV fluid challenge. 2. Suspect cardiac tamponade in an adult pt who has sustained blunt chest trauma if he has persistent jugular venous distention, tachycardia, and hypotension despite aggressive fluid resuscitation. CXR findings typically reveal a normal cardiac silhouette without tension pneumothorax. DD: lung contrusion, aortic rupture, esophageal rupture, bronchial rupture 3. Esophageal perforation due to iatrogenic cause is very frequent and radiography with watersoluble contrast is the best way to diagnose esophageal perforation. 4. For hemarrhagically unstable pts in whom blunt abdominal trauma is suspected, fluid resuscitation should be initiated, followed by ultrasound examination. If ultrasound is not definitive, then diagnostic peritoneal lavage is performed. Those pts with confirmed hemoperitoneum whould then undergo laparotomy for surgical repair. 5. Gental 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 attempt immediately. 6. Severe blunt chest trauma can cause direct physical injury to the underlying pulmonary 228

parenchyma and pulmonary contusions. Signs and symptoms include dyspnea, tachynpea, chest pain, hypoxemia worsened by iv volume expansion, and patchy, irregular alveolar infiltrates on CXR. Aspiration of gastric contents has a history of having vomited. 7. Penile fracture is a surgical emergency that requires emergent urethral imaging and surgical repair. The most common cause is a crush injury of the erect penis, most commonly during intercourse where the female is on top of the male. 8. Femoral neck fractures are intracapsular fractures and are most commonly seen in postmenopausal females and males over 70 years of age. The pt will classically present following a fall with inability to ambulate and hip pain. On exam, the involved limb is shortened and externally rotated. Active and passive range of motion of the affected limb elicits pain. The dx can be made with AP and lateral X-rays of the hip, and classification of the fracture using the Garden classification system may then be made based on radiographic findings as follows: Type 1: Valgus 外翻的 impaction of femoral head. Type 2: complete but non-displaced femoral neck fracture. Type 3: Complete fracture with displacement 50%. Type 1 or stress fractures can be managed nonoperatively with toe-touch weight bearing on crutches until there is radiogical evidence of complete healing. Garden types 2, 3 and 4 are unstable fractures and require open reduction and internal fixation or a primary arthroplasty 关节形成术. Elderly pts and those with severely displaced femoral neck fractures (type 4), are preferentially treated with arthroplasty. Arthroplasty is preferred because the risk of avascular necrosis of the femoral head is high, even following open reduction and intermal fixation, due to the tenuous blood supply of the femoral head. 9. Mastitis associated with breast-feeding is treated with analgesics, antibiotics and continuation of breast-feeding from the affected breast. The most commonly isolated organism is S. aureus. The most commonly used antibiotics are dicloxacillin or cephalosporins. 10. The differential dx of a widened mediastinum as a solitary finding includes processes as diverse as anthrax, various tumor, madiastinitis, aortic dissection, hemorrhage and large pericardial effusion among others. Acute madiastinitis may occur following heart surgery. Signs and symptoms include fever, chest pain, leukocytosis and mediastinal widening on CXR. Mediastinitis is a serious condition that requires drainage, debridement and antibiotic therapy. 11. The nature of this pt’s accident afn his scalp lacerations suggest that he has suffered blunt head trauma, After initial fluid resuscitation, he lapses into a state of decresed consciousness with right-sided hemiparesis. The mist likely explanation in this setting is a transtentorial (uncal) herniation secondary to right-sided epidural hematoma. Uncal herniation mauy also result from a subdural hematoma or an intracerebral mass. Epidural hematomas result from rupture of the middle meningeal artery. Because they are under arterial pressure, they expand rapidly. In this case, the fluid resuscitation likely increased the rate at which the hematoma expanded, thereby precipitating the above neurologic signs. Focal neurologic sings result form herniation of the parehippocampal uncus through the tentorial incisure, which causes pressure on the ipsilateral oculomotor nerve and posterior cerebral artery as well as compression of the contralateral cerebral peduncle against the edge of the tentorium. The specific lesions and their respective signs are in the table. Transtentorial (uncal) herniation 229

Lesions Comperssion of contralateral crus cerebri against the tentorial edge Compression of the ipsilateral oculomotor nerve (CN III) by the herniated uncus

Compression of the ipsilateral posterior cerebral artery Compression of the reticular formation

Signs Ipsilateral herniparesis Loss of parasympathetic innervation causes mydriasis (occur early) Loss of motor innervation causes ptosis and “down and out” gaze of the ipsilateral pupil due to upopposed trachlear (CN IV) and abducent (CV VI) action (occur later) Contralateral homonymous hemianopia Altered level of consciousness, coma

12. Acute ruptured appendicitis may be complicated by pelvic abscess. Pelvic abscess typically presents with lower abdominal pain, malaise, low-grade fever and a tender pelvic mass on rectal examination. 13. Isolated duodenal hematoma most commonly occurs in children following blunt abdominal trauma. It is treated conservatively with nasogastric suction and parenteral nutrition. Most hematomas will resolve spontaneously in 1-2 weeks. Surgery may be considered to evacuate the hematoma if this more conservative method fails. 14. The tx of pancreatitis is primarily supportive. Antibiotics may be used, but the evidence does not presently support the use of antacids, antichoinergics, glucagan or octreoties. Identifying the underlying cause may facilitate prevention of recurrent pancreatitis. 15. Legg-Calve-Perthes disease is characterized by avascular necrosis of femoral head. It typically presents in children four to ten years of age with insidious-onset hip or knee pain and an antalgic 镇 痛 的 gait. Physical exam shows marked limitation of internal rotation and abduction at the hip joint. Proximal thigh atrophy may also be present. X-rays may be negative initially, but serial studies will show changes in the femoral head consistent with necrosis and recalcification. MRI and bone scans show findings suggestive of femoral head necrosis much earlier than standard x-rays and may be used to make the diagnosis months earlier. Tx is aimed at maintaining placement of the femoral head within the acetabulum so that it may heal in the proper shape and position. This may be accomplished with splints or surgery. 16. Unilateral suacute hip pain in a male child coupled with a progressive antalgic gait, thigh muscle atrophy, decreased hip range of motion, and collapse of the ipsilateral femoral head on plain pelvic x-rays are findings suggestive of idiopathic avascular necrosis of the femoral capital epiphysis (Legg-Calve-Perthes disease.) (X-ray film!) 17. High-energy, blunt, rapid deceleration trauma to the chest commonly causes aortic injury. In most cases of aortic rupture, death is the immediate result. In pts with a contained rupture, the diagnosis must be made quickly. Widened mediastium and left-sided hemothorax are classic CXR abnormalities pointing to this dx. In these cases, the diagnosis can be confirmed via CT scanning. Mx of pts wht established aortic injury includes antihypertensive therapy where appropriated and immediated operative repair. 18. Oxalate absorption is increased in Crohn disease and all other intestinal diseases causing fat malabsorption. Increased absorption is the MCC of symptomatic hyperoxaluria and oxalate

230

stone formation. Under normal circumstances, calcium binds oxalate in the gut and prevents its absorption. In pts with fat malabsorption, calcium is preferentially bound by fat leaving oxalate unbound and free to be absorbed into the bloodstream. Failure to adequately absorb bile slats in states of fat malabsorption also cause decreased bile salt reabsorption in the small intestine. Excess bile salts may damage the colonic mucosa and contribute to increased oxalate absorption. 19. Pts suffering esophageal perforation most commonly present with acute-onset substernal pain. The diagnostic study of choice when esophageal perforation is suspected is a gastrografin contrast esophagogram. 20. Pts with mild to moderate head injury can be discharged under the care of an adult if they have a normal CT scan. The caretaker is given printed instructions detailing the signs and symptoms that warrant immediate return to the hospital. 21. This pt presents with symptoms and signs suggestive of meniscal injury. The episode of injury occurred one month ago, when acute pain and swelling were present. The current symptoms suggest ‘locking’, a phenomenon that is due to impaired extension of the knee. In addition of the pt’s history, a positive McMurry sign is present (popping sound on passive flexion/extension of the joint), which is specific for meniscal injury. Persistent symptoms (eg. mechanical symptoms) in pts with probable meniscal injury should be further evaluated by MRI or arthroscopy. Surgery (arthroscopic or open) is often necessary to correct the problem. 22. Persistent pneumothorax and significant air leak following chest tube placement in a pt who has sustained blunt chest trauma suggests traheobronchial rupture. Other findings include pneumomediastinum and subautaneous emphysema. The dx can be comfirmed with highresolution CT scanning, bronchoscopy, or surgical exploration. Operative repair is indicated. 23. Bowel ischemia and infarction ar possible early complications of operation on the abdominal aorta, such as abdominal aortic aneurysm reqair. This adverse effect can be minimized by cheching sigmoid colon perfusion following placement of the aortic graft. 24. All pts with acute carbon monoxide poisoning should be treated with 100% oxygen via a nonrebreather facemask. Early symptoms of carbon monoxide poisioning are typically neurologic and include agitation, confusion and somnolence. 25. Positive pressure mechanical ventilation increases intrathoracic pressure, which decreases venous return to the heart and thereby decreases the ventricular preload. In pts with hypovolemic shock, this effect may cause circulatory collapse if the pt’s intravascular volume is not replaced before mechanical ventilation is attempted. 26. Acute appendicitis is a clinical dx. Pts with a classic presentation should be operated on immediately to remove the inflamed appendix and prevent appendiceal rupture. 27. The medial meniscus is typically injured during forceful torsion of the knee with the foot planted. Pts complain of a popping sound and severe pain at eh time of injury; McMurray’s sign is commonly positive on physical exam. A bucket handle tear of the medial meniscus leads to locking of the knee joint during terminal extension. Because the meniscus is not directly perfused, effusion following injury typically is not clinically apparent for many hours following the injury. In cases of anterior cruciate ligment tear, the pt gives a history of a forceful hyperectension injury to knee or a noncontact torsional injury of the knee during deceleration. Effusion is seen rapidly following injury. Lachman’s test, anterior drawer test and pivot shift test are used for clinical dx. 231

Posterior cruciate ligament injury is classically seen in the “dashboard injury”, which refers to forceful posterior-directed force on the tibia with the knee flexed at 90 degrees. The posterior drawer, reverse pivot shift and posterior sag 下垂 tests will help in clinical dx. Medial collateral ligament injury is associated with abduction injury to the knee. The valgus stress test will help in clinical dx. Lateral collateral ligament injury is very rare and would be seen in adduction injury to the knee. The varus stress test will help in clinical dx. 28. For hemodynamically unstable pts in whom blunt abdominal trauma is suspected, fluid resuscitation shoud be initiated, followed by ultrasound examination. If ultrasound reveals intraperitoneal blood, the pt should then undergo urgent laparotomy for surgical repair. 29. When a pt presents with a pulsatile abdominal mass and hypotension, a presumptive dx of ruptured abdominal aortic aneurysm must be entertained and the pt should be taken immediately to the operating room. 30. Postoperative pulmonary complications are common, particularly in pts with known risk factors. These risk factors include smoking, preexisting pulmonary diasease, age>50, thoracic or abdominal surgery, surgery lasting > 3 hours, and poor general health. Postoperative measures such as incentive spirometry and deep breathing exercises are used to prevent such complications and improve outcomes by promoting lung expansion. 31. A hydrocele is a fluid collection within the processus or tunica vaginalis—the peritoneal projection that accompanies the testis during its descent into the scrotum. Hydrocele can be differentiated from other testicular masses by transillumination; a hydrocele will transilluminate while other masses will not. Most cases of hydrocele will disappear spontaneously by the age of 12 months and can be safely observed during that period. Hydroceles that do not resolve spontaneously should be removed surgically due to the risk of inguinal hernia. 32. In a steady resting state the RQ (Respiratory quotient) depends upon the proportions of metabolic fuels being oxidized for ATP production. A steady state RQ close to 1.0 indicates predominant oxidation of carbohydrates and net lipogenesis. The RQ for protein and lipid as sole sources of energy are 0.8 and 0.7, respectively. Assessment of the RQ is important when attempting to wean pts from mechanical ventilation, as overfeeding, especially carbohydrates, can cause excessive CO2 production and make weaning more challenging. This factor is especially important in pts with preexisting lung disease. 33. A varicocele is a tortuous dilation of the pampiniform 蔓形的 plexus of veins surrounding the spermatic cord and testis in the scrotum. A varicele results form incompetence of the valves of the testicular vein and occurs most frequently on the left side, possibly because the left testicular vein enters the left renal vein infeiriorly at a right angle thereby predisposing to impaired drainage. Pts are commonly asymptomatic. Those who do complain of symptoms may endorse a “dull” or “dragging” discomfort of the scrotum that is worse when standing. On exam, the affected side of the scrotum will feel similar to a “bag of worms” and valsalva maneuver will typically cause the mass to enlarge. Cystic dilations of the efferent ductules (spermatocele) are painless fluid-filled cysts that contain sperm. They are located on the superior pole of the testis in relation to the epididymis. These masses are distinct from testix and classically transilluminate. 34. Complete small bowel obstruction usually present with nausea, vomiting, abdominal bloating, 232

35.

36. 37.

38.

39. 40.

41.

42.

43.

44.

and dilated loops of bowel on abdominal x-ray. Adhesions, typically post-operative, are the most common etiology. Arterial occlusion of an extremity will cause pain, pulselessness, pallor, paresthesias and paralysis in the affected limb. Embolic occlusion classically causes sudden-onset severe pain and asymmetric pulselessness. Volkmann’s ischemic contracture is the final sequel of compartment syndrome in which the dead muscle has been replaced with fibrous tissue. Reflex sympathetic dystrophy is a vague painful condition seen as a sequel of infection or trauma which may be minor. It is characterized by pain, hyperesthedia and tenderness, which are out of proportion to the physical findings. It does not have an acute onset like in this pt and is not associated with compartment syndrome. Sudeck’s atrophy is a radiographic term for spotty rarefaction seen in pts with reflex sympathetic dystrophy. Following splenectomy, pts are at increased risk for sepsis secondary to encapsulated organisms like S. pneumoniae, N.meningitidis, and H.influenzae. Vaccinations against each of these organisms should be administered. Pneumococcal vaccine boosters are required every 5 years. An exploratory laparotomy is required in all pts with blunt abdominal trauma with signs of peritonitis or hemodynamic instablility. Three to four percent of pts with spinal cord injuries will develop post-trumatic syringomyelia. Whiplash is often the inciting injury. Symptoms develop months to years later. The condition involves enlargement of the central canal of the spinal cord due to CSF retention, resulting in impairment strength and pain/temperature sensation in the upper extremities or having a cape-like distribution, with preservation of dorsal column function. MRI is used for definitive dx. Drooping of the contralateral hemipelvis below its normal horizontal level during monopedal stance constitutes a positive Trendelenburg sign. It is caused by weakness or paralysis of the gluteus medius and minimus muscles, which are innervated by the superior gluteal nerve. Blunt trauma to the upper abdomen can cause a pancreatic contusion, crush injury, laceration or transaction. Pancreatic injuries may be missed by CT scan during the first 6 hours following trauma. An untreated pancreatic injury can later be complicated by a retroperitoneal abscess or pseudocyst. Fat embolism presents with dyspnea, confusion and petechiae in the upper part of the body and occurs after multiple fractures of long bones. Serial x-rays shows increasing diffuse bilateral pulmonary infiltrates within 24-48 hours of onset of clinical findings. Posterior dislocation of the shoulder may follow tonic-clonic seizures. In posterior shoulder dislocation the arm is classically held adducted and internally rotated and fullness is palpable on the posterior shoulder. Neurovascular impairment is unusual.

1/30/10 1. Pts treated with high-dose methylprednisolone within eight hours of spinal cord injury have significant and sustained motor and sensory neurological improvement. Thus, its use is warranted as the first priority after stablilizing a pt with clinical evidence of spinal cord injury. All pts with clinical evidence of a spinal cord injury should be imaged with CT scan to assess the bone and MRI to assess the cord and other soft tissues, such as the intervertebral disks. Tx 233

with iv corticosteroids should not be delayed for these imaging procedures. 2. A cystic lesion involving the pancreas on CT scan in the setting of acut pancreatitis with systemic toxicity must be considered an abscess and should be treated with drainage. In the absence of systemic toxicity, a pseudocyst may be presumed and magaged expectantly. 3. The first step in evaluating a pt with suspected peripheral artery disease (PAD) is to obtain an ankle-brachial index (ABI). The ABI is calculated by dividing the systolic blood pressure obtained by Doppler in the posterior tibial and dorsalis pedis arteries by that in the brachial artery. Ratio of 1 to 1.3 are considered normal. An ABI less than 0.9 is highly sensitive and specific for greater than 50% occlusion in a major vessel. ABIs less than 0.4 are consistent wit limb ischemia. After PAD is diagnosed by ABI, a number of different imaging studies may be performed to more accurately identify the occlude vessel. 4. TIG tetanus immunoglobulin, TT tetanus toxoid History of tetanus toxoid Clean minor wounds All other woulds immunization < 3 doses of tetanus toxoid in TT: Yes TT: Yes past TIG: No TIG: Yes >= 3 doses TT: Yes if last does >10 years TT: Yes if last does >5 years ago ago TIG: No TIG: No 5. Diverticulosis is the MCC of hematochezia in an elderly pt. Chronic constipation resulting from a low fiber diet is the most common predisposing factor for developing diverticulosis. 6. Any gunshot wound of the abdomen requires exploratory laparotomy. Any gunshot wound belowt the 4th intercostal space (the level of nipple) is considered to involve the abdomen. 7. MRI is the investigation of choice for defining soft tissue injuries of the knee. Surgery is rarely necessary for MCL (medial collateral ligament) tears; bracing and early ambulation is the preferred tx. Injury to MCL leads to increased angulation (abduction) of the effected knee on valgus stress. 8. Hypotension not responsive to fluid administration following trauma is suggestive of ongoing occult blood loss. Pts in this scenario must be treated emergently with surgical intervention to stop further hemorrhage. 9. Pregnancy test should be checked before ordering X-ray in any pt of childbearing age. 10. In a middle-aged adult, superficial unilateral hip pain that is exacerbated by external pressue to the upper lateral thigh (as when lying on the affected side in bed) suggests trochanteric bursitis. 11. In burn victims, clinical indicators of thermal inhalation injury to the upper airway and/or smoke inhalation injury to the lungs include burns on the face, singing of the eyebrows, oropharyngeal inflammation/blistering, oropharyngeal carbon deposits, carbonaceous sputum, stridor, carboxyhemoglobin level > 10%, or history of confinement in a burning building. The presence of one or more of these indicators warrants early intubation to prevent upper airway obstruction by edema. 12. Pain relief should be the prime objective in the mx of rib fracture as it will allow proper ventilation and prevent atelectasis and pneumonia. Oral agents, such as opiates and/or NSAIDs are most commonly utilized, but an intercostals nerve block with a long-acting local anesthetic can be used if oral or systemic analgesics are not sufficiently effective. Intercostal nerve blocks provide pain relief without affecting respiratory function, as opiate analgesics 234

13.

14.

15.

16.

17.

18.

19. 20.

21.

22.

23. 24. 25.

may, but it does carry some risk of pneumothorax. All hemodynamically unstable pts with penetrating abdominal trauma must undergo immediate exploratory laparotomy to dx and treat the source of bleeding, as well as to diagnose and treat perforation of any abdominal viscus in an effort to prevent sepsis. 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 with herniation of abdominal viscera. Typical symptoms include chest pain radiating to the shoulder, shortness of breath and abdominal pai. Respiratory distress may follow. A barium swallow or CT scan with oral contrast will be diagnostic. All diaphragmatic ruptures require operative repair. Intraabdominal pathology causing pain in one or both shoulders suggests subdiaphragmatic peritonitis. Among the possible blunt traumatic bladder injuries, only an intraperitoneal rupture of the bladder dome could, by itself, cause a chemical peritonitis. The other lower urinary tract structures are all extraperitoneal. For any pt who suffers blunt deceleration trauma (motor vehivel accident or fall from >10 feet), blunt aortic trauma must be ruled out. CXR is the initial screening test, and widening of the mediastium is the most sensitive finding. Acalculous 非 结 石 性 cholecystitis occurs in critically ill pts. The clinical presentation is vague and similar to calculous cholecystitis if the pt is able to interact. Imaging studies show gall bladder distention, thickening of the gall bladder wall and pericholecystic fluid. The emergent tx of choice is percutaneous cholecystostomy. In pts with significant total body surface area burns, the major cause of morbidity and mortality is hypovolemic shock. In the setting of adequate initial fluid resuscitation, bacterial infection (usually bronchopheumonia or burn wound infection) leading to sepsis and septic shock is the leading complication. Criteria for the systemic inflammatory response syndrome (SIRS): 1. Fever to hypothermia 2. Tachypnea 3. Tachycardia 4. Leukocytosis, leucopenia or bandemia. If a pt develops a whistling noise during respiration following rhinoplasty, one should suspect nasal septal perforation likely resulting from a septal hematoma. The most commonly injured viscera in blunt abdominal trauma is the spleen, followed by the liver and kidney. For hemodynamically unstable pts in whom blunt abdominal trauma is suspected, fluid resuscitation should be initiated, followed by ultrasound examination (FASTfocused Assessment with Sonography for Trauma). The next investigational step in the work-up of a solitary pulmonary nodule detected on CXR is usually high-resolution CT scan. The data obtained, when coupled with demographic data, can be used to determine a pt’s percent risk of malignancy, which is necessary for determinig further therapy. All pts who have clinical signs of a scaphoid fracture following an injury likely to cause such a fracture should be presumed to have a fracture (even if radipgraphs are negative) and treated with thumb immobilization in a spica cast and reevaluation by x-ray in 2-3 weeks. Hyperventilation helps to prevent and treat intracranial hypertension by causing cerebral vasoconstriction and thus decreasing cerebral blood flow. Tension pneumothorax is treated with immediate needle or tube thoracostomy. Moving from supine to sitting can increase the functional residual capacity (FRC) by 20% to 35%. In normal adults, this can amount to several hundred cubic centimers of lung volume. 235

Increasing the FRC can help prevent postoperative atelectasis. 26. Following blunt trauma, cardiogenic shock with a high-normal initial pulmonary capillary wedge pressure (PCWP) reading may be the result of a cardiac contusion. Tx is first with IV fluid to bring the PCWP to between 15-20 mmHg. Following that, positive inotropic agents should be used to increase cardiac output. Major forms of shock in thoracic trauma pts

MAP

HR

PCWP

Hypovolemic/Hemorrhagic Cardiogenic (LV dysfunction): contusion, MI, traumatic valve or septal rupture, arrhythmia Cardiogenic (RV dysfunction): contusion, MI Extracardiac obstructive: tension, pneumothorax, massive hemothorax Extracardiac obstructive: pericardial tamponade Neurogenic Septic (Hyperdynamic) MAP = mean arterial pressure; V=variable HR = heart rate; N = normal; U = unchanged

↓ ↓

↑ V

↓ ↑

PCWP after fluid challenge U or ↑ ↑↑

↓ ↓

V ↑

↓, N ↓, N

U or ↑ U or ↑

↓ ↓ ↓

↑ ↑ ↑ or ↑↑ ↑ ↑, N ↓, N ↑ ↑ ↓, N PCWP = pulmonary capillary wedge pressure

27. Non bleeding varices are managed with nonselective beta-adrenergic antagonists, such as propranolol. Such therapy can reduce the risk of bleeding by up to half. Pt has cirrhosis and PUD—conservative mx of his encephalopathy (oral lactulose), ascites (diuretics), portal hypertension and PUD (PPIs). Sclerotherapy, endoscopic band ligation and surgery are indicated after a pt has experienced a first episode of variceal bleeding, but these procedures are not recommended for prophylaxis. A portosystemic shunt or TIPS procedure are considered a last resort in variceal bleeding unresponsive to medical and endoscopic interventions and may worsen the encephalopathy in this pt. 28. Deep vein thromboses occur when Virchow’s triad of stasis, endothelial injury, and hypercoagulability are present. Major surgery is a significant risk factor for DVTs. Pts with DVT should be treated with a heparin product acutely and warfarin for several months. The goal of therapy is to prevent extension of the clot and development of future clots, not lysis of the clot already present. Streptokinase and TPA are clot-lysing enzyme used to treat acute STelevation MI. They are not generally recommended for the vast majority of DVT pts. 29. All pts with a clavicular fracture should have a careful neurovascular examination to rule out injury to the underlying branchial plexus and subclavian artery. 30. Acute GI perforation requires emergent laparotomy. If an affected pt is on warfarin, then reversal of anticoagulation must be rapidly achived pre-operatively by infusion of fresh frozen plasma. VitK is not appropriate for emergency. In general, tissue oxygen delivery does not become deficient until the hemoglobin drops below 7 g/dl. Transfusion (Packed RBC) is often not required in pts with chronic anemia. Platelet counts greater than 50,000/mm3 provide adequate hemostasis for most invasive procedures. Desmopressin (DDAVP) is given preoperatively to pts with mild hemophilia A in order to prevent excessive bleeding. It indirectly increases factor VIII levels by causing VWF release form endothelial cells. 31. Orotracheal intubation and surgical cricothyroidectomy are preferred way to establish an airway in apneic pt with head injury (obvious head and neck injuries). Needle cricothyroidectomy is an excellent field procedure to establish an airway especially in children. However, it is not suitable in adults due to risk of carbon dioxide retention especially in pts with head injury where hyperventilation can be required to prevent or treat intracranial 236

hypertension. 32. The initial tx of both complete and partial small bowel obstruction is IV fluid resuscitation, IV electrolyte replacement, NPO and NG tube gastric decompression. Surgical is typically required ultimately in pts with complete obstruction in order to rule out and prevent strangulation. 33. Venous insufficiency (valvular incompetence) is the MCC of lower extremity edema. It classically worsens throughout the day and resolves overnight when the pt is recumbent. 34. Technetium-99 labeled erythrocyte scintigraphy should be used in cases of GI bleeding where the source can not be identified. This study localizes the source of blood loss so that region can be further evaluated and treated by colonoscopy or angiography. 35. Rupture of the duodenum is frequently diagnosed by noting retroperitoneal air on abdominal x-ray. Duodenal injuries may then be better characterized using CT scan with oral contrast. 36. In case of amputation injury, amputated parts should be wrapped in saline-moistened gauze, sealed in a plastic bag, placed on ice and brought to the emergency department with the pt. 37. When hemorrhage occurs, tachycardia and peripheral vascular constriction are the first physiological changes. These responses act to maintain the blood pressure within normal limits until severe blood loss has occurred. 38. Dumping syndrome is a common postgastrectomy complication. This process leads to the fluid shift from intravascular space to the small intestine, release of intestinal vsoactive polypeptides, and stimulation of autonomic reflexes. The symptoms usually diminish over time and dietary changes are helpful to control the symptoms. In resistant cases, octreotide should be tried. Reconstructive surgery is reserved for intractable cases. 39. A chest x-ray required following central line placement (ideally should lie in the superior vena cava) to ensure proper positioning and absence of pneumothorax. 40. CT scan is the investigation of choice to dx an intraabdominal abscess. Musculoskeletal infections, such as osteomyelitis or abscess, frequenly result from hematogenous spread of organisms from another site, such as the skin. In such cases, S.aureus is the most common offending pathogen. AP and lateral lumbar films may be useful in making the dx of ureteral stones (if radioopaque), bowel obstruction and perforated abdominal viscus. A lumbar x-ray may also disclose the destruction of the vertebral bodies caused by spinal TB (Pott’s disease). Potts disease is a rare cause of psoas abscess resulting from contiguous spread. 41. Edema, stasis dermatitis and veneous ulcerations result form lower extremity venous insufficiency due to valve incompetence. Such disease classically occurs on the medial leg superior to the medial malleolus. Arterial thrombosis classically presents with a pt complaining of severe pain in a single ectremity. The onset of pain is less acute than that seen in arterial occlusion due to embolus. The extremity typically exhibits coolness to touch, pallor, pulselessness and paralysis on exam. Raynaud disease/phenomenon is characterized by arterial spasm in response to cold or emotional stress causing discoloration and discomfort of the distal digits. Raynaud phenomenon may ultimately result in distal digital gangrene if severe. Peripheral neuropathy predisposes to chronic ulceration resulting from unknown or neglected injuries or chromic pressure on the soles of the feet. This most commonly occurs in the setting of uncontrolled diabetes. 237

42. When circumferential full-thickness burns involving the extremities or chest are present, and escharotomy may be necessary to prevent vascular compromise and respiratory difficulty, respectively. 43. Perforated peptic ulcer causes sudden onset severe epigastric pain, which spreads over the whole abdomen deu to chemical peritonitis. Upright abdominal x-rays classically show free air under the diaphragm. 44. An acute blood loss in excess of 1500ml (25-30% in 70kg man) usually requires a blood transfusion. The hemotocrit is a poor indicator of acute blood loss as it generally remains near the normal level in the time period immediately following hemorrhage. 1/31/10 1. Parotid surgery involving the deep lobe of the parotid gland carries a significant risk of facial nerve palsy resulting in facial droop. 2. In pts who have had at leasr 3 tetanus vaccinations (a complete childhood series), tetanus Ig is not indicated following wounds, even if the length of time since the pt’s last vaccination is greater than 10 years. 3. The possibility of aortic disruption must be considered in every victim of a severe deceleration injury. Clinical signs can include hypertension of the upper extremities due to pseudocoarctation (caused by compression of the aortic lumen by the aforementioned hematoma) and a weak, hoarse voice due to pressure on the left recurrent laryngeal nerve by a periaortic hematoma. 4. Posterior urethral injury is associated with pelvic fractures. Pts present with blood at the urethral meatus, a high riding prostate, scrotal hematoma, inability to void despite sensing an urge to void, and a palpably distended bladder. 5. Hymenoptera 膜 翅 目 昆 虫 stings account for more deaths in the US than any other envenomation 毒液螫入 . Anaphylactic shock of any cause should be promptly treated with subcutaneous epinephrine in order to acutely prevent respiratory distress and circulatory collapse. Antihistamines are useful in facilitating relief of urticaria, angioedema and bronchospasm as ancillary agents, but epinephrine (exerts both alpha and beta-adrenergic effects resulting in vasoconstriction, bronchial smooth muscle relaxation and a decrease in vascular permeability) should be given first. 6. This ileus is possibly due to a vagal reaction due to urethral colic. Needle shaped crystals on urinalysis indicate uric acid stones. Uric acid stones, which are radiolucent, have to beevaluated by either CT of the abdomen or iv pyelography. Ileus will be over when the uretherolithiasis is treated. Stones less than 0.6 cm may pass spontaneously with hydration and analgesia, otherwise instrumental intervention is needed. 7. The tx of choice for fracture of the femoral shaft is closed intramedullary fixation of fracture. Plate and screw fixation is reserved only for pts who can not treated with intramedullary nailing, such as victim of polytrauma who are unable to be placed on the fracture table. 8. The first step in the mx of atraumatic massive hemoptysis (TB) is bronchoscopy to simultaneously localize and control the site of intrapulmonary bleeding. Bronchoscopy has the additional benefit of offering increased control and protection of the pt’s airway. When the underlying cause of hemoptysis is a vascular lesion, such as an arteriovenous malformation, then pulmonary angiography and embolization might be necessary subsequent therapeutic 238

steps. 9. Acute adrenal insufficiency is a potentially lethal postoperative complication. Preoperative steroid (lupus pt) use is the main cause. A high index of suspicion is required. Commonly, they present with nausea, vomiting, abdominal pain, hypoglycemia and hypotension. 10. IV catherters are one of the MCC of nosocomial infections. Femoral central venous catheters carry a higher risk of causing becteremia than subclavian catherters. IV catherter infections are MCC by cutaneous organisms, such as Stapylococci, but femoral catheters may also cuase G- bacteremia. Causes of postoperative fever—“5 W’s”: wind (po 1-2), water (3-5), walking (4-6), wound (5-7) and wonder drugs (>7 days). 11. After blunt chest trauma, hemorrhagic shock associated with decreased breath sounds and dullness to percussion over one hemithorax and contralateral tracheal deviation is most likely due to large ipsilateral hemothorax. 12. CT scan of a diffuse axonal injury shows numerous minute punctuate hemorrhages with blurring of grey-white interface. It is frequently due to traumatic deceleration injury. Pt loses consciousness instantaneously and later develops persistent vegetative state. 13. Synovial fluid analysis is essential in managing monoarticular arthritis because the fluid characteristics dictate treatment. For example, septic arthritis warrants antibiotic therapy and surgical washout of the joint whereas other types of arthritis can be managed conservatively with painkillers alone. Synovial fluid Normal Noninflammatory inflammatory Septic Appearance Clear Clear, yellow Clear ot opaque, Opaque, yellow yellow to green WBC/mcl 2000, often >50,000 Neutrophils (%) =75 Glucose (mg/ml) Serum Serum Between 25 and 50,000 leukocytes per mcl 14. Acute pain and swelling of the midline sacrococcygeal skin and subcutaneous tissues are most commonly due to pilonidal disease. The acute presentation involves infection of a dermal sinus tract originating over the coccyx. Tx is by drainage of abscess and excision of sinus tracts. 15. Early recognition and tx of diaphragmatic hernia is extremely important since the mortality of undiagnosed injury and subsequent bowel strangulation may be up to 30%. An elevated left diaphragm may be the only abnormal CXR finding. Pts usually have respiratory distress and deviation of the mediastinal content to the opposite side. 16. Stress (hairline) fractures of the metatarsals are not uncommon in athletes and military recruits; the second metatarsal is most commonly injured. Tx is with rest, analgesia and hardsole shoe. Point tenderness over the affected metatarsal is present on exam. Fractures of the 2nd, 3rd, 4th metatarsals are managed conservatively because the surrounding metatarsals act as splints and nonunion is uncommon. Plaster casting is used for pts with persistent pain

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following more conservative tx. Surgical intervention is reserved for fractures of the 5 th metatarsal, such as Jones fractures, or for displaced fractures not amenable to closed reduction. 17. Tension pneumothorax is an emergency situation and needs immediate needle thoracostomy based on clinical diagnosis. 18. Acute mesenteric ischemia classically presents with severe acute-onset midabdominal pain out of proportion to physical examination findings. The MCC is an embolus from the heart. Progression to bowel infarction causes peritoneal signs and the passage of bloody stool. 19. The risk factors for Developmental dysplasia of the hip (DDH) are Caucasian race, female gender, first-born infants, breech position and a family history of DDH. The Barlow and Ortolani tests (act to dislocate and relocate affected infant’s hips) are used to assess for hip dislocatibility. Positive physical exam findings should prompt a radiologic dx with ultrasound (< 4 months old) or radiographs (> 4 months old). Tx may involve use of a hip harness or spica cast. 20. Pts with peripheral vascular disease typically have risk factor similar to those for heart disease and present with claudication, impotence and skin changes. Ankle-branchial index (obtain resting and post-exercise systolic BP in the ankle and arm) is the best tool for determining the severity of disease. Segmental volume plethysmography and Doppler ultrasound may be used to aid in determining the location of a lesion causing peripheral arterial disease, but the dx should first be established with ABI. Doppler ultrasound is also used in the dx of DVT. 21. CT guided percutaneous drainage is the standard tx approach for pelvic abscess. Surgical drainage may be attempt if percutaneous drainage fails. 22. Diabetic foot ulcers result from neuropathy, microvascular insufficiency and immunosuppression. They classically occur on the plantar surface of the foot under points of greatest pressure, such as under the head of the first metatarsal bone. 23. History of a traumatic event and presence of crunching are compatible with fracture of metatarsal. 24. A mammogram should be the first step in evaluation of all pts over age 35 with a palpable breast lump. This is particularly important if there is a family history of breast cancer. Physical examination alone is insufficient to differentiate benign from malignant lesions. All suspicious lesions should then be biopsied. 25. Necrotized surgical infection is characterized by intensive pain in the wound, decreased sensitivity at the edges of the wound, cloudy-gray discharge, and sometimes crepitus. Early surgical exploration is essential. 26. Intermittent bloody discharge from one nipple is the classic presentation of intraductal papilloma, a benign breast disease. Masses are generally not appreciated in this condition, as the abnormality is small, soft, and located directly beneath the nipple. Ultrasound is best at detecting masses greater than 1cm in diameter. 27. Postoperative ileus follows most surgeries where the peritoneal cavity is entered. Morphine and other opiates compound this problem by decreasing GI motility. Signs and symptoms of postoperative ileus include nausea, vomiting, abdominal distention, failure to pass flatus or stool, and hypoactive or absent bowel sounds on physical exam. (In contrast, mechanical bowel obstruction causes hyperactive “tinkling” bowel sounds). 240

28. Slipped capital femoral epiphysis (SCFE) typically occurs in obese early adolescent males. Acute SCFE is an emergency condition and should be promptly corrected with external screw in order to prevent avascular necrosis of the femoral head and chondrolysis. 29. Colicky or paroxysmal abdominal pain with episodic hyperactive bowel sounds attributable to peristaltic rushes, nausea, vomiting, abdominal distention, diffuse abdominal tenderness and obstipation are typical signs of complete small bowel obstruction (SBO). SBO is treated surgically if the obstruction is complete or if signs of strangulation of a bowel loop are present. 30. Hypotension, tachycardia, flat neck veins, confusion, and cold extremities despite iv fluid resuscitation in a trauma pt indicates hypovolemic/hemorrhagic shock. Hemorrhage Class I Class II Class III Class IV classification Blood loss (cc) 1000 1000-1500 1500-2000 >2000 Blood loss % 40 Systolic BP Compensated Orthostatic Marked decrease Profound decrease HR 100 >120 >140 Respiratory 14-20 20-30 30-40 >35 rate Urine output >30 20-30 5-20 Anuria (cc/h) CNS status Normal/anxious Agitated Confused Confused/obtunded Capillary refill Normal Slight Significant Significant delay/Cool delay/cool delay/cold 31. Air under the diaphragm indicates perforated viscus, which is a surgical emergency. Once diagnosed, immediately obtain surgical consulation for emergent exploratory laparotomy. 32. Hemodynamic stability and the need for blood transfusion are the determinants that guide surgical versus non-surgical mx of pts with splenic trauma. If a pt being treated with observation experiences hemodynamic instability unresponsive to a 2L saline bolus or otherwise requires a blood transfusion, then laparotomy is indicated for splenorrhaphy or splenectomy. Following splenectomy, pts are at a greater risk of infections by encapsulated organisms such as H.influenzae, S. pneumoniae, and N.meningitidis. 33. Acute epidural hematoma has a classic presentation of uncomsciousness followed by a lucid interval followed by gradual deterioration of consciousness. CT scan is diagnostic and it shows a biconvex hematoma. 34. Pts with compartment symdrome complain of severe pain, pain with passive range of motion, paresthesias as well as pallor and paresis of the affected limb. The presence of pulses does not rule out compartment syndrome. Fasciotomy is the tx and must be done urgently. 35. Acute cholecystitis presents with right upper quadrant pain, fever and leukocytosis. The majority of pts with acute cholecystitis may be treated with observation and supportive care initially, followed by elective cholecystectomy within a few days of the same hospitalization. Emergent cholecystectomy is required for pts with biliary gangrene or perforation.

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