USMLE 3 CCS


CBT step 3 is not much different, the exam still has 75% MCQs and 25% computer simulated cases (CCS). Some of the good advises from the residents are:
1. Do these cases exactly the way you are trained in your residency programs, follow the standardized protocols you learn during residency.
2. Apply common sense and general medical knowledge as much as you can if you don't know the right answers.
3. In office settings and if specially the patient is coming for first visit, do the complete physical exam. In ER do the limited focused physical exam.
4. The frequently encountered problem is forgetting about the clock forwarding settings, so keep in mind to forward the clock.


The exam's questions can be broadly categorized as

A: Practical work oriented questions. most of the questions in this category are related to the practice of medicine 
B: Very direct or cram able questions….these are the questions for which you need to have very good retaining power

Format

Mix Variety of questions are asked some are long questions others are average. In all I think in Each block 5-7 questions are really big rest is average length like in step 2.
Degree of difficulty: I would say very enjoyable exam not very difficult nor very easy.
Time: If you are comfortable with reading from the screen then you will manage the time part

Tips

Here is what you should do: For pre residency test takers
You should revise and revise again and again each topic so that you are comfortable
Again the exam is not very difficult if you really put effort you will enjoy it

Questions are asked like below

Risk factor for a disease
Mechanism of disease
Diagnosis
First line Rx
Second line management
Complications of Rx
Your response to the patient during history
Risk factor of death from a particular disease
Prognosis of a disease
Any major clue or physical finding of particular disease during physical examination

Some extremely high yield subjects:
Medicine - Cholesterol guidelines, HTN, asthma, DM
OB - Pregnant women with medical problems
Gyn - Guidelines in Pap smear, PID, amenorrhea, STDs, DUB
Pediatrics - Growth charts, Rashes, Respiratory problems 
Surgery - Study trauma very well and orthopedics



High Yield CCS Cases For USMLE III

Please discuss these cases individually and give your case order sheets


1. Fat embolism. Multiple fractures leading to ARDS.
Typically a patient with trauma to the tibia or femur who has altered sensorium WITH pulmonary infiltrates and ARDS like picture. Very hypoxic.
You may be shown a picture of the fundus with a yellowish/whitish fat embolus seen in one of the retinal arteries. It is unlikely that they describe shimmering fat globules in urine as the diagnosis will then be too easy. CT head will be normal and no bacteria will grow out of any cultures. Treatment is supportive.


2. Sickle cell crisis. An African American boy presenting with lower back pain, colicky abdominal pain and Sickle cell crises - ER
Sickle cell disease, in the USA, we know is a disease primarily affecting the African American patient. It is due to a substitution of an amino acid (Valine for Glutamate at position 6) on the beta chain of hemoglobin. Patients range from asymptomatic disease to acute chest/infarctive/embolic syndromes that are life threatening.

There are three main types of sickle cell disorders:
1. Sickle cell anemia
2. Hemoglobin SC disease (for sickle SC disease, remember that hematuria is more commonly found in it)
3. Sickle beta-thalassemia

Patients can develop many types of problems due to sickle cell disease. Anemia leads to fatigue. 
Aplastic crisis: Pallor is an important sign. One should also be alert after a non-specific fever that may be due to Parvovirus B19. Parvovirus infection can precipitate Aplastic crisis. 
Hand-and-foot syndrome: This is usually one of the earliest signs due to infarction in the digital bones and blood vessels.. 
Painful episodes called "sickling crisis" usually requires opiates to abort the pain. 
Severe infections: Due to sickling in the splenic vessels, the spleen slowly dies due to multiple infarcts. These patients have reduced immunity (because spleen introduces antigens to the lymphocytes to evoke good antibody response). Encapsulated organisms including Streptococcus pneumoniae and Hemophilus influenzae are particularly left unchecked. 
Splenic sequestration crisis: Spleen goes crazy and suddenly pools in and holds on to a large number of blood cells. Characterized by LUQ pain and abdominal pain. 
Stroke: This again is due to sickling and clogging up of capillaries.
Acute chest syndrome: Fast or difficult breathing, chest pain, high fever, and coughing are symptoms of Acute Chest Syndrome.15% to 43% of sickle cell population will contract ACS.
One can find hypoxia (paO2<60 and sats <90%). One would also find infiltrates in the lungs. Usually bilateral.

Lab test: CBC, Reticulocyte count, Haptoglobin, LDH, LFT, ESR, RF, ANA. 
Hb electrophoresis reveals Hb S. UA: Mic. Hematuria.
Xray: if there is back or feet, hands pain- bone necrosis

Once diagnosed with the acute chest syndrome, patients should be given:

1.      OXYGEN

2.      Hydration: I.V. fluids

3.      Strong analgesics (iv), Morphine or Hydrocodone then switch to Ibuprofen. 

4.      Broad spectrum antibiotics, including a macrolide

5.      Bronchodilators. 

6.      Packed RBCs transfusion if the hemolysis is severe

7.      Folic acid

8.      Ophthalmology consult for retinopathy - Laser photocoagulation. 

If they are at high risk for complications (adults and those who have a history of cardiac disease and severe pain in the arms and legs), patients should be given early transfusions.
One drug that has improved the quality of life for sickle cell patients is Hydroxyurea. It is known to increase the level of fetal hemoglobin in the patient and prevents excessive deoxygenation. It also decreases the level of sickle hemoglobin.
Peculiar problems of sickle cell disease also include Salmonella osteomyelitis, proliferative retinopathy and avascular necrosis. It is important though to remember that the commonest type of osteomyelitis in a sickle cell patient still remains Staphylococcal (like general population).
Preventive strategies useful to a sickle patient include Vaccinations against H. influenzae and Pneumovax. Hepatitis B vaccine also may be useful because of the frequent transfusions they receive


3. Typical case of Cholecystitis. Pt mostly comes with fever, chills and  RUQ tenderness, muscle guarding worse with inspiration.
Lab: CBC, UA, serum amylase & lipase, LFT, B-HCG if female pt. PT/PTT, blood type & screen. First choice for evaluation is U/S. if it is biliary colic, sonogram make a diagnosis.
if sonogram is doubtful, then HIDA can make a diagnosis.
Recognize appropriate treatment of asymptomatic gallstone disease.

If pt has pain and fever start on : Cipro 500 mg Bid for 10 days or Metronidazole 500 mg TID for 10 days. Bentyl 20 mg  Tid, AC for 10 days.

If pt has acute severe pain, nausea & vomiting: Hospitalize, NG tube, IV antibiotics, IV fluids, narcotics.
Good response: Plan surgery after acute attack is over
Poor response: Immediate surgery
Except under very unusual circumstances the gall bladder should be left alone. Exceptions include a concomitant porcelain gallbladder (risk of cancer), patients unable to clear Salmonella typhi infection, and possibly sickle cell patients.
If chronic small stones: Trial of ursodiol is beneficial.


4. Cocaine-related myocardial infarction
The accurate identification of patients with cocaine-related myocardial infarction can be difficult as the EKG may be abnormal in many patients with chest pain after cocaine use, even in the absence of acute MI.  The EKG is reportedly abnormal in 56-84% of patients with cocaine-related chest pain, and as many as 43% of cocaine abusers without AMI meet EKG criteria for the initiation of reperfusion therapy.
Because of the limited experience with thrombolytic therapy in patients with cocaine-related infarction, reports of catastrophic complications associated with its use in cocaine users, and the difficulty involved in using standard EKG criteria to identify AMI, the routine use of thrombolysis in patients who may have cocaine-related infarction is not advised.  Thrombolytic therapy should be considered only after treatment with oxygen, aspirin, nitrates, and benzodiazepines has failed, and when immediate coronary angiography and angioplasty are not available.


5. Colo-rectal cancer. Anemia in an elderly male. Colorectal cancer is the second leading cause of cancer death in the United States. True primary prevention includes:
1. Stressing a low fat, high fiber diet, adequate calcium intake, and identification of any risk factors such as a strong family history of colon cancer, which might increase an individual's risk.
2. Dietary supplementation with D-Glucarate is an exciting new approach.
Most colon cancers develop from benign polyps.
Screening for Colorectal Cancer:
1. An annual fecal occult blood test, which checks for minute traces of blood in the stool.
2. Flexible sigmoidoscopy once every 3-5 years to detect colorectal cancer at its earliest and most treatable stage. Begin at age 50.
3. An annual colonoscopy is recommended for high risk patients of any age with prior history of cancer, a strong family history of the disease, or a predisposing chronic digestive condition such as inflammatory bowel disease.

Who Is At Increased Risk For Colon Cancer Needing Colonoscopy?

PERSONS WITH ONE OR MORE OF THE FOLLOWING ARE AT RISK FOR COLON CANCER
1. Woman who have been diagnosed with breast or ovarian or uterine cancer
2. Women after menopause with iron deficiency anemia
3. Persons with a sibling, parent or child with colon cancer
4. Persons who are passing frank blood in the stool
5. Men with iron deficiency anemia 
6. Persons found on screening exams to have blood present in the stool

What are the Symptoms of Colon Cancer?
Right sided, ascending colon tumors often present with fatigue, weakness, and anemia of iron deficiency of unknown origin.  
Left Sided, changes in bowel habits ( constipation and/or diarrhea ), crampy left lower quadrant pain and even perforation.

Diagnosis of Colon Cancer:
The diagnosis of colon cancer depends on a variety of methods including barium enema, sigmoidoscopy, colonoscopy and biopsy once a mass is found. Colonoscopy remains the gold standard for visualization, biopsy and removal of colonic polyps.

How Is Colon Cancer Treated?
The surgical resection of colon cancer with 3-5 cm disease free margins and resection of the mesentery at the origin of the blood supply, including primary lymphatic drainage sites, is required treatment to attempt a cure of the disease. Usually colostomy can be avoided unless the cancer is too low. Today, adjuvant therapy is standard for patients with stage TNM 3 or Duke's B2 and C colon cancer.


6. Barbiturate overdose
In small doses, the person who abuses barbiturates feels drowsy, disinhibited, and intoxicated.
In higher doses, the user staggers as if drunk, develops slurred speech, and is confused.
At even higher doses, the person is unable to be aroused (coma) and may stop breathing. Death is possible. It has a narrow therapeutic-to-toxic range. This is the reason why barbiturates are dangerous. It is also why barbiturates are not prescribed often today. In addition to having a narrow therapeutic range, barbiturates are also addictive.
Symptoms of withdrawal or abstinence include tremors, difficulty sleeping, and agitation. These symptoms can become worse, resulting in life-threatening symptoms including hallucinations, high temperature, and seizures.
Pregnant women taking barbiturates can cause their baby to become addicted, and the newborn may have withdrawal symptoms.
The treatment of barbiturate abuse or overdose is generally supportive. The amount of support required depends on the person’s symptoms.
If the patient is drowsy but awake and can swallow and breathe without difficulty, the treatment just monitor the patient closely.
If the patient is not breathing, mechanical ventilation untill the drug have worn off.
Activated charcoal may given via nasogastric tube.
Admitted to the hospital or observe in the Emergency Department for a number of hours.


7. Ectopic Pregnancy. Pregnant woman in shock. The most common place is in the fallopian tube.
What causes the ectopic pregnancy?
1. Advancing age
2. Pelvic inflammatory disease
3. Previous ectopic: about 10-20% of those attempting pregnancy after one ectopic will have another.
4. Tubal surgery or defects
5. Previous termination of pregnancy
6. DES exposure  
Most patient report missed period, positive pregnancy test, some abdominal pain, and some irregular vaginal bleeding. Some women report fainting or suddenly, without warning a woman is very unwell, collapses and is taken to hospital.
What tests are used to diagnose ectopics?
1. Obviously first of all a pregnancy test. If the test is negative then ectopic pregnancy is virtually excluded.
2. Vaginal ultrasound can reliably demonstrate a pregnancy in the uterus from about 5 weeks onward.
What are the treatments?
Medical treatment: with a drug called methotrexate, which is given by injection. This makes the ectopic pregnancy shrink away by stopping the cells dividing, tube pregnacy must be small and low B-HCG.
Laparoscopic surgery: open the tube and remove the pregnancy (salpingotomy), or remove the tube (salpingectomy).
Laparotomy: either salpingotomy or salpingectomy performed.


8. TENSION PNEUMOTHORAX: This is a 45 year Patient, smoker. He has a positive family history of cardiac disease, hypertension, obesity, and stroke. The patient is obese (he has a body mass index of 29) . He does not engage in regular exercise (dyspneic after 1 minute of brisk walk)

Patients typically present with mild shortness of breath, pleuritic chest pain and cough.

TENSION PNEUMOTHORAX is an EMERGENCY. IT IS a CLINICAL DIAGNOSIS.

No need to examine everything: PE (HEENT, chest, CVS, extremities) 

Heent: distended neck veins.
Exam: Lungs: no breath sounds, a hypertympanic percussion sounds on the affected side.
Heart: tachycardia

History and Physical: Essential Facts

·     Patient is cyanotic and in marked respiratory distress

·     There is chest asymmetry, with hyper-resonance on right side. Breath sounds are also absent on that side

·     Cardiac examination essentially normal

·     Peripheral pulses present but weak

·     No pulsus paradoxus (a fall in pulse amplitude with quiet inspiration)

Then:
* Always start with ABC on Unstable Patient.

Next, click Order button at the bottom of the screen, and enter the following orders (one on each line):

·         Chest x-ray: Chest x-ray, portable, click on Confirm Order button. Click OK. Stat.

·         Oxygen, pulse oximeter: choose Inhalation for route and Continuous for frequency.

·         Morphine: (Give The patient some Pain killer) choose Intravenous for route and Continuous for frequency.

·         ECG: choose ECG 12-lead; Urgency: stat.  

Obtain Results: Chest X-ray findings: Right tension pneumothorax

New Order: 

* Needle insertion (Needle thoracostomy) FOLLOWED BY TUBE Thoracotomy (insertion of a chest tube) if needed.

* IV Access
* Pulse Oximetry (seconds to get result), ABG?
* Portable CXR immediately after tube insertion (you will get Collapsed lung and the impression is Tension pneumothorax, If done after 20 minutes the Lung is completely expanded)

* Click the Change Location button, and select Intensive Care Unit (ICU). Confirm move. Recorded vital signs are displayed Click OK.

Now we should add more treatment for the patient. Order the following orders:   

1. Albuterol (inhalation, continuous)

      2. Atrovent (inhalation, continuous)

* Order CXR after 6 hours (most probably the case will close because the patient already thanks you for pain relief).

* Transfer patient to ward (If the patient is stable)

      Order the following orders:

      1. Advise patient, smoking cessation (routine, start now)

      2. Advise patient (Breathing) exercise program (routine, start later)     

      3. Advise patient, weight reduction (routine, start later)

D/C patient home. 

Final diagnosis: Tension pneumothorax


9. Dementia & Depression in an  elderly.
PSEUDODEMENTIA: Term applied to apparent cognitive impairment associated with psychiatric disorders, most often depression (50-100%). Four criteria proposed by Caine for diagnosis:
1) intellectual impairment in a patient with a primary psychiatric disorder
2) features of impairment are similar to those seen in CNS disorders
3) the cognitive deficits are reversible
4) there is no known neurological condition to account for the presentation

Major characteristics of the dementia syndrome of depression (all characteristics need not be present):
Mental status changes Motor manifestations:
dysphoria, apathy
decreased motivation 
anxiety, depressed affect
persecutory delusions 
psychomotor retardation 
impaired memory retrieval 
poor word list generation
variable performance 
awareness of cognitive deficit

Neurovegetative signs  
sleep disturbance 
loss of appetite and weight 
constipation 
impotence

Motor manifestations
bradykinesia, masked facies, stooped posture, slow, hypophonic speech

History 

subacute onset and rapid progression of intellectual decline 
past history of mood disorder 
family history of mood disorder
Laboratory  
1. positive Dexamethasone test  2. enlarged lateral ventricles


10. Iron deficiency anemia: A 27 y/o woman with bleeding .
CBC with diff.: Low Hgb & Hct, MCV:  <80 Microcytic, 80-100 Normocytic, >100 Macrocytic.
Peripheral smear & Reticulocyte Index: should be <2% with anemia, if the idex high consider hemolysis.
Iron Def. Anemia: Look for low iron or ferritin, high TIBC.
This anemia is common in woman of reproductive age because of menstrual irregularities.
Treat the underlying cause and Iron supplementation. FeSO4  325 mg  PO BID.


11. STROKE:
Pt with risk factors htn/chol/dm/tob with C/O sudden weakness, physical exam consistant with umn lesion.
Management:
1. Head CT scan w/o contrast: shows Ischemia
2. Use Heparin only if: A FIB or crescendo stroke
3. Use Thrombolysis only if stroke within 3 hours of onset. Remember for MI it with in 6-8 hours
4. TPA is the thrombolysis of choice. It is the only FDA aproved.
5. When you give Heparin give it with Warfarin.

TIA - Transient Ischemic Attacks      
Transient ischemic attacks (TIAs) are focal neurologic deficits caused by retinal or cerebral vascular disease. They last less than 24 hours. Crescendo TIAs are defined as two TIAs within 24 hours, three within 3 days, or four within 2 weeks. Acute TIA is defined here as a TIA that occurs within 2 weeks of presentation to a physician.

Diagnostic Tests
There is no routine, standard laboratory evaluation of patients with TIA because the individual medical history and specific characteristics of the TIA influence the optimal sequence and extent of diagnostic testing.
1.  Duplex Ultrasound of the carotids may be helpful for those patients:
whose symptoms are attributable to ischemia in a distribution of the anterior (carotid) circulation.
who are candidates for endarterectomy of the carotids, where benefits of the surgery are likely to outweigh the burdens. If ordered, duplex ultrasound should be obtained within 3 days of presentation of an acute TIA (Grade C).

2.  Echocardiography should be considered for those patients whose TIA is thought to be cardiogenic. This study usually does not need to be performed on an emergency basis. If a cardiac origin of an embolus is suspected, the patient can be treated with heparin anticoagulation without an echocardiogram. The diagnostic yield of echocardiography in a patient over the age of 40 without cardiac murmur or evidence from the history/physical examination to suggest cardiac disease is so low as to make the test usually unnecessary.
When cardiac disease is strongly suspected and external 2-D echocardiography is not diagnostic, additional yield may be obtained by transesophageal echocardiography.

3. CBC, Creat, ESR , glucose, PT/PTT, RPR/MAHTP, ECG - the studies could be obtained within 24 hours.
4. Imaging Studies - Brain CT scan
5. Additional Tests / In selected cases the following additional tests may be appropriate:
Anticardiolipin Antibody, Antithrombin III, Protein S, FBS, Lipid profile,
Telemetry/Holter Monitor
Selective, Digital, or Magnetic Resonance Angiography
Magnetic Resonance Image of Brain

6. Initial Medical Management of TIA                      
1.Blood Pressure Control. We encourage the use of antihypertensive agents that work by peripheral action, are short acting, and are unlikely to drop the blood pressure precipitouslly.
2.Anti-platelet agents. The antiplatelet agents aspirin and ticlopidine are both beneficial in the prevention of stroke following a TIA .
Aspirin dose of 325 mg/day
Patients who do not respond to or tolerate aspirin are candidates for ticlopidine 250 mg bid . Patients offered ticlopidine must be willing to accept the supervision associated with the use of this agent.
Plavix / Clopidogrel  75 mg/day  is safer than Ticlopidine.
The combination of aspirin 325 mg and the antiplatelet agent dipyridamole  200 mg (Aggrenox)

7. Major Contraindication to TPA: Recent bleeding, recent trauma, recent CPR, recent operation, history of bleeding, BP more than 180/110
8. Most common cause of sudden stroke: emboli
9. Most common source of Emboli is the heart.
10. Location of stroke:
ACA = legs
MCA = face
ICA = vision
Lentico Striate Artery = Pure Motor
Pons = MLF (Ipsilateral Adduct failure) = Lateral (7 TH nerve Bells Palsy).
Vertebral artery = Tongue = Medial = Horner = Lateral.


12. Alzheimer's Dementia.
Affects 15% of people over  age 65. Occurs in Down's syndrome pts at younger ages (30-40).

Gradually progressive, neurofibrillary tangles.
Alzheimer's Disease: senile degenerative dementia (50%-90 of dementia pts) - Loss of cortical tissue (cerebral atrophy) with increased senile plaques.

Criteria for the clinical diagnosis of probable Alzheimer's disease
* Dementia established by clinical examination and documented by the Mini-Mental State Examination, include: Blessed Dementia Scale, or some similar examination and confirmed by neuropsychologic tests. Deficits in two or more areas of cognition.
* Progressive worsening of memory and other cognitive functions
* No disturbance of consciousness
* Onset between ages 40 and 90, most often after age 65
* Absence of systemic disorders or other brain diseases that could account for the progressive deficits in memory cognition
Lab. Orders:

CBC, Lytes, TFTs, PRP all normal. UA toxicology -ve.

CT: Evidence of cerebral atrophy with progression documented by serial observation
MRI shows changes highly suggestive of Alzheimers - tangled spaghetti  patches.
Certain dx: not till autopsy - on PM see structural changes, abnormal proteins in brain biopsy.  See shrinkage < neurons in cognitive areas of brain.
Early Signs: subtle loss of memory. Person neglect, ADL. Gradual loss continues. Loss of communication skills.
Later:  ultimate loss of short and long term memory. Normal life span. May have good physical health.
Med Intervention: No real medical therapy. Nursing support primary.
Med Rx: 

Donepezil (Aricept) 5-10 mg tablet /day
Tacrine (Cognex) Not a cure. Does not appear to stop progression as was hoped. Acts to increase amount of acetylcholine in brain to improve memory. Helps to improve in a minority of patients.
Side effects: Hepatic failure, GI, abd. Pain, skin rash.
Rivastigmine tartrate (Exelon) 6-12 mg cap/day 
Premarin for ladies

Multivitamins 1 tb qd po

Aspirin For vascular dementia
Other supportive med Rx therapy for agitation: antidepressants, antipsychotic, sleeping aids.
Nursing focus:  Safety, Help maintain function as long as possible, Care for caregiver.
Continuing Care: Medicare doesn't cover custodial long term.  Must become impoverished to go on medicaid.  Few families able to cope with entire trajectory of the illness. Nursing home care essential for some.

As for Alzheimer: Remember, on the exam, when ever you counsel it takes 5 minutes for it.

- Social services consult
- counsel, no driving
- counsel, advance living will
- reassure patient/family
- counsel medical alert bracelet


13. Secondary Amenorrhea:
Any secondary amenorrhea in a lady of reproductive age is pregnancy related unless proven otherwise. The sensitivity of urine HCG is excellent therefore the test is reliable. After pregnancy has been excluded one may proceed to checking prolactin, LH, FSH.
Women with regular menses now with no menses for 7 months : Management of metroragia and menoragia in a woman who is on oral contraceptives is a favorite USMLE question. OC + complain of bleeding = break through bleeding
If bleed Ist few months of oc = add Progesterone
If bleed later in the cycle = add Progesterone
If bleed after years of use = add Estrogen
If bleed early in the cycle = add Estrogen
** If problem occurs after above correction: add stronger dose in all the above cases.


14. COPD .
Cxray: flattening of diaphragms, increased lung volume, small heart.
Lab: ABG, Alpha 1 antitrypsin level, PFT
Management
1. O2 Goal to keep PaO2 60-80 mm Hg, Stop smoking
2. Bronchodilators:
A. Atrovent: Ipratropium Bromide 2 puffs qid - Should be 1st choice in COPD.
B. Albuterol Inh  2 puffs qid.
C. Combination: Combivent Inhaler 2 puff qid. Or  DuoNeb Sol. Inh 1 vial by neb. Q6hrs
3. Prednisone 40 mg q d for 7-14 days then taper to lowest dose and switch to inhaler: Azmacort: Triamcinolone 1 puffs tid.
4. Cough meds, expectorant: Atuss EX  1 tsp tid
5. Vaccinations: Influenza annually,  Pneumococcal q 5-10 yrs if age > 65 yrs.


15. TCA Overdose.
Amitriptyline: Elavil, Nortriptyline: Pamelor, Imipramine: Tofranil.
The morbidity and mortality caused by tricyclic antidepressant (TCA) overdose are well recognized. Among newer antidepressants, the selective serotonin reuptake inhibitors (SSRIs) are thought to be safer in overdose.
At therapeutic doses tricyclic antidepressants block the reuptake of norepinephrine, serotonin, and dopamine

Their mechanisms of toxicity include:

A. Neuromuscular reuptake inhibition
B. Membrane depressant effects on sodium channels of the myocardium
C. Alpha blockade
D. Central sympathetic reflex inhibition

CLINICAL SYMPTOMS:

ANTICHOLINERGIC: tachycardia, mydriasis, hyperthermia, agitation, hypertension, flushed skin, decreased GI motility, urinary retention
CARDIOVASCULAR:
Dysrhythmias- sinus tachycardia, AV block, Torsades, V-tach, Vfib
Conduction abnormalities- QRS widening, prolonged PR interval, QT prolongation
Hypertension- usually short-lived and minimal
Hypotension- may be prolonged and severe
CNS- agitation, disorientation, ataxia, confusion, lethargy, seizures, coma

HEENT- mydriasis, blurred vision, dry mouth, nystagmus
PULMONARY-pulmonary edema, ARDS, aspiration pneumonitis

LEVELS/RANGE OF TOXICITY:
In adults, 10-20 mg/kg is considered a moderate to serious exposure where coma and cardiovascular symptoms are expected. Approximately 35 mg/kg is thought to be a lethal dose without medical intervention.
CV toxicity:

Sinus tachycardia- supportive measures only
Wide complex dysrhythmias
Sodium bicarbonate 1-2 mEq/kg IV bolus followed by maintenance infusion to maintain pH 7.4-7.5
Hyperventilation-reserved for conditions where administration of large quantities of sodium bicarb would be contraindicated (pulmonary edema, cerebral edema, head trauma, poorly controlled CHF)

Ventricular Arrhythmias
Sodium bicarbonate- same dosing as above
Lidocaine 1-1.5 mg/kg bolus over 1 minute then 2-4 mg/min infusion

Hypotension: Fluids and Norepinephrine 8-12 ug/min (generally high dose is necessary)
 
CNS toxicity
Seizures: Diazepam: Adults: 5-10 mg over 2-3 minutes, may repeat every 10-15 minutes (maximum of 30 mg total).
Peds: 0.25-0.4 mg/kg to maximum 10 mg- maximum 5mg if child less than 5 y.o.
Lorazepam:  Adults: 1-2mg over several minutes Peds: 0.04 mg/kg
May try barbiturate if patient fails to respond to benzodiazepines

Enhanced Elimination
Reduce absorption: AC/C for all patients- recent studies suggest that activated charcoal is as effective as AC/lavage and AC/lavage/AC. Lavage may be indicated within 1 hour of ingestion or in patient who arrives with decreased level of consciousness and unknown time of ingestion.
Increase elimination: MDAC has been shown to enhance the rate of elimination- 25 grams q 4hr following the 50g initial load (sorbitol with every 2-3 doses)

Disposition
Admit any patient with a QRS> 100msec.
Admit any patient with a seizure.
Admit any patient in need of psychiatric or medical support.
Patients who have been decontaminated, who never seize or develop abnormal EKG's (other than sinus tachycardia) can be safely discharged after 6 hours of observation if otherwise stable.
Patients with significant symptoms or any EKG changes, or persistent mild symptoms should be admitted and monitored until CNS returns to baseline and normal EKG for 24 hours.

Nortryptiline toxicity
ensure ABC
labs: ECG, ABG
Rx: Gastric lavage
Activated charcoal with intermittent gastric suctioning
Induce alkalinisation with NaHCo3 to maintain pH of 7.45 to7.55
If he is intubated hyperventilate to a PCo2 not< 25mmHg
If ECG normal and patient is asymptomatic, observe for 6 hrs in ER otherwise admit into icu
After Admission ECG should be normal for 24hrs to discharge for psychiatric disposition


16. Viral Hepatitis A (RNA Virus). A young man with fatigue and jaundice.                                       
Transmission: Hepatitis A virus (HAV), the most common cause of viral hepatitis worldwide, is an RNA virus transmitted exclusively by the fecal-oral route.
Its prevalence is as high as 95% in underdeveloped countries with poor sanitary conditions. The prevalence is >50% in persons older than 50 years in the United States, Canada, and Europe but falls to less than 10% in persons younger than 20 years. Therefore, many persons traveling to endemic regions do not have natural immunity and should receive passive immunization with immunoglobulin before travel.
Diagnosis: The presence of active HAV infection is detected by a positive IgM anti-HAV antibody; the presence of the IgG antibody indicates previous infection and immunity.
Signs and Symptoms:
Fever (60%); unusual with HBV and HCV
Malaise (67%), Fatigue (major complaint in HCV)
Nausea (80%) ,Vomiting, Anorexia (54%)
Jaundice (in adults, 62%); 66% of HCV anicteric
Dark urine (84%)
Abdominal pain (56%)
Headache
Meningismus (occasional)

Management:
(Supportive measures are the only treatment necessary in most cases of acute HAV infection.)
Rest and balanced diet
Symptomatic relief medications
Family members: hepatitis evaluation & passive immunization with immunoglobulin 0.02 mL/kg IM
Serial follow up of liver function tests
In patients with severe cholestasis, a short course of prednisolone (30 mg/day with a taper) may reduce the severity of symptoms such as pruritus and malaise and reduce the serum bilirubin level.

Immunization:
Active Immunization: Hepatitis A Vaccine x 2 doses about 6-12 months apart.
A single dose of a highly purified, formalin-inactivated hepatitis A vaccine is highly protective against HAV. A booster dose is required 6-18 months later for full immunity. 
Passive Immunication (prophylaxis or post-exposure prophylaxis to Hepatitis A:
Pooled human Immune Serum Immuno Globulin (ISIG) 0.02 mL/kg single IM dose is recommended for travelers to endemic areas or for household & sexual contacts with serologically confirmed hepatitis A person, to be administered as soon as possible within 2 weeks of exposure.  The duration of protection appears to be dose related, with the 0.02 mL/kg dose providing protection for approximately 3 months and a 0.05 mL/kg dose providing protection for 4 to 6 months.


17. Cystic Fibrosis: A 7 month old child with fool smelling stools and recurrent episodes of bronchiolitis.
Cystic fibrosis in 5 yo child
O2 mask
Labs: sweating test (CL 60 mEq/dl dgn). Sputum culture & sensitivities of cultured organisms.
CXR, Pulmonary function test, ABG's

Tx:
IV ceftriaxone + gentamycine for pulm. infections.
Albuterol Inh
Chest physiotherapy:
postural drainage + percussion
breathing exercise and vigorous coughing
Recombinant human deoxyribonuclease-jet nebuliser


18. Cervical Dysplasia - Found on 25 yo for well women's exam. Also, A 26 yo healthy woman came in for examination (cin III in pap smear).
Cervical dysplasia is a condition in which the cervical tissue does not grow normally, causing precancerous changes which can range from mild to moderate to severe. In the most severe cases it can lead to cervical cancer.

Risk factors are thought to include:
Human papilloma virus (HPV) which is spread sexually is known to greaten the risk of developing cervical dysplasia and cancer. cigarette smoking & substance abuse;
TB;
DES exposure;
Sex & pregnancy at an early age.
Multiple lifetime sexual partners

Screening for cervical cancer
Regular Pap smears are recommended for all women who are or have been sexually active and who have a cervix.
Testing should begin when the woman first engages in sexual intercourse. Adolescents whose sexual history is thought to be unreliable should be presumed to be sexually active at age 18.
Pap smears should be performed at least every 1 to 3 years. Testing is usually discontinued after age 65 in women who have had regular normal screening tests. Women who have had a hysterectomy including removal of the cervix for reasons other than cervical cancer or its precursors do not require Pap testing.

Management of minor Pap smear abnormalities

Satisfactory, but limited by few (or absent) endocervical cells
Endocervical cells are absent in up to 10% of Pap smears before menopause and up to 50% postmenopausally.
Management. The Pap smear should either be repeated annually or only recall women with previously abnormal Pap smears.

Unsatisfactory for evaluation
Repeat Pap smear midcycle in 6-12 weeks. If atrophic smear, treat with estrogen cream for 6-8 weeks, then repeat Pap smear.

Benign cellular changes
Infection--Candida. Most cases represent asymptomatic colonization. Treatment is offered for symptomatic cases. The Pap should be repeated at usual interval.
Infection--Trichomonas. If wet preparation is positive, treat with metronidazole (Flagyl), then continue annual Pap smears.
Infection--predominance of coccobacilli consistent with shift in vaginal flora. This finding implies bacterial vaginosis, but it is a non-specific finding. Diagnosis should be confirmed by findings of a homogeneous vaginal discharge, positive amine test, and clue cells on saline suspension.
Infection-herpes simplex virus. Pap smear has poor sensitivity but good specificity for HSV; positive smears usually are caused by asymptomatic infection. The patient should be informed of pregnancy risks and the possibility of transmission. No treatment is necessary, and the Pap should be repeated as for a benign result.

Inflammation on Pap smear
Mild inflammation on an otherwise normal smear does not need further evaluation.
Moderate or severe inflammation should be evaluated with a saline preparation, KOH preparation, and gonorrhea and Chlamydia tests. If the source of infection is found, treatment should be provided, and a repeat Pap smear should be done every 6 to 12 months. If no etiology is found, the Pap smear should be repeated in 6 months.

Persistent inflammation may be infrequently the only manifestation of high-grade squamous intraepithelial lesions (HGSIL) or invasive cancer; therefore, persistent inflammation is an indication for colposcopy.

Atrophy with inflammation is common in post-menopausal women or in those with estrogen-deficiency states. Atrophy should be treated with vaginal estrogen for 4-6 weeks, then repeat Pap smear.

Hyperkeratosis and parakeratosis. Parakeratosis is defined as dense nuclei within a keratin layer. When no nuclei are present, the cells are designated hyperkeratotic. Parakeratosis and hyperkeratosis occur as a reaction to physical, chemical, or inflammatory trauma, and it may clinically appear as leukoplakia. Benign-appearing parakeratosis or hyperkeratosis requires only a repeat Pap test in 6 months. When this finding persists, colposcopy is indicated.

Management of squamous cell abnormalities
Atypical squamous cells of undetermined significance ( ASCUS)
ASCUS indicates cells with nuclear atypia, but not atypia caused by human papilloma virus (HPV).
The patient is asked to return every 6 months for a repeat Pap smear. The American College of Obstetricians and Gynecologists (ACOG) advises a colposcopic examination if a patient receives two or more ASCUS reports (repeat Pap smears being obtained every 6 months) or if the patient's compliance is uncertain with the original report.

Low-grade squamous intraepithelial lesions ( LGSIL)
LSIL includes human papilloma virus (HPV) and CIN 1 (or mild dysplasia). Koilocytotic atypia is indicative of HPV.
Repeat Pap smears every 4 to 6 months is recommended, with colposcopy being indicated if there is persistence or progression. However, because some women will progress and because of the high rate of false-negative Pap smears, clinicians may perform colposcopy after the initial LGSIL report.

High-grade squamous intraepithelial lesion ( HSIL).
If the Pap smear is consistent with HSIL (or persistent or high-risk LSIL), colposcopy and biopsy should be performed.
If biopsy results are consistent with CIN I, provide careful observation and follow-up.
If biopsy results are consistent with CIN II or III, cryotherapy, laser vaporization, LEEP or cone biopsy should be completed. If biopsy results are consistent with invasive disease, further staging procedures are indicated.

Management of glandular cell abnormalities
Endometrial cells on Pap smear. When a Pap smear is performed during menstruation, endometrial cells may be present. However, endometrial cells on a Pap smear performed during the second half of the menstrual cycle or in a post-menopausal patient may indicate the presence of polyps, hyperplasia, or endometrial adenocarcinoma. An endometrial biopsy should be considered in these women.

Atypical glandular cells of undetermined significance ( AGUS). Colposcopically directed biopsy and endocervical curettage is recommended in all women with AGUS smears, and abnormal endometrial cells should be investigated by endometrial biopsy, fractional curettage, or hysteroscopy.

Adenocarcinoma. This diagnosis requires endocervical curettage, cone biopsy, and/or endometrial biopsy.
Colposcopically directed biopsy

Liberally apply a solution of 3-5% acetic acid to cervix, and inspect cervix for abnormal areas (white epithelium, punctation, mosaic cells, atypical vessels). Biopsies of any abnormal areas should be obtained under colposcopic visualization. Record location of each biopsy. Monsel solution may be applied to stop bleeding.
Endocervical curettage is done routinely during colposcopy, except during pregnancy.

Treatment based on cervical biopsy findings
Benign cellular changes (infection, reactive inflammation). Treat the infection, and repeat the smear every 4-6 months; after 2 negatives, repeat yearly.
Squamous intraepithelial lesions
Treat on the basis of the histological biopsy diagnosis. Patients with CIN I require no further treatment because the majority of these lesions resolve spontaneously. Patients with CIN II or CIN III require treatment to prevent development of invasive disease.
These lesions are treated with cryotherapy, laser vaporization, or loop electric excision procedure (LEEP).


19 Pulmonary nodule on CXRAY:    
A solitary pulmonary nodule consists of a solid nodule 1-6 cm in diameter that is surrounded by normal aerated lung tissue.
Once this picture is found, one works it up according to the probability of it being malignant. Some clinical features and some radiological features are useful pointers.
The best is to compare it with another X-ray of the chest that is more than 2 years old (if available). If no change has occurred, it is most likely benign.

Features that point towards a malignant potential are:

Age > 35 yrs
Smoker
Weight loss
Spiculated edges of lesion
<20 % of lesion calcified
In all the above 5 scenarios, a histologic diagnosis is important. if none of the above exist then one should re X-ray it in 6 months
If the lesion is in the medial 2/3 of the lung fields then a bronchoscopic biopsy is best. If in the peripheral 1/3 then a CT guided biopsy is appropriate.
Once a malignancy is established then one has to work - up a non small cell carcinoma. A small cell Ca is considered non-operable and is treated with chemotherapy.


20. A 17 yo with DKA. and NIDDM pt with acute exacerbation, Dx: Ketoacidosis. Also TYPE II DM - 70 yr black male, resistant  DM.
Screening appropriate for patients with:
a) family history of DM (remember DM type I has a stronger correlation with genetic transmission, but DM II is the frequent encounter-90%)
b) significant obesity
c) recurrent or hard healing skin wounds,
d) recurrent genital or UTI infections (especially yeast) pay special attention to nonSTD's UTI's in young man
e) pregnancy related problems-gestational diabetes, infant larger than 9 lb (over 4kg)
f) symptomatic patients with 3P symptoms (polyuria, polydipsia,weight loss-some include polyphagia too) may be dgn without further testing when random PG is greater than 200mg/dl

Screening methods:

-fasting plasma glucose140mg/dl -DM (only one measurement is cosidered dgn.now!)
-positive oral glucose tolerance test 200mg/dl

Different criteria for pregnancy:

-screening at 24-28wks for all pregnant women!
-glycosuria anytime in pregnancy
-fasting PG105 mg/dl
-OGT 150 mg/dl
Diffuse abdominal tenderness and rigidity in young person -check glucose level& serum/urinary ketones

Management:

ALL DM patients should have:
1. Diet control-ask for dietetician consult in CCS.
caloric intake for normoponderals ~35kcal/day, obese ~5-15kcal/day , food composition:carbohydrate 55-60%-complex glucocide preferred, protein 10-20%, fat  25-30% limit alcohol use recomand cessation of smoking
2. physical exercise-moderate effort proved to reduce insulin needs
This should control type II DM for a good period of time
Monitoring of therapy: self assessment of patient require intensive education-self-monitoring blood glucose devices (SMBG) 3 times/day-weekly blood glucose measurement at office-evaluation of therapy with Hb A1c at after 2 months ketone urinary assay

Pharmacologic therapy should be implied if:
-patient is unable of self assessment
-noncompliance with prescribed tx
-failure to achieve a normoglycemic status after a reasonable period of time
-patients presenting with diabetic coma,
-inability to mantain dietary intake
-infection(any fever)
-Type I DM
3. Preventive care:
a) vaccinations-consider pneumoccocal and influenza vaccine for all diabetics + normal vaccinations related to age
b) yearly measurement of lipidic profile
c) monthly measurement of blood pressure
d) foot care education
4. Pharmacologic measures:

Type II DM
a) oral antidiabetic drugs:
-sulfonylureas:
use rather short drugs as glipizide/glyburide
ContraIndication: DM I, pregnancy, children-caution in hepatic or renal disease toxic reactions: skin rash, blood dyscrasias, cholestatic jaundice, Disulfuram-like effects with alcohol
Drug interactions: Salicilates,Warfarin, Sulfonamides, Cloramphenicol, Methyldopa, Miconazole, MAOI-may potentiate the hypoglycemic effect of sulfonylureas

-biguanide: metformin-good choice for patients displaying hyperlipidemia associated with DM (increase HDL); when used alone metformin does not produce hypoglycemia.
ContraIndication: liver, renal,heart failure, pulmonary isf., pregnancy, alcoholism
b) Insulin therapy learn at least 1 type of insulin from each class i.e. short-acting insulin: Regular-onset 0.25-1h/semilente 0.5-1 h medium acting:lente onset 1-4 h long acting:ultralente onset 3-8h
Complications of insulin tx:
-Hypoglycemia-could be life threating-educate the patient regarding the signs, instruct to have permanent access to sugar/chocolate
-insulin allergy-erythema, induration, pruritus at inj. site-treat with purified human insulin
-lipoatrophy/lipodistrophy change the site of injections

Chronic complications of DM
1) Ophtalmic complications
recommandations: obtain an ophtalmo consulation at the time of dgn for DM II,and at 5 years after onset in type I-yearly consultation after that
a. FO exam may reveal diabetic retinopathy: nonproliferative-limited to retina-microaneurysms, hemorhages, exudates-cotton wool aspect; proliferative- neovascularisation
b. visual disturbances: acute monocular loss-retinal detachment, retinal embolic infarction;bilateral loss usually stroke
blurred vision-diabetic cataract
2) diabetic neuropathy:
pain-amytriptiline/application of capsaicin
sensory defficit/motor defficit-no tx
autonomic neuropathy-a) postural hypotension-treat spmtm
neurogenic bladder-recurent UTI's-intermitent catherisation
3) Diabetic nephropathy-the principal cause of morbidity and mortality in diabetics, give ACE I, treat aggresivelu UTI's
Hyperlipidemia-hypercholesterolemia & hypertrygliceridemia frequent accompany diabetes-increase in plasma tryglycerides &VLDL-give gemfibrosil along with diet.

IN DKA WHERE DO YOU MANAGE THE PATIENT, ER, ICU, INPATIENT?

ICU till the patient has been stable on his old method of insulin administration , ie sub q


DO YOU GIVE K & WHEN?

Along with insulin, some give a bolus of insulin and then start infusion, some start with infusion... controversial but both acceptable..

DO YOU ORDER ABG's & WHEN?

STAT and q 2 hours


21. A 3 years old african american child presents with jaundice after a few days of respiratory infection treated with septrin, which is due to G6PD deficiency, so that you may need to stop septrin at first and should order G6PD TEST.

The pt present with pallor, jaundice and splenomegaly. Recent h/o URI treated with Bactrim (sulfa).

Order:
O2 

IV hydration to prevent renal co from hemoglobinuria
Cbc?Diff.:  hgb and hct 8.0/34, MCV 89
CMP: bun/cr 20/1.2

Haptoglobin: Low
LDH, PT, PTT

Reticulocyte count: High
UA: urine hemosiderin and Hb.

Peripheral smear showed:  Heinz bodies, spherocytes and fragmented RBC's

Normocytic normochromic and Heinz bodies on peripheral smears, think G6PD
Order quantitative G6P assay: positive

Treatment:

If still on bactrim, stop it.
Mild anemia can watch for now without transfusion.

Counsel to avoid bactrim, fava beans and napthalene.

Remember to repeat G6pd level in 6 mo, as can be normal initially since older cells with lower G6PD levels are already destroyed in acute phase. 


22. Rheumatoid arthritis. A 26 year old female patient comes to your office with joints pains. She has swelling in hands and knees, unable to get up in the morning because of the stiffness and tiredness the pain over the last 2 months.

Pt's chief complaint is generalized fatigue, morning stiffness 1-2 hours multiple joints, knee swelling (patient limping) and pain.

1. PE including HEENT, heart, lung, extremity.
2. Check CBC, chem 7 and order rheumatoid factor, x ray right knee, 

3. Prescribe Motrin or Naproxen, follow up in two weeks to go over lab results with patient. change location to home.
4. Patient returns for a follow up visit at a office setting. I would order follow-up/interval history and repeat PE including HEENT, cardiac, lung, extremity. Pt improved overall. RF is positive, confirming the diagnosis. At this time, I would repeat CBC, Chem 7 to follow up on side effect from NSAID, i.e. GI bleed, renal involvement. 

5. Continue Naproxen and order physical therapy and patient education (since this is her new diagnosis for her to live with).   Then follow up in one month next then three months. That's it for this patient, I think. Patient's symptom was mild requiring no steroid or methotrexate agents in this case.


23. Cardiac Tamponade: A 33 y/o male patient presents with multiple injuries after explosion. He is grasping for air and has lightheadedness. A piece of wood pierced his left sternal border.

PE: Heent, lung, heart, hypotension, distant heart sounds, pulsus paradoxus.

Lab: ECG, dminished QRS voltage. 

Cxray: Mild cardiomegaly.  Echo: accumulation of fluid in the pericardial sac.

Managemant: 

IV fluid, Pericardiocentesis. Surgical Thoracotomy. 


24. Lead Poisoning: Child living in an old house coming to regular checkup
CBC, UA, Blood lead level (25 micro/dl), Free erythrocyte protoporphyrin (35micro/dl)
knee & wrist Xray: increased density in metaphyseal plate long bones = lead lines
Tx
1. Report to local health board 
2. EDTA + dimercaprol for 5 days
3. Penicilamine for 3-6 months

Educate the patient: remove from the environment.


25. ITP (Hx: A 5-year-old with nose bleeding and SBP of 90)

1) PE including Heent, heart, lung, skin
2) IV access, normal saline iv fluid
3) Lab: Bleeding time, CBC, PT, PTT
4) Nose packing

5) Admit to ward

6) Hematology consult - Bone marrow aspiration

7) IVIG and IV Prednisone
8) Remove nose packing 
9) D/C home - appt in office 


26. Colon Carcinoma - 50 yo old lady.
Colon cancer screening
age 40: DRE/every yr
age 50: DRE + fecal blood test/every yr, flexible sigmoidoscopy every 3 yrs
High risk:
1) FH/O colon cancer in 1st degree relative-age 40: DRE + fecal blood test/every yr; flexible sigmoidoscopy and Barium enem or colonoscopy every 3-5 yrs after 2 normal exams 1 yr apart
2) IBD of 8 yr duration: colonoscopy every yr


27. Pneumocystis Carni Pneumonia
PCP is the most common life-threatening opportunistic infection occurring in patients with HIV disease. In the era of PCP prophylaxis and highly-active antiretroviral therapy, the incidence of PCP is decreasing.

Clinical presentation
PCP usually presents with fever, dry cough, and shortness of breath or dyspnea on exertion with a gradual onset over several weeks. Physical findings are often minimal; however, tachypnea may be pronounced, and patients may be so dyspneic that they are unable to speak without stopping to rest. Circumoral, acral, and mucous membrane cyanosis may be evident.

Laboratory findings
* Complete blood counts and sedimentation rates show no characteristic pattern in patients with PCP. Serum LDH concentration is frequently increased.
* Arterial blood gas measurements generally show increases in PaO2. Up to 25% of patients may have a PaO2 of 80 mm Hg or above while breathing room air.
* Pulmonary function tests. Patients with PCP usually have a decrease in diffusing capacity for carbon monoxide (DLCO).
* Radiographic presentation: PCP in AIDS patients usually causes a diffuse interstitial infiltrate. High resolution computerized tomography (HRCT) may be helpful for those patients who have normal chest radiographic findings.
Pneumatoceles (cavities, cysts, blebs, or bullae) and spontaneous pneumothoraces in patients with PCP are common.

Laboratory diagnosis
* Sputum induction. The least invasive means of establishing a specific diagnosis is the examination of sputum induced by inhalation of a 3 to 5% saline mist. If the sputum tests negative, an invasive diagnostic procedure is required to confirm the diagnosis of PCP.
* Transbronchial biopsy and bronchoalveolar lavage. The sensitivity of transbronchial biopsy for PCP is 98%. The sensitivity of bronchoalveolar is 90%.
* Open lung biopsy should be reserved for patients with progressive pulmonary disease in whom the less invasive procedures are nondiagnostic.

Therapy and prophylaxis
Trimethoprim-sulfamethoxazole ( Bactrim, Septra) is the recommended initial therapy for PCP. 
Adverse effects include rash (33%), elevation of liver enzymes (44%), nausea and vomiting (50%), anemia (40%), creatinine elevation (33%), and hyponatremia (94%). The most common adverse reactions that necessitated a change in therapy were neutropenia (15%) and severe rash (15%).

Pentamidine is an alternative in patients who have adverse reactions or fail to respond to TMP-SMX. 
Adverse effects include anemia (33%), creatinine elevation (60%), LFT elevation (63%), and hyponatremia (56%). The most common adverse effect requiring a change in therapy is neutropenia (32%). Pancreatitis, hypoglycemia, and hyperglycemia are common side effects of pentamidine.

Corticosteroids. Adjunctive corticosteroid treatment is beneficial with anti-PCP therapy in patients with a partial pressure of oxygen (PaO2) less than 70 mm Hg, or oxygen saturation less than 90% on room air. Contraindications include suspected tuberculosis or disseminated fungal infection. Treatment with prednisone (40 mg twice daily for 5 days, then 40 mg daily for 5 days, and then 20 mg daily until day 21 of therapy) should begin at the same time as anti-PCP therapy.

Prophylaxis
PCP is the most common life-threatening opportunistic infection in HIV-infected patients. HIV-infected patients who have CD4 counts less than 200 cells per microliter or who have survived an episode of PCP should receive prophylaxis against PCP.
Trimethoprim -sulfamethoxazole (once daily to thrice weekly) is the preferred regimen for PCP prophylaxis because of efficacy and simultaneous efficacy in prophylaxis against toxoplasmosis.
Dapsone (100 mg daily or twice weekly) is a prophylactic regimen for patients who can not tolerate TMP-SMX. Adverse reactions included anemia, LDH elevation, methemoglobinemia, nausea, and skin rash.


28. Pericarditis
DX: chest pain especially with inspiration & lying down; pericardial friction rub
EKG:  with diffuse elevation of ST segment
Echocardiagram: may show pericardial effusion if present.
* May cause CARDIAC TAMPONADE!

PERICARDIAL EFFUSION

DX (esp. of cardiac tamponade):
Low cardiac output Sx: dyspnea, tachycardia, hypotension, jugular vein distension, decreased heart sounds, paradoxical pulse >10 mmHg, Kussmaul's sign (rise in venous pulse with inspiration)
EKG may show electrical alternans, & decreased QRS voltage
Chest x ray may show cardiomegaly
Echocardiogram & CT scan will show pericardial effusion & thickening
Cardiac catheterization may show equalization of pulmonary wedge pressure with the RA, RV, & pulmonary artery diastolic pressure, & also the "square root" sign in the ventricular pressure pulses.
RX:  Immediate pericardiocentesis may be lifesaving in cardiac tamponade !


29. CHF - MI Classic : Myocardial Infarction
After obtaining history, 12 lead ECG to confirm, CXR, Pulse oximetry, establish IV and collect blood for CBC, cardiac enzymes: ck-mb, troponin-T, serum electrolytes, lipids.
Patient must be monitored for cardiac activity
Oxygen intranasal
Morphine sulphate iv
Sublingual Nitrogly ( check HR)
Metoprolol iv bolus ( if HR and BP are ok, generally avoided in inf. wall MI's)
Aspirin chewed
Iv bolus Heparin
IV streptokinase after ruling out contraindications.


30. Neonatal hyperbilirubinemia or Neonatal jaundice in 2 day well and active neonate.
Labs: CBC
bilirubin total-normal 10-12mg with <5mg/day increase
bilirubin direct <1mg/dl anytime
Tx: observation alone
Dx: :normal physiologic jaundice.


31. Acute Abdomen-ER.
For differential diagnosis purposes let us see the abdomen in 4 anterior quadrants and the left and right flanks.
RUQ: perihepatic structures
Liver- hepatitis, Budd chiari (esp if pt. has Nephrotic/paroxysmal nocturnal hemoglobinuria), ruptured hepatic adenoma (young female on oral contraceptives), hepatic trauma, Perihepatitis (e.g. Fitz-Hugh-Curtis syndrome-chlamydia or gonococcus).
Gall bladder- calculous or non calculous (esp in pt in ICU or on cephalosporins) cholecystitis, Gallstone colic
Duodenum-ulcer (on exams- think of Zolinger Ellison)
Lung base- Lower lobe pneumonia, pleuritis
Diaphragm-irritation due to blood in peritoneum (also pain in Right shoulder when patient is in head low position-esp seen in splenic rupture-inspite of spleen being left sided)

RLQ: Structures around cecum and those on right side of uterus.
Appendix-Appendicitis-acute or chronic
Cecum-Typhilitis esp in post chemotherapy patient - occurs with Pseudomonas and Clostridium septicum with approximately equal frequency.
Ovary- cyst rupture or torsion, fibroid- red degeneration, ECTOPIC pregnancy, Tubo-ovarian abscess (PID)
GI-rarely diverticulitis (usually occurs on left side).

LUQ: Spleen and structures around it.
Stomach, Spleen, pancreas, colon-splenic flexure

LLQ: Sigmoid colon- especially diverticulitis that is seen in elderly population and is treated with antibiotics: Cipro 500 mg Bid for 10 days + Metronidazole 500 my Tid for 10 days, hydration-PO or IV and stool softening. Encourage fiber in diet.  Uterine structures-as in LLQ area.

Lab: CBC, UA, Chem 7, Amylase/Lipase, LFT, PT/PTT, B-HCG, Lactic acid. 


32. Retinal detachment: refers to the separation of the outer retinal pigment epithelial layer from the inner neurosensory retinal layer, often a result of a tear in the neuronal layer, causing fluid to leak between and separate the two.
The classic triad of symptoms in an acute RD consists of floaters, flashes of light, and a visual field defect.  However, the triad is not always present.  The visual field deficit is peripheral if the RD involves only the peripheral retina.  Should the RD involve the macula, patients will complain of a loss of central vision.  Loss of visual field is an important sign of RD, particularly when it occurs unilaterally and no other neurologic signs or symptoms are present.  The flashing lights can last for only a few seconds and may occur over a period of days to weeks.
Although in emergency medicine retinal detachment is commonly associated with the sequellae of trauma, many factors can place the patient at risk for RD, including myopia, glaucoma, and cataract surgery.
The presence of symptoms or signs suggestive of RD should prompt urgent referral to an ophthalmologist.  Treatment depends upon the type of RD, the location, and whether the macula is involved.


 33. Hyperkalemia : Order an EKG Look for sx. 

If no sx and no EKG changes give Kayxelate, po/ngt/enema.
If there is changes then: Stop Potassium, give IV Calcium gluconate, give IV glucose & insulin.
Do not give Kayxelate for emergencies.
RX:
1. To control cardio toxicity: Ca gluconate 10% 10 cc amp over 2-5 min.
* Be extra careful if pt on Digoxin; use EKG monitor.
2. Kayexalate (Na Polystyrene Sulfonate) 30 gm in 100 cc 20% sorbitol PO q4h. (decreased 0.5-1 meqK).
3. Na HCO3 7.5% 50 cc amp 1-2 amp + 10-15 unit regular insulin in 500 cc D10W over a couple h.
4. Lasix 40 mg IV
5. Dialysis !


34. Foreign body aspiration. A 1 year old baby in respiratory distress with history of asthma in the family.
The peak incidence of foreign body aspiration is six months to four years, and clinical manifestation is sudden onset. Sudden onset of coughing, gagging, choking, dyspnea, afebrile. And also an object that was previously visible is no longer visible. It’s very suggestive. If it is extrathoracic you are likely to hear stridor and a croupy cough. If it has gone down intrathoracic you are going to see more cough and wheezing.
Diagnosis: extrathoracic, x-rays are helpful if it is radiopaque and one key link that I think is relatively likely to show up on exams is what happens if you see a coin? And what you will see is that coins in the sagittal plane are in the larynx or trachea. The way you can remember that is the tracheal rings have an opening in front so that if a coin is going to slide down into the trachea it’s going to be pointed in this direction. So when you do an x-ray you are going to see it on end, whereas if it’s in the esophagus it’s going to be in the coronal plane. So nice little tip there if you see an x-ray with a coin in it.
Management of these: extrathoracic; if you have partial obstruction don’t try to dislodge it because it may lead to complete obstruction and you want to arrange for emergency bronchoscopy. Intrathoracic, you just need to arrange for bronchoscopy.


35. Acute Adrenal Insufficiency or Adrenal Crisis  (Addison's Disease)
SX: Weakness (99%), Pigmentation of skin (98%), Weight loss (97%), Abdominal pain (34%),  Nausea & Vomiting, Salt craving (22%), Diarrhea (20%), Constipation (19%), Syncope (16%), Vitiligo (9%), fever, lethargy.
Hypovolemia, orthostatic hypotension, tachycardia, hyponatremia, hyperkalemia.

DX:
* Low serum cortisol level, & inadequate serum cortisol response 30 or 60 min after IV or IM Cortrosyn (synthetic ACTH) 0.25 mg (normal is >18-20 ug/dl with increment of 7 ug/dl or greater)
* Obtain baseline serum cortisol and ACTH levels.  Normal response is indicated when the cortisol level at least doubles in response to ACTH stimulation.  
* Plasma ACTH levels are typically elevated in patients with primary adrenal failure and are normal or unmeasurable in patients with primary ACTH deficiency.

RX:
Volume Replacement: IV D5NS >2 -3 liters
Glucocorticoid Replacement: IV hydrocortisone 100 mg q8h.
During ACTH stimulation testing, dexamethasone (4 mg IV) can be used instead of hydrocortisone, to avoid interference with testing of cortisol levels.
Fluorocortisol (mineralocorticoid) 0.1 mg qd
Supportive Rx for glucose, electrolytes, calcium imbalance, temp. abnormalities, etc.
Correct precipitating causes.


36. Chest pain on exertion. A 32 yo woman with sob and chest pain on exertion. Involves stress test and precripton for a anti-anginal along with anti-hypertensive agent .
Chest pain has 4 dangerous causes:
1. Ischemic heart disease
2. Pneumothorax
3. Aortic dissection
4. Pulmonary embolism:

The best stress test in general is exercise stress testing but patients with intermittent claudication cannot exercise adequately. In such patients a chemical stress test needs to be performed.
Dipyridamole stress is preferred over Dobutamine but in a case with obstructive lung disease Dipyridamole may produce bronchospasm whereas Dobutamine would not- therefore Dobutamine stress test would be the test of choice in a patient like this.
Angina is defined as unstable if it fulfils any of the following criteria:
Angina at rest, or angina for the first time, angina after an MI, angina of increasing severity or duration.
It is said to be stable if it occurs on exertion and disappears shortly after rest (within 5-10 minutes)
Myocardial infarction is defined as muscle damage to the heart.
The most important mechanism of unstable angina is plaque rupture. Risk of plaque rupture increases if there is a thin coat of fibrous tissue over it, or thee is a lot of inflammatory reaction around the plaque or if the core is large and filled with fat.
The single most important intervention in a patient with USA or MI is administration of Aspirin and it is advised to be given right at the onset of the symptoms. Nitrates do not save lives.

HTN increases the risk of stroke, MI, heart failure, renal failure, diabetic nephropathy and aortic dissection.
The first line agents that should be used in patients should be Thiazide diuretics or beta blockers. Diuretics have proven to be the best. One can use other agents too but only if the above two give an inadequate response or if  there is a reason not to use them.


37. Thalassemia Anemia (Alpha-thalassemia & Beta-thalassemia)
The thalassemia syndromes are a heterogeneous group of inherited anemias characterized by defects in the synthesis of one or more globin chain subunits of the adult hemoglobin tetramer (Hb A). This leads to deficient hemoglobin accumulation, resulting in hypochromic and microcytic red cells & ineffective erythropoiesis and hemolytic anemia.

SIGNS AND SYMPTOMS:
Thalassemia trait has no signs or symptoms.
Pallor, Poor growth, Inadequate food intake, Fatigue, Shortness of breath, Splenomegaly, Jaundice, Maxillary hyperplasia, Dental malocclusion, Cholelithiasis, Pathologic fractures

LAB:
In the presence of normal iron status, increased levels of Hb A2 (to 4 to 6%) and/or increased Hb F (to 5 to 20%) by quantitative hemoglobin analysis supports the diagnosis.
The distinction between alpha- and beta-thalassemia depends on the measurement of the minor hemoglobins Hgb A2 & Hgb F.  If these are normal, the diagnosis of alpha-thalassemia is most likely, although rare subjects with beta-thalassemia also have normal levels of Hb A2 and Hb F.

Hemoglobin electrophoresis:
Elevated Hb A2 levels in beta-thalassemia trait
Elevated Hb A2, elevated Hb F, reduced or absent Hb A1 in beta-thalassemia major or intermedia

Peripheral blood:
Pronounced microcytosis, Anisocytosis, Poikilocytosis, Hypochromia, Punctate basophilic stippling, High percentage of target cells, nucleated RBC, Reticulocyte count elevated

Hematocrit:
28-40% in alpha-thalassemia trait and beta-thalassemia trait
May fall to less than 10% in beta-thalassemia major

Therapy for severe Thalassemia disease (Mild cases require no therapy)

1. Transfusions to an Hb of more than 9 g/dl prevents skeletal deformities and usually can be achieved with 1 unit of RBCs every 2-3 weeks or 2 units every month.
2. Splenectomy removes the primary site of extravascular hemolysis and should be considered if RBC transfusion requirements increase and exceed 1.5 times the previous levels.   It should not be performed if the patient is younger than 5-6 years because of the risk of sepsis. To decrease the risk of postsplenectomy sepsis, immunization against pneumococci and Haemophilus influenzae should be administered 1 month before surgery if not done previously.
3. Iron chelation therapy with deferoxamine mesylate, 50-100 mg/kg per day, usually is administered by continuous SC infusion for 10-12 hours/day.
4. Bone marrow transplant should be considered in young patients who have thalassemia major and have HLA-identical related donors.
5. Administer polyvalent pneumococcal vaccine one month prior to splenectomy;  Folate supplementation.
6. Prophylaxis with a daily regimen of penicillin;  Treat infections promptly .


38. Renal Cell Carcinoma - A obese 45 yo black female comes to clinic with fatigue and anemia. Studies revealed RCC.
What are the symptoms/signs of RCC? 
Symptoms/signs of RCC are generally caused by either invasion of the tumor beyond the confines of the kidney causing pain, hematuria (blood in the urine), or a flank mass.  Symptoms of advanced disease (metastatic) include weight loss, fever, hypertension, night sweats, and the sudden onset of a varicocele (varicose veins of the testis) in a male patient.
What is the classic triad?
Pain, hematuria, and a flank mass constitute the classic triad; however, this is only seen in approximately ten percent of patients and usually only those with advanced disease.
How does one diagnose RCC?
Computerized tomography is the most sensitive imaging technique.  However, abdominal ultrasonography (USG) is a useful adjunct to CT, especially in differentiating hyperdense cysts from solid tumors.
How do you treat someone with RCC?
Prior to treatment one needs an evaluation primarily aimed at determining the extent of cancer spread (staging).  Currently, the most commonly employed method used is the American Joint Committee for Clinical Staging, referred to as the TNM Clinical Classification.
RCC can grow locally into very large masses and invade through the surrounding fascia into adjacent organs.  They also metastasize through lymphatic channels into regional and mediastinal nodes or by hematogenous routes primarily to the lungs, bone, and brain.
How do you treat RCC?
The mainstay of treatment for primary RCC is surgical removal.  Surgery is the only currently known curative therapeutic modality.  Radical nephrectomy is the procedure of choice for clinically localized RCC.


39. PUD - A 28 yo black female comes to clinic with hx of NSAID use for back pain. Rectal shows guaic positive stool. Prescribe ppi (Aciphex 20 mg q d). Patient needs EGD.
Perforated peptic ulcer and Perforated Gastric Ulcer - ER
CBC, blood type and cross matching, electrolyte, bun/cre, ng tube. In addition to above maybe a serum amylase. 

Cxray and Abdomen Xray Upright or decub. which will reveal free intraperiton air.  ABCs and urgent referral to a surgeon?


40. Aortic Aneurysm Case - (Real case) A 58 yo wm with chest pain. Xray reveals widened mediastinum. Hypertensive and in excruciating pain. 

Start Nitroprusside to lower BP and vascular consult nailed the case. Don't forget other tests to r/o MI.
Thoracoabdominal aneurysms, which are usually fusiform, involve different portions of the descending thoracic and abdominal aorta.
The causes of these aneurysms are usually degeneration, atherosclerosis, and aortic dissection. Occasional causes are trauma, infection, and aortitis. Most of these aneurysms are fusiform. Without surgical resection, the 2-year survival rate is about 24%, with half of these deaths due to rupture of the aneurysm.

SX:
Thoracoabdominal aneurysms may be asymptomatic. Most, however, produce symptoms before rupture. The patient may complain of pain in the chest, abdomen, flank, or back, or symptoms may be related to compression of adjacent structures, such as the tracheobronchial tree, esophagus, or recurrent laryngeal nerve, the last causing hoarseness.

DX:
Rarely, the diagnosis is made by palpation of the abdominal aortic component. A plain radiograph of the chest showing widening of the descending thoracic aorta is most common. MRI or CT provides a more exact diagnosis, including the location and extent of the aneurysm. Total contrast aortography in multiple views is necessary for complete evaluation of associated disease of the renal, visceral, or iliac arteries.

RX:
Treatment is surgical, consisting primarily of graft replacement. A combined thoracoabdominal incision is usually used. A Carlens (double-lumen endotracheal) tube provides deflation of the left lung and selective ventilation of the right lung.
Paraplegia, paresis, or both are the most dreaded complications of operation for thoracoabdominal aneurysms.  The incidence of paraplegia or paresis is 31% in type II aneurysms but significantly less in other types of thoracoabdominal aneurysms when the simple cross-clamp technique is used.

Dissecting aneurysms of the aorta are characterized by an intimal tear with hemorrhagic intramural separation of the medial layer of the aortic wall. The intimal tear originates, with decreasing frequency, in the ascending aorta, the descending aorta, and the aortic arch. The dissection usually extends distally but may extend proximally and creates a false lumen. Initial dissection may result in rupture and fatal hemorrhage. The dissection may also rupture into the pericardium to involve the aortic valve or coronary arteries and produce cardiac tamponade, acute aortic valvular insufficiency, heart failure, or occlusion of the coronary arteries. Distal dissection may cause obstruction of the major brachiocephalic arteries and cause a stroke or occlusion of the renal or mesenteric arteries followed by renal failure, mesenteric infarction, or occlusion of the iliac arteries with resulting ischemia in the limbs. The predominant underlying pathologic condition is medial degeneration in Marfan's syndrome.  Most patients have associated uncontrolled hypertension. Additional risk factors include pregnancy, coarctation, and idiopathic kyphoscoliosis. The initial course of the disease has an extremely grave prognosis, with death in 50% of patients within the first 2 days of onset. A small percentage of patients survive a few years without treatment. Aortic dissection occurs twice as often in men as in women, and most patients are in the fourth to seventh decades of life.


Aortic Dissection Summary
1) PE including heart, lung, HEENT

2) CBC, Chem 7, Cardiac Enzymes, Cxray, pulse ox, ABG, EKG

3)Labetalol if BP is very high, morphine for pain
4) CT chest or aortogram
5) Move patient to Intensive care unit
6) Arterial line, Nitroprusside and Metroprolol.

7) Thoracic surgery consult


41. MANAGEMENT OF UNSTABLE ANGINA
SOB, diaphoresis, N/V, dizziness, lightheadedness.
Hospitalization, continuous ECG monitoring, 12 lead EKG, Cxray, MB-CPK, Troponin, CBC, CMP.
Correction of precipitating risk factors:  smoking, DM, HTN, obesity, arrythmias, anemia, hypoxemia.
ASPIRIN: clopidogrel (plavix 75 mg) or ticlopidine if  allergic to aspirin.
HEPARIN: unfractionated IV heparin: APTT one and a half to 2 times
LMWH: as effective as unfrac.heparin to be continued for 48 hrs. or until angiography is performed.
If heparin induced thrombocytopenia develops. Lepirudin,
abciximab in pts with renal failure
tirofiban eptofibatide, monitor for thrombocytopenia, bleeding complications, not to be used in ST elevation MI.
NITRATES: start NTG 0.4 mg SL x3 then IV nitroglycerine preferred, after 24 hrs switch to long acting prep: Imdur 60 mg qd.
BETA BLOCKERS: Metoprolol 25-50 mg in combination with nitrates: comb. reduces the risk of subsequent MI.
Morphine for pain refractory to medical therapy
Lipid lowering therapy: Primary goal to LDL<100, HDL>45, hold OCs if woman >35 y/o and smokes.
Refractory ischemia, recurrent symptoms, elevation of base line MB-CK or troponin despite medical therapy, refer for angigraphy.
Asymptomatic after 48 hrs of drug therapy: modified bruce protocol test, strongly positive referred for angiography.
Early angiography and revascularization: no difference in combined rate of death.


42. Acute MI-ER . A middle age man with acute chest pain.
Here is my management for an uncomplicated MI
If the presentation of chest pain suggestive for MI: P/E chest, abdomen, extremities = 3 minutes
1) Aspirin chewing
2) O2 mask
3) IV line
4) ECG 12 lead
5) ECG monitoring
6) Vitals monitoring
7) Cardiac enzymes (CPK-MB,cTnT)
8) Pulse oxymetry monitoring
9) Morphine sulphate i.v.

Other Labs: CBC with diff, ABG's, CMP, PT & aPTT, blood type & crossmatching, LFT's, Urinalysis, TFT.
Image: CXR, abd plain films, cardiac ECHO


If no inferior MI, no hypotension, Nitroglycerin iv
Look for CI to thrombolysis-if no CI-heparin iv  then streptokinase bolus
If CI to thrombolysis-stenting PTCA call interventional cardio
If patient is stabilized-transfer in CCU
D/C oxygen
Adm.Metoprolol iv
Continue monitoring for 3 days
Diet liquid
Psyllum cysapride to prevent constipation
2'nd day, Tc scintigram-evaluation of affected myocardium, complete P/E
3'rd day continue measures- early ambulation (go to the bathroom)
4'th day non-stress submaximal effort test, discontinuation of monitoring, transfer in ward room
5'th day D/c of iv medication, start propranolol p.o. (chose because of low cost)
Cardio-Pul. examination
Check patient immunization status: if no influenza & pneumo
advise patient to stop smoking & drinking
6'th day begin solid alimentation
7'th day again submaximal treadmill test, discharge

Final recommendations:

diet low salt low cholesterol
continue aspirin indefinite
come back to control in one month
rest at home for 3 months
I forgot to mention that a coronary angiography should be performed before discharge.
I wouldn't start on liquids the first day... probably NPO first day with iv D5.. I'd wait till the second day to start a low salt cardio diet thereafter.


43. Post menopause women-HRT -Office setting.
* Sings Of Menopause: 3 months of amenorrhea, skipped periods, irregular menses or long heavy bleeding, vaginal atrophy, Hypoestrogenemia, FSH>40 IU/I.
* Withdrawal bleeding: give Provera 10 mg qd for 7 days, if no bleeding, repeat in 3 months if still no withdrawal bleeding assume she is in menopause. Consider starting HRT.
* If pt has heavy menses or bleeding between menses perform biopsy or D&C.

Hormone Replacement Therapy

A. Woman with Hysterectomy: Premarin 0.625 mg qd  or  FemPatch once weekly.
B. Woman with intect uterus: Femhrt 1 tb qd or CombiPatch twice weekly.
C. If pt has contraindication to HRT: Clonidine 0.1 mg qd or Medroxyprogesterone 10 mg qd
D. Calcium 1000 mg & Vit D3 400 IU qd
* Patient Monitoring:
1. Annual Pap smear
2. Annual Mammogram
3. Uterine Bx for abnormal bleeding
4. Dexa bone scan to evaluate Osteroporosis
5. Monitor lipid profile


44. Temporal Arteritis -Office setting.
Unilateral headache in an elderly patient who may also develop some visual problems should always suggest GCA.
It is probably the only indication for an urgent ESR check. ESR could be elevated. Almost always over 50 and if not diagnosed for long, nearing 100 or more.
Immediately start high dose steroids-minimum of 60 mg prednisone a day.Do not wait for performing tests or for results of tests otherwise patient may become blind due to AION (anterior ischemic optic neuropathy)
A temporal artery biopsy consisting of 4 cm of the temporal artery should be performed within 4 days and remember that lesions may be skip lesions (it is like Crohn's disease of the artery!)
There is an overlap between PMR (Polymyalgia Rheumatica) and GCA in about 40% of patients. Remember that GCA needs higher doses of steroids than plain PMR.


 45. CHF Excacerbation -ER  and An old man with ischemic heart disease and COPD, Dx: congestive heart failure and pneumonia.
RX of Heart Failure:
1. Removal of the precipitating cause, & Correction of the underlying cause
2. Dietary salt & fluid restriction & Hypertension control  (keep BP low if tolerated)
3. Medication Rx for CHF:
A. Diuretics if there is fluid retention or worsening of CHF, as Lasix 40-100 mg or Bumetanide 1 mg IV.
B. ACE Inhibitors - Angiotensin Converting Enzyme Inhibitor  (first line of Rx)
Accupril (Quinapril) 10 20 40 mg tab usually 10 40 mg once daily or in equally divided bid doses
Monopril (Fosinopril) 10 mg tablet Start 10 mg once/d; usual 20 40 mg/d once daily.
Vasotec (Enalapril) 2.5 5 10 20 mg tablets 2.5 20 mg/d once daily.
C. ARB - Angiotensin II receptor blockers
Hyzaar (Cozaar 50 mg + Hctz 12.5 mg) or Diovan/Valsartan 80-320 mg
D. Other Vasodilators:
Hydralazine, minoxidil, prazosin - in hypertensive pts
Nitroglycerin, isosorbide, nitroprusside - in ischemic pts
E. Enhancement of myocardial contractility:
Digoxin 0.125 - 0.25 mg/day - esp. in atrial fibrillation pts or in severe CHF
Dopamine, Dobutamine, Amrinone
F. Beta-blockers as:
Carvedilol (nonselective B-blocker with alpha1 blocking & antioxidant properties)
Coreg (Carvedilol) 3.125,  6.25,  12.5,  25 mg PO bid for CHF or Hypertension


46. HIV related Pneumonia -ER.
Also Female 34 year old, multiple sexual parin the past. Comes to ER with ARC (AIDS related complex) symptoms, as she said. No history of HIV positivity (HIV1 nor HIV2), exposures (not sure). Elisa and Western blot both negatives. PCR (polymerase chain reaction) also negative.
NB: There is a small percentile of patient with AIDS without obvious evidence of virus or antibodys. Treat as HIV +ve.
Any patient with a history of exposure and symptoms of AIDS with or without lab evidence is treated as HIV positive.
Intitiate retroviral therapy,
Monitor CD4 level, and viral load.
Vaccination for pneumococcus, influenza, hep. B if Hep B Ag negative.
The only thing to do is refer her to a psychiatrist for evaluations. She is a medical board student who has been reading a lot of stuff about AIDS. Type of Hypochondriac. 


47. Dx: hypothyroidism and Turner syndrome. Real Case) A 13 yo girl with short statue.
In the beginning, for patients with coronary disease, start with a low dose of thyroxine- either 12.5 or 25 micrograms or else one can precipitate angina. Then gradually advance the dose(every 2 weeks -increase dose by 12.5--25 micrograms).
On the other hand when a patient is in myxedema coma the doses used are high and most importantly for them you should administer steroids prior to the thyroxine- not because their adrenals have failed but because the adrenal becomes underactive because of the low basal metabolic rate and cannot cope with the suddenly increased metabolic rate that occurs due to initiation of thyroxine therapy.
Thyroid function tests are the most important tests to interpret in endocrinology therefore it is vital to review them now.
In hyperthyroidism - total T4 is elevated unless  the patient hasT3 toxicosis(which is rare-but not on the boards) where T4 will be low.
TSH will be low unless the hyperthyroidism is Pituitary driven (secondary) toxicosis(See important principles).
Toxicosis due to thyroiditis and factitious administration will also have  low TSH and High T4 and a low thyroid uptake scan but thyroglobulin in thyroiditis is elevated but in external administration of thyroxine it is low.
In Grave's disease there are eye signs and positive TSH receptor blocking antibody. Iodine uptake by thyroid is high.

The two most important tests in evaluation of hypothyroidism are TSH and free T4 (total T4 may be almost equally good as free).
If a new patient has high TSH and symptoms of hypothyroidism- treat as hypothyroidism.If no symptoms-then check free T4. If free T4 is normal in such a new patient then the patient has what is called subclinical hypothyroidism and needs to be treated IF patient has goiter or thyroid antibodies or history of Radioactive iodine treatment in the past. These  predict the possibility of future development of hypothyroidism.

If the patient has had a pituitary ablation/surgery then use free T4 as the guide. If the patient is known to be on treatment  with thyroxin and has an elevated TSH but normal T4 then he has a compliance problem and usually forgets to take meds but popped in his dose just before coming to the doctor who checked the labs.

Individuals with Turner syndrome may have a short neck with a webbed appearance, a low hairline at the back of the neck, and low-set ears. Hands and feet of affected individuals may be swollen or puffy at birth, and often have soft nails that turn upward at the ends when they are older. All these features appear to be due to obstruction of the lymphatic system during fetal development. Another characteristic cosmetic feature is the presence of multiple pigmented nevi, which are colored spots on the skin.
It is standard medical practice to treat girls with Turner syndrome with estrogen to induce breast development and other features of puberty if menses has not occurred by age 15 years at the latest. Girls and women with Turner syndrome should be maintained on estrogen-progesterone treatment to maintain their secondary sexual development and to protect their bones from osteoporosis until at least the usual age of menopause (50 years).
Most women with Turner syndrome do not have ovaries with healthy oocytes capable of fertilization and embryo formation. Current assisted reproductive technology, however, may allow women to become pregnant with donated oocytes.
From 5-10% of children with Turner syndrome are found to have a severe constriction of the major blood vessel coming out from the heart, a condition known as "coarctation of the aorta". This can be surgically corrected as soon as it is diagnosed.
Approximately 1/3 of individuals with Turner syndrome have a thyroid disorder, usually hypothyroidism. Symptoms of this condition include decreased energy, dry skin, cold-intolerance and poor growth.

In most cases, it is caused by an immune system attack on the thyroid gland (also known as Hashimoto's thyroiditis). Although it is not known why thyroid disorders occur with a high frequency in Turner syndrome, the condition is easily treated with thyroid hormone supplements.


48. Coma: As with all critical patients, the evaluation and treatment should begin with the 'ABCs' (Airway, Breathing and Circulation). Supplemental oxygen should be given to all patients with altered mental status. A fluid bolus of 250-500 ml normal saline or lactated Ringers is indicated for hypotension.
The "coma cocktail" consists of glucose, thiamin and Narcan® (naloxone). These agents are effective antidotes for two of the rapidly treatable etiologies of coma or altered mental status. Naloxone is a specific antidote for opiates. Glucose, either as an oral supplement or intravenously (IV) as Dextrose 50%, is given for suspected hypoglycemia. An acceptable alternative to supplemental glucose is an Accucheck® or other bedside glucose determination. Thiamin is given to prevent the development of Wernicke's encephalopathy in patients who are nutritionally deficient and who are given glucose.
An Accucheck® shows a glucose of 94mg/dL. There is no response to 2 mg IV naloxone. The oxygen saturation rises to 98% on 15L by non-rebreather mask and there is no significant change in blood pressure or heart rate after a bolus of 500 cc normal saline.
Appropriate laboratory evaluation includes electrolytes (including calcium), blood urea nitrogen (BUN) and creatinine, osmolarity, blood alcohol, urinalysis, complete blood count (CBC), arterial blood gases (ABG), EKG and toxicology screen. Radiologic studies should include a minimum of a CXR ana noncontrast CT of the head. A lumbar puncture should be performed once CT has ruled out a space occupying lesion or edema.
I think this is a case of "myxedema coma"secondary to surgery.
Labs: CBC, Hb, Hct, WBC with diff, Electrolytes, TSH, Free T4, Blood Glucose, Urine analysis, BUN, blood cultures.
Treatment: ABC
Confirm hypothyroidism and start thyroxine iv , monitor cardiac activity, hydrocortisone.

Myxoedema coma

the clue is the incision mark ,in front of neck n pt went into hypo after that. not treating brought her to this condition myxoedema coma Rx:  levothyroxine i/v, hydrocortisone, warm the pt, reat any underlying infection, assisted mechanical ventilation


49. Management of Turner's syndrome, Mental retardation.
Turner's syndrome is the most common sex chromosome abnormality of human females. Its incidence in newborns is approximately 1 in 2,500. Individuals with this disorder have a female phenotype, but invariably have abnormalities in reproductive function.

The incidence of mental retardation is not increased over normal, and individuals with Turner's syndrome are often happy and productive members of society.
Due to gonadal dysgenesis, Turner's syndrome individuals do not produce appreciable quantities of gonadal sex steroids. Prior to puberty, plasma levels of adrenal androgen are normal, which allow development of sparse pubic and axillary hair. Lack of sex steroids is reflected in absense of negative feedback and consequent elevations in luteinizing and follicle stimulating hormones.

Therapy for human Turner's syndrome is directed at correcting the somatic abnormalities, augumenting the short stature and inducing secondard sexual characteristics and menses - lack of the later can be psychologically very disturbing to affected individuals. The primary treatment is estrogen therapy, begun at an age of 13-14 years and administered with gaps to allow withdrawal menstruration. To date, no therapy has been effective is significantly augmenting final height.

Turner's syndrome is commonly diagnosed prenatally, often in women undergoing amniocentesis or chorionic villus sampling for other reasons. Advanced maternal age does not seem to be a risk factor by itself for this disorder. Ultrasonography is a valuable tool for detecting fetuses with Turner's syndrome: typical findings include a thickened neck, cystic hygroma and renal or left-side cardiac abnormalities. Presumptive diagnosis by ultrasound should be confirmed cytogenetically. Many of the fetuses diagnosed prenatally with Turner's syndrome are electively terminanted.


50. Myoglobinuria.
Myoglobinuria results from necrosis, especially acute, of muscle fibers (rhabdomyolysis)
Typical clinical features
Common: Weakness; Pain; Tenderness; Muscle swelling. May be asymptomatic
Predisposing factors
Exercise: Progressive exercise ® é Fatigue & Myalgia
Fasting
High ambient temperatures
Toxins & Drugs
Genetic
Time course
Early: Pigment in urine may occur immediately or with delay up to 24 hours
Late: Severe rhabdomyolysis may be followed by fibrosis & contractures
Complications
Compartment syndrome
Muscles in closed space swell & become ischemic
May require fasciotomy
Renal failure with acute tubular necrosis
Hyperkalemia
Disseminated intravascular coagulopathy
Laboratory
Urine dip stick (benzidine)
Positive: Myoglobin; Hemoglobin; Hematuria
Negative: Porphyria
Myoglobin in urine: Radioimmunoassay; Use urine fresh & neutralized
Serum CK: Very high; Half life of ~ 3 days
Muscle biopsy
Scattered muscle fiber necrosis & degeneration
* Do not perform diagnostic muscle biopsy for at least 1 month after episode. Biopsies performed near time of rhabdomyolysis will give spurious biochemical results
MRI with gadolinium enhancement: Increased signal; T2 > T1
Treatment
Maintain airway & circulation
Prevent acute tubular necrosis
Normal saline IV: 10 to 15 mL/kg; Continue if adequate urine output
Isotonic Sodium bicarbonate
Mannitol: 0.3 to .05 g/kg IV; Monitor K+
Furosemide: 40 to 80 mg IV initially; Up to 200 mg total
Treat other complications
Hyperkalemia
Disseminated intravascular coagulation


51. Dx: dysfunctional uterine bleeding.  A 15 y/o girl with vaginal bleeding >10 pack per day during menstruation and also Age of 17 yo girl with painful vaginal bleeding in the past 2 months.
Dysfunctional uterine bleeding (DUB) is heavy or irregular menstrual bleeding that is not caused by an underlying anatomical abnormality, such as a fibroid, lesion, or tumor. DUB is the most common type of abnormal uterine bleeding.
A normal menstrual cycle occurs every 21-35 days with menstruation for 2-7 days. The average blood loss is 35-150 cc, which represents 8 or fewer soaked pads per day with usually no more than 2 heavy days.

Most cases of DUB are associated with anovulatory bleeding. Anovulatory bleeding is common in women who have just started menstruating and during the several years preceding menopause. When ovulation does not occur, the level of estrogen and progesterone in the uterus is disturbed, leading to DUB. Anovulation, however, does not always lead to DUB and there are other causes as well. Women with ovulatory cycles may also experience DUB.

The major categories of DUB include the following:
Estrogen breakthrough bleeding
Estrogen withdrawal bleeding
Progestin breakthrough bleeding

Diagnosis typically involves a medical history, physical and pelvic examination, laboratory tests, and sometimes imaging tests. In women over age 35, a biopsy or a D & C (dilation and curretage) is performed to rule out endometrial hyperplasia or cancer.
In the patient with unstable vital signs, perform a CBC, (PT), (aPTT), and type and cross-match.
Pregnancy must be ruled out by urine and/or serum human chorionic gonadotropin.
Consider thyroid function tests.

Imaging Studies:
Workup by the gynecologist should include a pelvic ultrasound to evaluate for fibroids or other structural lesions that may cause abnormal vaginal bleeding.
Transvaginal ultrasound (TVUS): Consider TVUS if the patient may be pregnant or may have anatomic problems or polycystic ovarian syndrome.

Procedures:
Pelvic examination
Pap smear
Before instituting therapy, many consulting gynecologists perform an endometrial sampling to diagnose intrauterine pathology and to exclude endometrial malignancy.

Perform endometrial biopsy for the following patients:
All patients older than 35 years
Obese patients
Patients with diabetes mellitus
Patients with hypertension
Patients with suspected polycystic ovarian disease
Dilatation and curettage is indicated in the following situations:
Consider dilatation and curettage (D&C) in patients at high risk for endometrial hyperplasia and carcinoma.
Consider D&C rather than endometrial biopsy if suspected diagnosis is endometritis, atypical hyperplasia, or carcinoma.
Perfori in patients having heavy, uncontrolled bleeding.
Perform if histologic examination is required but biopsy is contraindicated.
Perform if medical curettage fails.

Treatment
DUB is usually painless and is generally not a problem unless the woman is upset by the bleeding or is trying to conceive.
Hormone therapy typically involves oral contraceptives or progesterone therapy to regulate bleeding patterns. Treatment depends on the patient's age and the severity and timing of the bleeding.

Hemodynamic instability
Establish ABCs.
Initiate 2 large-bore intravenous lines (IVs), oxygen, and cardiac monitor.
Administer IV conjugated estrogen (Premarin) with repeated doses if necessary until bleeding stops, which is usually within 1-3 hours.
If bleeding continues after instituting IV estrogen, insert a pediatric Foley catheter into the cervical os and inflate to tamponade the bleeding. The balloon is distended with saline until the bleeding stops. If the patient has an unusually large uterus, a larger balloon (15-30 cc) may be needed. The Foley catheter may need to be clamped to reinforce the tamponade if blood begins to exit through a large-caliber catheter. The balloon is left in place for 12-24 hours to control bleeding.
For older, hemodynamically stable (hematocrit 25-35%) patients with a known history of DUB, iron-deficiency anemia, and moderate amount of prolonged bleeding, administer an oral contraceptive containing a combination of high doses of estrogen and synthetic progesterone (eg, Ortho-Novum 1/50) 4 times per day for 7 days to arrest bleeding. Oral contraceptives may aggravate an already suppressed hypothalamic-ovarian axis in young postmenarchal patients; therefore, use them only in patients with an established menstrual history. Exclude pregnancy prior to initiating therapy.

Appropriate oral contraceptives include the following:
Modicon 21 (ethinyl estradiol, norethindrone)
Ortho-Novum 1/50 (mestranol, norethindrone)
Levlen 21, (ethinyl estradiol, levonorgestrel)
Lo/Ovral (ethinyl estradiol, norgestrel)
Demulen 1/30,50 (ethinyl estradiol, ethynodiol diacetate)
Progestins alone are the drug of choice to treat anovulatory DUB and should be reserved for patients with a clear-cut diagnosis. These can be started safely in the ED after the severe acute bleeding episode is curtailed with IV estrogen and pregnancy has been ruled out.

Consult a gynecologist if administering combination therapy to a mature patient with a history of DUB, moderate bleeding, and a negative pregnancy test.
Consult a surgeon for acute hemorrhage with hemodynamic instability. One of the following procedures may be necessary:
D&C
Hysterectomy (rare)
Endometrial ablation


52. ATRIAL FIBRILLATION
RX of Rapid Atrial Fibrillation with Ventricular Response:
Electrical cardioversion 100-200 joules, if hemodynamically compromised.
Verapamil 5-10 mg IV (0.075 - 0.15 mg/kg)
Cardizem (Diltiazem) IV bolus for rate control of atrial fib/flutter.
* Start 0.25 mg/kg IVP over 2 min (ave pt = 20mg dose),
after 15 min if inadequate response, 0.35 mg/kg (ave pt = 25 mg dose) over 2 min;
Infusion Rx start at 5 mg/h, range 10 - 15 mg/h.
** Calcium blockers are contraindicated in atrial fib assoc. with  WPW Syndrome.
** Caution should be employed when using digoxin, or IV verapamil in pts with the WPW synd & Atrial fib., since these drugs can shorten the refractory period of the accessory pathway and can increase the ventricular rate, thereby placing the pt at increased risk for vent. fibrillation.
Chronic PO verapamil is not associated with this risk.
Digoxin 0.25-0.75 mg IV
 Metoprolol 5-10 mg IV, or
Quinidine, flecainide, amiodarone,  Sotalol, procainamide to prevent recurrence of atrial fibrillation.
PO Digoxin, verapamil, of propranolol to control the ventricular rate of chronic atrial fib.
Chronic anticoagulation for chronic atrial fib. pts. (Keep INR 2-3)
Radiofrequency catheter ablation of AV junction followed by permanent pacemaker in refractory cases where the ventricular response cannot be controlled.

Prevention of Embolic Complications
Heparin
After 48-96 hours in AFib, patients should usually be heparinized
In patients with unclear onset of timing of AFib, heparin may be started early
Aim for activated partial thromboplastin time (APTT) of 50-70 seconds
Subcutaneous heparin may also be effective (20-30KU qd in divided doses)

Warfarin (coumadin) may be started after 1-2 days of heparin
Overall decreased risk of stroke 65-80% of patients (from 4.5% to 1.4%)
This applies to all patient groups, including those >70 years old
Moderate dose warfarin (PT 1.2-1.5X control; INR 2-3) effective for non-rheumatic AFib
Higher dose warfarin (INR 3-4) is required for rheumatic fever-associated AFib
Should begin treatment with heparin + warfarin x 2-3 days, then discontinue heparin
No significant increases risk of bleeding with moderate dose warfarin (INR 2-3)
Warfarin (INR 2-3) more effective than warfarin (INR 1.2-1.5) + ASA 325mg/d
If cerebral ischemic events with AFib occur, INR 2-4 prevented recurrences without significantly increasing bleeding risk
INR below 2.0 was associated with >2X increased risk of stroke in AFib

Aspirin
Aspirin favored in non-valvular AFib patients >65 yrs without other stroke risks
Aspirin (325mg/day) may be as effective as warfarin in <75 yr olds with no other cardiac abnormalities or risk factors for heart disease. In AFib, aspirin is always better for stroke prophylaxis than placebo

Patients should be on anti-coagulation unless contraindicated by:
Active Bleeding
Significant Liver Impairment
High risk of Falling
Protein C or S deficiency (high risk of skin necrosis, thrombotic events)
History of adverse reaction to warfarin (consider sc heparin)
Increasing age (>75) and intensity of anti-coagulation are risk factors for bleeding

Transesophageal Echocardiography (TEE)
TEE is method of choice for visualization of clots in atrial appendage. Should be used to rule out atrial thrombi in patients undergoing cardioversion. The ACUTE Pilot Study suggests that TEE can be used to rule out significant clots. Therefore, patients with AF and no clots on TEE can safely be cardioverted early. Following cardioversion, 4 weeks of warfarin are recommended.


53. A. Black male with hypertension.
Initial ER labs for HTN:
CBC, UA, BUN/CR, lytes, EKG, CXR
Malignant HTN
= HA + Eye SX + Resp SX + chest pain + change in MS
Always R/O secondary HTN (found in only 5% cases) COA,contracept,Conns,Cushing, pheo, ras
HTN HX + Weakness + Tiredness + Diuretics HX = Contraction Alkolosis...
 Management = DC Diuretics, DC Antacid, give K, CA, MG, and IVF
Very first step in essential HTN management = lifestyle modification = Salt/wt/tob/etoh/yoga... off these
Strongest correlation with decr. in BP = wt (ie: weight loss)

Antihypertensive Drugs
Blacks: Diuretics and Ca. Channel blockers
Elderly: ca blockers, diuretics and ace inhibitors
Angina: Beta blockers, ca blockers
Diabetics: ace inhibs, ca blockers
CHF: diuretics and ace inhibs
Asthmatics: diuretics and ca blockers
ACE inhs are not very effective in blacks . (In elderly and black we don't give ace inhibitors because they have low plasma renin activity).
Antihypertensive Drugs Contraindications:
1. B.Blockers: diabetes, asthma, peripheral vascular disease, CHF
2. Diuretics: diabetes and hyperlipidemia, Gout
3. Ca blockers: CHF
4. Ace inhibs: pregnancy

B. Moderate hypertension in an African-American patient with NIDDM .
Diabetic: A 30 yo diabetic male routine office visit. Involved patient education, hypertension control, and lipids control.
htn + Lipids + mi = Give Beta Blocker, even though it is contraindicated with high lipids.
htn + African + dm = Give ACE-I even though it is contraindicted in Blacks
htn + mi + dm = Give Beta blocker even though it mask hypoglycemia.
All pts with DM should be start on an ACE I even if don't have HTN.


54. Abd. pain - Acute Pancreatitis. Understand the appropriate use of laboratory and imaging studies in the diagnosis of acute pancreatitis. Pancreatic enzymes are spilt into the bloodstream. Lipase is more specific for pancreas than amylase.
Any very ill individual should have abdominal imaging to assess necrosis and rule out infected necrosis or abscess formation.
CT is much better than U/S. One may expect to find pseudocyst (treated with internal drainage) or abscess (treated with external drainage) or necrotic tissue (phlegmon-treated by debridement).


55. Acute Diverticulitis :
Order sheet- intravenous fluids , (bowel rest) in addition to antibiotics
evaluation- is CT necessary to confirm the dx.
follow up- colonoscopy to rule out sigmoid cancer
Symptomatic Diverticulosis: mild--discharge with antispasmodics and high-fiber diet;
If severe, cbc, UA and flexible sigmoidoscopy, barium enema or colonoscopy.
Diverticulitis: cbc, ua/culture, hct, typing and cross-match, pt, ptt, bleeding time, blood culture (before antibiotics), lfts and electrolytes, x-ray, ct. Sigmoidoscopy and Barium enema should be delayed. iv fluid, npo, surgical consultation, antibiotics


56. Dx: AIDS with PCP and Herpes esophagitis. AIDS: A young guy with pneumonia and pain on swallowing.
1. HIV-infected persons should use latex condoms during every act of sexual intercourse to reduce the risk for exposure to herpes simplex virus (HSV) and to other sexually transmitted pathogens (AII). They should specifically avoid sexual contact when herpetic lesions (genital or orolabial) are evident (AII).
2. Prophylaxis of initial episodes of HSV disease is not recommended (DIII).
3. Because acute episodes of HSV infection can be treated successfully, chronic therapy with acyclovir is not required after lesions resolve. However, persons who have frequent or severe recurrences can be administered daily suppressive therapy with oral acyclovir or famciclovir (AI). Valacyclovir also is an option (CIII). Intravenous foscarnet or cidofovir can be used to treat infection due to acyclovir-resistant isolates of HSV, which are routinely resistant to ganciclovir as well (AII).
4. Oral acyclovir prophylaxis during late pregnancy is a controversial strategy recommended by some experts to prevent neonatal herpes transmission. However, such prophylaxis is not routinely recommended. For patients who have frequent, severe recurrences of genital HSV disease, acyclovir prophylaxis might be indicated (BIII). No pattern of adverse pregnancy outcomes has been reported after acyclovir exposures


57. Vaginitis
Yeast Candidiasis Vaginitis (Candida albicans)
DX: KOH or wet smear for fungus monilia, hyphae/spores; positive cultures for Candida fungus     
RX:
1-day regimens:
Diflucan/ Fluconazole 150 mg 1 tab PO 1x only  or  

Sporanox/ Itraconazole 200 mg tab PO bid x 1 day

3-day regimens:
Sporanox/ Itraconazole 200 mg tab PO daily x 3 day
Monistat 3 (miconazole) 200 mg supp. hs x 3 days
Terazol 3/ Tarconazole 80 mg vag supp. x 3 days.
5-day regimen:
Nizoral/ Ketoconazole 400 mg PO bid x 5 days
 
Trichomonas Vaginitis
DX: motile trichomonas on smear
RX:  Flagyl (metronidazole) 500 mg 4 tab x1 or 2 tab bid x 1 day only  (same Rx for partner also) or 500 mg bid x 7 days

Bacterial vaginosis
Gardnerella vaginitis, Corynebacterium vaginitis, Anaerobic vaginosis, Hemophilus vaginitis, non-specific vaginosis
DX:  Clue cells on saline slide, fishy odor, white to gray thin, homogeneous exudate discharge; vaginal pH >4.5.
RX:
Flagyl (metronidazole) PO 500 mg bid x 1  or  2 g in single dose or   Clindamycin PO 300 mg bid x 1 week.
MetroGel-Vaginal metronidazole 0.75% gel 1 applicatorful bid x 5 days,

Organisms: Polymicrobial in nature: anaerobes, Mobiluncus species, G.vaginalis, Bacteroides species, peptostreptococci, & Mycoplasma hominis.

Tx Of Gonorrhea
Cipro 500 mg PO x 1 dose
Cefixine 400 mg PO x 1 dose
Ceftriaxone 125 mg IM x 1
Plus Azithromycin 1 gm PO x 1 or Doxycycline 100 mg bid x 7 days for Chlamydia Rx also

Genital Herpes
For first episode:
Acyclovir 400 mg tid x 7-10 days  or  Valacyclovir 1 gm bid x 7-10 days
For recurrent episodes:
Acyclovir 400 mg tid x 5days  or  Valacyclovir 500 mg bid x 5 days
For suppressive Rx:
Acyclovir 400 mg bid  or  Valacyclovir 500 mg daily

Chancroid: Azithromycin 1 gm PO x1  or  Ceftriaxone 250 mg IM x1

Granuloma-Inguinale
Bactrim DS tb orally BID for a minimum of 3 weeks, or Doxycycline 100 mg PO BID for a minimum of 3 weeks.
Therapy should be continued until all lesions have healed completely.

Syphilis
Benzathin Penicillin G 2.4 million units IM x 1 dose, or Doxycycline/Vibramycin 100 mg PO bid x 2 weeks
For Early Latent Syphilis:  Penicllin G 2.4 million units IM x1 dose
For Late Latent Syphilis: Benzathin Penicllin G 2.4 million units IM x 3 consecutive weeks


58. Alcoholic intoxication
The Stages of Alcohol Withdrawal Syndrome
Stages 1: Onset 6-8 hours
SX: agitation, anxiety, tachycardia, hypertension, N & V, anorexia, headache, insomnia, craving for alcohol, diaphoresis, tremor
Stages 2: Onset 24 hours (may be delayed up to 6 days)
SX: hallucinations (auditory or visual, tactile, olfactory or mixed), illusions, disordered perception, autonomic hyperactivity of stage 1 continues.
Stages 3:  Onset 7-48 hours
SX: grand mal seizures; 3-4% of untreated patients progress to stage 3; more than 50% have multiple seizures; >30% have Delirium Tremens if untreated.
Stages 4:  Onset 3-5 or more days
SX:  Delirium tremens DT, (global confusion, autonomic hyperactivity, hallucinations); 5-6% of patients progress to stage 4; in 15% of these, DT resolve in <24 hours; in 80%, DT usually resolve in <3 days.

Drug regimens for managing Alcohol Withdrawal Syndrome
For mild to moderate symptoms:
Chlordiazepoxide/Librium 25-100 mg q6h PO, then taper down dose (Half life 5-15 h)
Oxazepam/Serax 15-30 mg q6h PO, then taper down dose (Half life 5-10 h)
Diazepam/Valium 5-20 mg q6h PO, then taper down dose (Half life >10 h)

For severe symptoms:
Lorazepam/Ativan 1-4 or more mg q2-4h IV or by IV infusion.  (Half life >10h)
Midazolam/Versed 1-5 or more mg q2-4h IV or by IV infusion (Half life 1-4h)

Adjunctive therapy:

Disulfiram
Thiamine IV for 4 days, fluid & electrolytes (esp. Magnesium), psychiatric evaluation, management of coexisting medical/surgical conditions, nutrition, referral to chemical dependency clinic or rehabilitation program when stable.
Seizure Rx: Lorazepam/Ativan or Diazepam/Valium IV; Dilantin & others as indicated.
Hypertension Rx: Beta-blockers or Clonidine as indicated.
GI bleeding Rx as indicated.


59. Pulmonary tuberculosis
PPD conversion is a change from a negative PPD within the past 2 years to a positive PPD and is associated with a risk >3% per year of developing active DISEASE thus once disease is ruled out the patient should be given INH for 9 months.
If non compliant then weekly therapy for 12 months.
A change by more than 5 mm of induration is considered significant (examiners frequently trick people by saying erythema which has no significance).
There are a few  other risk factors which are  also associated with a higher risk of developing the disease. If anyone has these risk factors he/she should also be treated with INH for 9 months.
Risk factors include:
Steroid ingestion >15 mg/day
Diabetes
Total gastrectomy in the past
IV  Illicit drug use
On dialysis
CXR with evidence of old tuberculosis (healed).

Children < 5 years age exposed to an infective case of TB should be treated too but for 3 months regardless of PPD result.
IF PREGNANT with risk factors-Treat.
Without risk factors-delay treatment until after delivery.
All HIV patients should be treated for 12 months if they are recent converters.


60. Opiate overdose
The opiate intoxication syndrome was first described as a triad of depressed level of consciousness, miotic pupils, and decreased respiration.
Acute heroin overdose is a common daily experience in the urban and suburban United States and accounts for many preventable deaths. Heroin acts as a pro-drug that allows rapid and complete central nervous system absorption; this accounts for the drug's euphoric and toxic effects. The heroin overdose syndrome (sensitivity for diagnosing heroin overdose, 92%; specificity, 76%) consists of abnormal mental status, substantially decreased respiration, and miotic pupils. The response of naloxone does not improve the sensitivity of this diagnosis. Most overdoses occur at home in the company of others and are more common in the setting of other drugs. Heroin-related deaths are strongly associated with use of alcohol or other drugs. 

Patients with clinically significant respiratory compromise need treatment, which includes airway management and intravenous or subcutaneous naloxone. Hospital observation for several hours is necessary for recurrence of hypoventilation or other complications. 

Methadone maintenance is an effective preventive measure, and others strategies should be studied.


61. Acute pulmonary edema
RX of Acute Pulmonary Edema:
Sitting up position
O2 supplement
Morphine 2-5 mg IV (Have Naloxone available prn resp. depression)
Lasix 40-100 mg or Bumetanide 1 mg IV
Nitroprusside IV 20-30 ug/min if systolic BP >100 mmHg.
Digoxin IV; Dopamine, Dobutamine, or Amrinone if needed.
Aminophylline 240-480 mg IV for bronchospasm.
Rotating tourniquets to the extremities if needed. ? Phlebotomies?
Dialysis in renal failure pts.


62. Hypertensive Heart Failure
Treatment Of Hypertesion
Young Pt: B-blockers
Elderly: Diuretics (Thiaside) + ACE I + CA-B
African American: Diuretics
Both eld. & Afr. Americans have low renin + high volume, so they respond poorly to ACE-I.
MI: B-Blockers.
Asthma: CA-Blockers.
Peripheral Vas: CA-blockers
Nonidm: ace-I
IDM: ace-I, B-Blockers contraindicated.
High Cholest: any except high dose of Diuretics & B-blockers without isa.
CHF: ace +diuretics, B-blocker contraindicated.
Pregnancy: Hydrilazine + A-methyl dopa
CHF: B-Blockers (betablockers in no more contrindicated...actually it is the choice).
Elderly + bph: Alpha Blockers.
Drug withdrawl: Clonidine
CAD: B-Blockers.
CRI: lasix
Hyperlipidimia: Alpha blockes (Prazosin, Terazosin)
** The mortality drives your dicision.
** Remember HTN and white coat: send home with BP cuff.
** First time HTN repeat at three different occasion.
** BP 160/110 or higher is always HTN even first time.


63. Dx: right side bacteria endocarditis. A young guy with drug addiction with acute dyspnea.
Infective endocarditis of the right-side heart valves occurs commonly in injection drug users. Right-sided endocarditis involving the tricuspid valve and less often the pulmonary valve and artery may result from IV use of illicit drugs or from central vascular lines, which facilitate entry of microorganisms and may damage the endocardium. Organisms may originate from the skin (eg, S. aureus, Candida sp, coliform bacilli).
Right-sided endocarditis is characterized by septic phlebitis, fever, pleurisy, hemoptysis, septic pulmonary infarction, and tricuspid regurgitation.

Intravenous Drug Users:
1. May be the result of exacerbation of underlying valvular disease with increased opportunity for bacteremia via constant injections (i.e. drug use does not preclude DNV disease).
2. For the majority, results from endothelial damage over time by materials used to “cut” the drugs (i.e. talc). Therefore the tricuspid valve (most common single valve involved in IV drug use endocarditis and “first contact” for these substances) right heart, even pulmonary valve, will be involved in this population.
3. Different organisms:
a. Predominantly Staph aureus, (sometimes MRSA), particularly with tricuspid valve endocarditis
b.Enterococcus faecium (strains resistant to Vancomycin occurring)
c.Gram (-) organisms (rarely HACEK): Pseudomonas; B. cepacia; Serratia; often with regional/ geographic specificity
d.Fungal endocarditis does occur (Candida tropicalis and other non-albicans species)
e.Often have polymicrobial endocarditis
4.Presentation is varied, but may consist of the “classic triad” of Cough, Pleuritic chest pain, and Hemoptysis (may initially resemble pneumonia; reflects embolization to the lung)
5.On exam, the classic findings are missing (pt usually has not had disease long enough for chronic symptoms to appear). Do find fever, isolated tricuspid valve regurgitation.
6.Complications: Relapsing infection even more of a problem since many of the organisms are harder to treat, have developed resistence. Fungi (i.e. Candida) cause huge vegetations and therefore multiple and major emboli, no effective treatment. Heart Failure may be very abrupt as the invading organisms are usually highly virulent.

Diagnostic criteria
Blood cultures, Urine & throat
Echocardiography in diagnosis of endocarditis: “evidence of vegetation”
Transesophageal echocardiogram.
New murmur/ insufficiency
The EKG may show arrhythmias and conduction disturbances. 
Positive diagnosis = 2 major criteria OR 1 major + 3 minor criteria OR 5 minor criteria

Treatment
Treat with 20 million units of penicillin G by continuous intravenous administration, along with gentamicin 1 mg/kg q8h. Once cultures are back, use antibiotics according to the organism isolated.
Endocarditis due to staphylococcus aureus or epidermidis may be treated with nafcillin 2 gin q4-6h for 4-6 weeks and gentamicin 1 mg/kg/q8h for the first 3-5 days.
After 2 weeks of IV therapy, the patient may be switched to oral antibiotics.

Prevention of Bacterial Endocarditis
PROPHYLACTIC REGIMENS FOR DENTAL, ORAL, RESPIRATORY TRACT, OR ESOPHAGEAL PROCEDURES
for oral/dental procedures the initial amoxicillin dose is reduced to 2 g, a follow-up antibiotic dose is no longer recommended, erythromycin is no longer recommended for penicillin-allergic individuals but clindamycin and other alternatives are offered;
Standard general prophylaxis:
Amoxicillin  Adults: 2.0 g; Children: 50 mg/kg PO 1hour before procedure  or
Ampicillin   Adults: 2.0 g IM or IV; Children: 50 mg/kg IM or IV within 30 minutes before procedure
Penicillin-allergic:
Clindamycin  Adults: 600 mg; Children: 20 mg/kg PO 1 hour before procedure.   OR
Cephalexin* or Cefadroxil*   Adults: 2.0 g; Children: 50 mg/kg PO 1 hour before procedure,   OR
Azithromycin or Clarithromycin   Adults: 500 mg; Children: 15 mg/kg PO 1 hour before procedure


64. Dx: UTI and pregnant . Young married woman with urinary frequency and suprapubic discomfort.
Pregnant women with asymptomatic bacteriuria
should be treated with a three- to seven-day course of antibiotics, and the urine should subsequently be cultured to ensure cure and the avoidance of relapse.29 Although amoxicillin is frequently suggested as the agent of choice, E. coli is now commonly resistant to ampicillin, amoxicillin and cephalexin. Thus, treatment should be based on the results of susceptibility tests. Nitrofurantoin or trimethoprim-sulfamethoxazole may also be used; however, caution should be exercised in the third trimester because the sulfonamides compete with bilirubin binding in the newborn.

Most pregnant women with pyelonephritis
should be hospitalized. Initially, these patients should receive intravenous antibiotic therapy. They should complete a 14-day course of acute antibiotic therapy followed by nightly suppressive therapy until delivery. Recent studies have shown that selected pregnant women with pyelonephritis can be treated with either outpatient intramuscularly administered ceftriaxone (Rocephin) or orally administered cephalexin.28 Ceftriaxone, a third-generation parenterally administered cephalosporin, is a suitable agent for inpatient treatment. Tetracyclines and fluoroquinolones should be avoided in pregnancy.


65. Parkinson's disease 
The slow development of bradykinesia & gait disorder
increased tone & muscle rigidity (lead-pipe & cogwheel rigidity)
resting tremor (pill-rolling)
dementia in later phase & depression
Diagnosis
The diagnosis of PD may be difficult in the early stages.
PD is characterized by the presence of resting tremor, rigidity, and bradykinesia, and a good response to levodopa.

It is now evident that many patients who were initially considered to have PD later evolved into a clinical picture more typical of multiple system atrophy (MSA) or progressive supranuclear palsy (PSP).

Differential Diagnosis:
Other causes of parkinsonism, such as head trauma, drug ingestion, carbon monoxide, cyanide, and manganese poisoning, are usually obvious; normal-pressure hydrocephalus and Jakob-Creutzfeldt disease may not be.
Secondary parkinsonism, e.g., resulting from toxic, tumors, infarcts, hydrocephalus, post-trauma, post-encephalitic Parkinsonism, or AIDS, also should be considered in the differential diagnosis but is relatively easy to differentiate from PD on the basis of other clinical criteria.
Drug-induced parkinsonism related to neuroleptic agents should also be considered in the appropriate situation. It is particularly important to recall that metoclopramide (Reglan), which is typically used in ulcer disease, is a neuroleptic agent capable of inducing or aggravating parkinsonism.

Drug therapies
Levodopa + Carbidopa: (Sinemet)  10/100. 25/100. 25/250, 50/500 long acting pill.
Carbidopa (Lodosyn) 25-200 mg /day
Dopamine agonists: Bromocriptine mesylate (Parlodel) 2.5 - 5 mg tab; Pergolide mesylate (Permax) 0.05m - 0.25 - 1 mg tab
Anticholinergics:
Ethopropazine (Parsidol), Benztropine (Cogentin), Biperiden (Akinetin), Trihexyphenidyl hydrochloride (Artane)
Amantadine: Amantadine (Symmetrel) 100 mg tab
MAO-B Inhibitor: Selegiline (Eldepryl) 0.5 mg tab
COMT inhibitors:
entacapone (Comtan) - reduces "wearing-off" time of levodopa.
tolcapone (Tasmar)

In general an L-dopa preparation is the treatment of first choice.
The major indication for use of L-dopa is the incapacity of bradykinesia.  Most physicians introduce L-dopa therapy when symptoms start to interfere with quality of life.
Surgery Therapy  if refractory to drug Rx.
Psychosis in Parkinson's Disease:

In patients with advanced Parkinson's disease, there is also a high prevalence of affective comorbidity. This increase in affective symptoms and the relatively high incidence of cognitive and affective side effects of the antiparkinsonian medications contribute to the increase in psychoses observed in these older patients. The most significant risk factors for developing psychosis in Parkinson's disease are
(1) coexistence of dementia,
(2) protracted sleep disturbances, and
(3) nighttime use of long-acting dopaminomimetics.

The Use of Risperidone for Psychosis and Agitation in Demented Patients With Parkinson's Disease
This pilot study investigated effectiveness and tolerability of risperidone for the treatment of psychosis and agitation in 9 inpatients with Parkinson's disease and dementia. Investigators found risperidone to be effective and safe, without worsening extrapyramidal symptoms or further impairing cognition.

Clozapine, at daily doses of 50 mg or less, is safe and significantly improves drug-induced psychosis without worsening parkinsonism.


66. Dx: acute exacerbation of asthma. (Real Case) A Young man with dyspnea with a past history of asthma due to sudden exposure to pollen or cats and also A 37 yo man with difficulty on breathing,
Dx: acute asthma attack

ABG & chest x ray, bedside spirometry, etc.
* Identify & correct precipitating cause.

A. Bronchodilator Rx
Epinephrine 1:1000 solution 0.3-0.6 ml SQ q30min up to 3x prn.
Terbutaline 0.25 mg SQ (peak 15-30 min, duration 4-6 h)
* Avoid or use cautiously in patients with heart disease or hypertension.
Aerosol Rx:
Proventil (albuterol) 0.5% soln 0.5 ml in 2.5 ml NS q4-6h
Alupent (metaproterenol) 0.3 ml in 2.5 ml NS q4-6h or
Bronkosol (isoetharine) 0.5 ml in 2.5 ml NS q4-6h or
Isuprel (isoproterenol) 1:200 0.5 ml in 2.5 ml NS
Atrovent (ipratropium) 2 puffs q6h
Atrovent 0.5 mg (1 unit dose vial) in 2.5 ml NS q6-8h via nebulizer.

Aminophylline IV 5-6 mg/kg loading over 20 min, then infusion at 0.5-0.6 mg/kg/h
(reduce the dose in CHF, liver disease, elderly, cimetadine pts). Keep level: 10-20 ug/ml.
B. Glucocorticoid Rx:   IV Solumedrol 60-125 mg q6h initially
C. Bronchoscopic removal of mucus plug may be needed.
D. Mechanical ventilator, if:
1. Continuous increase in pCO2 after Rx
2. Continuous deterioration of clinical status, pO2 after Rx
3. Impending respiratory muscle exhaustion
4. Obtundation or coma occurs.

Consider Noninvasive ventilation support as nasal mask/CPAP (Continuous Positive Airway Pressure) or BiPAP bilevel positive airway pressure) with inspiratory pressure of 10 cmH2O and expiratory pressure of 5 cm H2O, adjust by increment of 3 cm H2O to keep paO2 > 90%.
Contraindications to CPAP or BiPAP:
acute facial trauma, agitation, allergy or hypersensitivity to the mask material, coma, excessive airway secretions, hemodynamic instability, high risk of aspiration, inability to cooperate, inability to maintain life-sustaining ventilation if the mask becomes displace, marked cardiac dysrrhythmias, suspected laryngeal or upper airway injury, unstable ventilatory drive.
E. Miscellaneous:  IV infusion of 1.2 gm of magnesium sulfate in 50 ml saline.
F. Supportive care: 1. O2 supplement   2. Hydration   3. Antibiotics if there is suspected infection

Asthmatic child coming to the ER:
O2 mask, IV line
Labs:  CBC, ABG's, CHEM 7
pulse oxymetry
CXR
Spirometry
1. Albuterol inhaled 2 puffs    2. Beclomethasone inhaled 2 puffs 5 minutes after albuterol
If the patient status improve-move to ward room and keep him there for 3 days.Consider chronic maintanance therapy with Cromolyn Na 2 puffs qid and Albuterol inhaled. RAST test before discharge. Recomand removal of allergens.
If the patient status is worsening intubate + mechanical ventilation
epinephrine s.c.
methylprednisolone i.v.
Albuterol inhaled via neb.
move to ICU
vitals monitoring  + ECG monitoring
keep in ICU until improvement +1day
weaning before move, take off iv medication and replace with inhaled medication
keep in ward room for other 3 days.
RAST test
Tx at discharge: Cromolyn Na and Albuterol inh.


67. Dx: NSAID induced gastritis. A middle age woman with epigastric pain.
NSAID including aspirin, they reduce a protective substance in the stomach called prostaglandin. These drugs usually cause no problems when taken for the short-term. However, regular use can lead to a gastritis as well as a more serious ulcer condition. Symptoms of gastritis: pain or gnawing in the upper abdomen, nausea and vomiting. In the chronic phase, the pain may be dull and there may be loss of appetite with a feeling of fullness after several bites of food. Very often, there are no symptoms at all. If the pain is severe, there may be an ulcer as well as gastritis.
Treatment: For most types of gastritis, reduction of stomach acid by medication is often helpful. Beyond that, a specific diagnosis needs to be made. Antibiotics are used for infection. Elimination of aspirin, NSAIDs or alcohol is indicated when one of these is the problem. For the more unusual types of gastritis, other treatments may be needed. Gastritis by itself is rarely a serious problem.


68. Kidney Dx: A 20-year-old white male presents to the Emergency Department with the sudden onset of right flank pain, diaphoresis, nausea and vomiting. The pain is severe, classified as a "15 out of 10" by the patient and radiates to the left testicle. The patient has no prior medical history and his past surgical history is significant for an appendectomy at age 17. He takes no medications and has no allergies. Social history is as follows: chews tobacco occasionally, ingests alcohol socially, no other drug use. He is a college student hired as summer help for the county road crew and lives with his parents.
On exam you find a well-developed, well-nourished male with sunburn on the face, arms and neck. He is in significant painful distress, unable to sit or lie still.
VITAL SIGNS: 130/90 112 24 99.2 po
Skin: diaphoretic
Abdomen: soft, near absent bowel sounds, ? tenderness LLQ
GU: normal male genitalia, both testicles descended and non-tender
LABORATORY DATA: Urinalysis: dip 4+ for blood, micro pending. chemistries including BUN/cr pending
complete blood count pending

Approach to this patient
Differential diagnosis, is initially differential of painful hematuria:
UA has already been requested, that should tell:
If the RBC are:
1.Dysmorphic or there are casts.
2.Normal shaped RBCs
3.Or pyuria
Start IV Hydration and narcotic analgesics
If 1 is true: Serology for ABS of all the antibodies plus C3 and C4.(If this is NL: 24hr urine protein: if this is more than 1 gram,  do GFR and if this is ABNL consider: GAN,exercise hematuria, malignant HTN, IG A nephropathy (If this is ABNL :GFR ADN 24hr  prot more than 1gr
consider renal biopsy: To r/o: Primary GN, Lupus Nephritis, Vasculitis, Goodpastures', Wegeners', Infections )
If 2 is true, which is possible given the clinical presentation: would add 24 hr collection of CA, uric acid and  creatinine (considering one suspects stones) and PH would do an  ABD x-ray ( To R/O stones, Most of the kidney stones are calcified and radiopaque). Then I would do an  IV Pyelography: To confirm stones, radiolucid vs radioplaque.:
If pyelography is normal: Cystoscopy: R/O Tumors, prostatic dx, polyps.
If positive and Cysts or masses: CT + US
If proven calcium: By elevated calcium Excretion+Radiopacity+PH 6.5
Start fluids and if there is HypercalCiuria:
Dietary restriction of calcium, sodium and thiazides
If inceased uric acid excretion, Presumably radiolucent:
Use K citrate to alkanize the urine, better dissolution of the calcium and Allopurinol.
If mixed: Allopurinol + Thiazide
If PH is high and radiopaque, due to Struvite stones (Staghorn Calculi) Hydration, Might need Percuataneous
Nephrolithotomy and Acetohydroximine which is an effective urease inhibitor, plus Perioperative Antiobiotics (Proteus Infection) If Cystine increased: Alkalinization of the urine and Penicillamine and tiprim.
PYURIA: C & S: if negative, think about INTERSTITIAL NEPHRITIS. If +ve: BAC. INFECTION, TB. TREATMENT.
 


69. Obesity with Hypertension
Obesity with hypertension at the office, In the first visit not generally labelled as hypertensive. (Of course also depends on the BP if it is sky high treat it). However the work-up is carried out as follows:
CBC, Hct, Blood Glucose, Serum Creatinine, Uric acid, Serum electrolytes, (Lipids Fasting) and triglycerides, UA, EKG, CXR To be labelled as a hypertensive, BP has to be recorded in three different time and should be consistently high. However, in the first visit advice possible life style changes and non-pharmacologic methods.
Weight
Exercise: particularly in this case
Stop smoking, alcohol consumption to be decreased
Diet: restrict sodium, cholesterol, and saturated fat.
Appointmet for next visit by then you will have your results and guage the patient and start an appropriate regimen.
one more point on obesity itself Rx of obesity multidisciplinary approach to wt loss., hypocaloric diets, behaviour modification, aerobic exercises and social support, emphasis on maintenance of wt loss.


70. BPH: medical and surgical treatment indication and adverse effect
Benign Prostatic Hyperplasia: Nonmalignant enlargement of the prostate gland with age.
Benign prostatic hyperplasia (BPH) is clinically evident in 50% of men by age 50 and in 80% by age 80. Androgens, particularly dihydrotestosterone, appear to play a major role.
Hyperplasia of the prostate, with subsequent increase in the fibromuscular stroma, results in a narrowing of the urethral lumen as it traverses the prostate (static component). This narrowing creates bladder outlet obstruction.

Symptoms, Signs, and Diagnosis
Symptoms of bladder outlet obstruction due to BPH include hesitancy, weakness of urinary stream, intermittency, and a feeling of incomplete bladder emptying. The bladder tends to become more irritable, manifested by urinary frequency, nocturia, and urgency.
Initial evaluation should also include a history and digital rectal examination along with urinalysis and measurement of the serum creatinine level. Digital rectal examination may disclose enlargement of the gland, prostatic firmness, or a nodule, which increases the suspicion of prostate cancer.
A blood test to measure serum creatinine should be performed to assess kidney function. A urinalysis that reveals > 4 red blood cells per high-power field in uninfected urine requires intravenous urography and cystoscopy to rule out kidney or bladder cancer. An abdominal ultrasound may help differentiate obstructive from renal causes of an elevated creatinine level. Further diagnostic testing (eg, uroflowmetry, postvoid residuals, more complex urodynamic evaluation) may also be necessary.
Measurement of serum prostate-specific antigen (PSA) is not part of the diagnostic evaluation of BPH but may help exclude prostate cancer as a cause of urinary tract obstruction.

Treatment
BPH should be treated when symptoms are sufficiently bothersome or when evaluation discloses recurrent urinary tract infection or an increased creatinine level. Absolute indications for treatment, such as refractory urinary retention, are discussed below. Treatment usually starts with drug treatment. However, for patients with urinary retention, surgery may be appropriate initial treatment, because it maximally reduces outflow resistance.

Drug treatment: Drug treatment usually results in minimal objective improvement but significant symptomatic improvement. Selective and uroselective a-blockers reduce the dynamic component of obstruction. Selective -blockers block 1a and 1b subtypes equally. By blocking the 1a receptors of smooth muscle at the bladder neck, these drugs decrease outlet resistance. By blocking 1b receptors, these drugs may cause cardiovascular adverse effects, particularly hypotension. Dose titration over several weeks avoids hypotensive episodes. Uroselective -blockers have at least a 30-times greater affinity for 1a over 1b subtypes. They do not, therefore, require dose titration and have little effect on blood pressure.

Terazosin and doxazosin are selective -blockers; they are available in titration packs, which may make prescribing easier. The drugs are taken once a day at bedtime, thereby minimizing adverse effects of postural hypotension (in 6 to 8% of cases) and tiredness (in 6 to 10%). Other adverse effects include asthenia (in 6 to 10%) and dizziness (in 5 to 10%). Adverse effects tend to be minor and reversible through dose reduction. Tamsulosin is a uroselective -blocker. The dosage is 0.4 mg daily, one-half hour after the same meal each day. The incidence of cardiovascular adverse effects is low. In responsive patients, symptoms generally improve within a few days.

The 5-a-reductase inhibitor finasteride inhibits the conversion of testosterone to dihydrotestosterone. It shrinks overall gland size, thus reducing the static component of obstruction, and decreases obstructive events and the need for surgery in glands > 50 g. A 3-month trial is necessary to determine if finasteride is effective. The adverse effects of finasteride are minimal. About 5% of patients develop sexual dysfunction (ie, decreased libido, decreased ejaculatory volumes, erectile dysfunction). Finasteride also causes a 50% reduction in the serum PSA level; thus, a normal PSA level in men treated with finasteride is one half that of men not treated with this drug.

Minimally invasive therapy: New ablative technologies do not require that patients be hospitalized or given general or regional anesthesia. The effectiveness of these technologies is being evaluated. These technologies use different energies (eg, microwave, radiofrequency, ultrasound) to destroy prostatic tissue. A transurethral device (catheter) is placed after the patient is given local anesthesia or conscious sedation, and the surrounding prostatic tissue is heated to 60 to 100° C (140 to 212° F), causing tissue death. Cystoscopy performed months after an ablative procedure often does not show much obvious visual improvement; however, follow-up over several years has found sustained efficacy using subjective factors (eg, urinary frequency, nocturia).

An intraprostatic stent (a titanium alloy mesh tube) can be placed under local anesthesia inside the prostatic urethra, opening the urethra. Its placement has been suggested for elderly debilitated men poorly able to undergo anesthesia. Unfortunately, if an infection develops within the stent, surgical removal would be necessary. Surgical removal may be traumatic and challenging, requiring regional or general anesthesia.

Surgery: Surgical treatment remains the gold standard for symptomatic BPH. It provides the most reliable and immediate subjective and objective improvement. Surgery is recommended when BPH causes renal insufficiency, recurrent retention, recurrent urinary tract infection, bladder calculi, or gross hematuria. Hydronephrosis or a postvoid residual volume > 500 mL may also require surgical treatment. Open prostatectomy is usually reserved for patients with large prostate glands (> 100 g) or in whom other pathology (eg, a vesical calculus) exists. It requires an abdominal incision and longer convalescence than transurethral approaches. Transurethral resection of the prostate (TURP) is less invasive than open prostatectomy but requires regional or general anesthesia in an inpatient setting. Its complications include infection, bleeding, and a 20% risk of reoperation within 10 years. Retrograde ejaculation after surgery is usual, whereas impotence or incontinence is rare. Transurethral incision of the prostate (TUIP) is best for patients with glands < 30 g and obstruction at the bladder neck. The complications of TUIP are the same as those of TURP but are significantly less severe and less frequent.


 71. Scoliosis : Dx and Tx
A structural lateral curvature of the spine.
Sixty to 80% of cases occur in girls. Two to 3% of children aged 10 to 16 yr have detectable idiopathic scoliosis. Scoliosis may first be suspected when one shoulder seems higher than the other or when clothes do not hang straight, but is often detected on routine physical examination. An initial complaint may be fatigue in the lumbar region after prolonged sitting or standing. This may be followed by muscular backaches in areas of strain, such as the lumbosacral angle. Pain is uncommon in adolescents with idiopathic scoliosis and therefore requires further evaluation.

The spinal curve is more pronounced when the adolescent bends forward. Most curves are convex to the right in the thoracic area and to the left in the lumbar area, so that the right shoulder is higher than the left. One hip may be more prominent than the other. X-ray examination should include anteroposterior and lateral views of the spine with the patient standing.

Complications are related to the type of curve: the greater the curve, the greater the likelihood of progression after skeletal maturity. Prognosis depends on the site and severity of the curve and the age of onset of symptoms. Fewer than 10% of cases require active treatment.

Prompt referral to an orthopedist is indicated, and treatment includes preventing further deformity (eg, with a cast or Milwaukee brace) or surgically correcting the deformity. Scoliosis and its treatment may interfere with the adolescent's self-image; wearing a brace may cause self-consciousness. The primary care physician's role for adolescents with scoliosis, in collaboration with an orthopedist, includes diagnosis and counseling about treatment options and adjustment.


72. Pregnant woman: risk of plane travel, how dangerous, what risk, when safe etc.
Screening in pregnancy
* Hepatitis B & C
* Syphilis
* HIV: Screening (HIV test) should be offered to every woman who gets pregnant. If positive, Zidovudine prophylaxis should be started during the latter half of pregnancy. IV zidovudimne must be given during labor and the newborn must be given Zidovudine for 6 weeks.
* Gestational Diabetes screening : Glucose Tolerance Test - 26th -28th week
Three percent of pregnant women will get gestational diabetes. Symptoms are minimal. Treatment is necessary to prevent macrosomia (big baby), congenital defects and SIDS. All pregnant women should be screened using a random glucose test. 15 percent of women have high glucose levels on this screening test, but only a small percentage of these women will actually have gestational diabetes when further testing is done.
* HTN
* Group B Streptococci (GBS) Test - between 35 and 37 weeks
Nearly 30% of women have this colonizer bacterium in the GIT. Vaginal and rectal swabs are taken for Group B Streptococci. GBS can cause meningitis or other serious infections in neonates. If positive for GBS, the mother is given Ampicillin IV during labor. Also IV Ampicillin should be offered to mothers whose membranes rupture before they can be tested, those whose membranes rupture occured 18 or more hours before delivery or temp >100.4F during labor. The antibiotic should be given as soon as labor starts. Use Clinda IV in PCN allergic.
* Asymptomatic bacteruria: Screening is done in the first trimester. If positive, treat with Amox/Nitrofurantoin/Oral Cephalosporin. Then check every visit.
* Wt gain
* Proteinuria
* Fetal heart sound


73. Dx: H. Pylori duodenal ulcer.(Real CCS Case) A middle age man with burning sensation with eating.
Risks factors for acquiring Helicobacter pylori infection.
Infected Parents (increase a child's risk of getting infected), overcrowding, poverty, increased infection with age, occupation (bronchoscopist, gastroenterologist, ENT) are risk factors for acquiring H. pylori infection.
H. pylori has been implicated strongly as the antigen which initiates gastric MALT (mucosa associated lymphoid tissue) lymphomas (B-cell lineage). Nested case control studies have implicated it as a factor in the development of Type I gastric adenocarcinoma.

DX of H. pylori:
A. H. pylori serology (80 - 90% sensitivity & specificity)
B. Breath test with 13C or 14C labeled urea to drink. (94 - 98% sensitivity & specificity)
C. Stomach or duodenal mucosa biopsy urease test or histologic identification of organisms or culture of biopsy.

THERAPY FOR HELICOBACTER PYLORI:
The ONE WEEK  3-drug regimen is recommended as first-line therapy for eradication of H.pylori in patients who test positive:
Amoxicillin 1 gm BID , or Metronidazole/Flagyl 500 mg BID plus
Clarithromycin /Biaxin 500 mg BID, plus
Pantoprazole (Protonix) 40 mg BID

The 10-day regimen with
Omeprazole /Prilosec 20 mg  BID or Lansoprazole 30 mg bid
Clarithromycin /Biaxin 500 mg BID
Metronidazole 500 mg BID or Amoxicillin 1 gm bid
has 87-91% cure.

Other FDA-approved Rx options (as of July 1998):
Lansoprazole 30 mg bid + Clarithromycin 500 mg tid + Amoxicillin 1 gm BID x 10 days


74. Pulmonary sarcoidosis
Triad diagnostic of Sarcoidosis and needs no tissue confirmation. It consists of Bilateral hilar adenopathy, Erythema nodosum and polyarthritis.
90% of patients have pulmonary involvement and commonest presentation being BILATERAL HILAR ADENOPATHY.
For tissue diagnosis biopsy lesions other than erythema nodosum.
Steroid therapy (>6 months therapy)is indicated if patient has any of the following:
CNS or CARDIAC involvement, uveitis, Cosmetic disfigurement, hypercalcemia or hypercalciuria significant enough to cause renal impairment.
Pulmonary sarcoidosis should only be treated if there are respiratory symptoms or extensive involvement as per CXR or PFT.
Cough due to endobronchial lesions can be treated with inhaled corticosteroids.


75. Spleen rupture:
Bedside Abdominal U/S, DPL (for unstable), CT (for stable) and emergent surgeon consult.
Chest x-ray, supine & erect abdomen x-ray.
CBC, typing and cross matching, reserved the blood at least 3 pint. BT, PT, aPTT
LFT, Glucose (glucometer), electrolyte, bun, creatine, UA, HIV test, serum amylase, ABG, blood ethanol, urine drug screens.
Emergency call for surgeon
Vital, Cardiac, and BP monitoring on bed side. Foley cather and Urine output check.
NPO, Ringer's lactate sol. IV before results from Lab.


76. Lithium Toxicity
1) Lithium usually becomes effective after a lag time of from 7 to 10 days.
Pt comes to ER with nausea, vomiting, diarrhea, unsteady gait. Resting tremor - the earliest sign of toxicity

PE: Tachycardia, nystagmus, dysarthia, hyperreflexia, fasciculation and ataxia.

2) It will induce leukocytosis (so baseline CBC), EKG: Tacy, Lithium level (.08-1.2), Lithium-induced hypothyroidism (TSH level), Moniter RFTs, BUN and creatinine
3) Management: Hold Lithium. If Lithium level < 2.5 start IV hydration with normal saline & correct lytes.

If Lithium level > 2.5 stat Hemodialysis.


77. Management of DM type II as - Office:
A 50 year old obese women came to your office complaining of fatigue and blurring of vision.

Lab tests:
CBC
Blood glucose (fasting and random or postprandial)
Urine analysis ( for microalbumin, ketones, sugar)
HbA1C
Lipid profile

The patient is considered diabetic if fasting blood glucose is higher than 126 mg/dl or if the postprandial blood glucose is higher than 200 mg/dl. The goal is to keep the blood glucose below these levels.

Management:
-Educate the patient:
-Diet modification
-Weight reduction/Exercise plan
-smoking and alcohol cessation.

* Consider hypoglycemic drugs if the dietary and exercise therapy fail:
Sulphonylurea hypoglycemic drugs (Glibizide, Tolbutamide, Chlorpromide) or Metformin. Both if blood glucose is high.

- If the patient has HTN-----> consider captopril (ACE-I is of special benefit in hypertensive DM patient becuase it preserves renal function ) . 
-If the patient is hyperlipidemic ----> consider Pravastatin (Pravachol 40 mg QD) (HMG-COA reductase) for the elevated LDL combined with gemfibrozil (Lopid 600 mg bid before meals) for the elevated triglycerides.

- Refer to ophthalmologist to monitor for retinopathy or any vision problems.

- Refer to Podiatry (if has a feet lesions) and Nutritionist to reinforce your advise.


78. CHILD ABUSE

PE: Complete examination
If abuse is suspected during the PE, Admit the child in ward room
labs: CBC PT PTT Bleeding time
CXR, skeletal Xrays, and Skull Xray
Ophthalmologic consult for retinal hemorrhages
Refer the patient to Social worker and Report to local authorities

SPOUSAL ABUSE
PE: As above.
Aside for specific investigations & tx suggested by P/E refer the patient to victim assistance service
Type (educate the patient) and then select (safety plan) It is very important in spousal abuse.

Elderly Abuse
Investigations and tx suggested by P/E, then referral to elder protective services.
N.B. whenever you are uncertain about were you should refer the patient type: "refer the patient" and choose from the list.


79. A 29 y/o female pt. with a panic attack. Chest pain, sob, an imminent sensation of death.
Admit the pt to the  ER order EKG, ABG, CBC, Chem 7, TFT. UA with Urine tox. 

Every thing was normal. Mild tachycardia.

Start Pt on xanax 0.5 mg 1 tb TID prn.

Educate Pt about her dx. and Relaxation.

D/C home. F/U appt in the office

Dx: Panic Attacks. 


General Cases
1. A 13 month old child brought for a routine visit. How do you proceed with this case?
A: Measure and plot on a standard chart the head circumference, length, weight, and weight for length. Share the information with the parent. Examine the toddler's feet and observe his walking and gait. Reassure the parent about normal variations. As part of the complete physical examination, the following should be noted:
-Nevi, cafe au lait spots, or birthmarks
-Tooth eruption, caries, baby bottle tooth decay, or dental injuries
-Excessive injuries or bruising that may indicate inadequate supervision or abuse
-Other evidence of neglect or abuse
Assessment of risk of high-dose lead exposure (living in old house).
Tuberculin test (PPD) (If performed at 12 months)

Lab: CBC,UA, sedimentation rate, and MMR vaccination & PPD (having contact with tb, malnutrition)
Immunizations are these:  but the 13 month old must be told to come back at 15 for such immunizations.
Hemophilus Influenza Type b (Hib) Vaccine #4 (If administering certain combination vaccines and not administered at age 12 months)
Diphtheria, Tetanus, Pertussis (DTP) Vaccine #4 (Hib and DTP can be combined)
Hepatitis B Virus (HBV) Vaccine #3 (If not administered previously)
Measles, Mumps, and Rubella (MMR) Vaccine #1 (If not administered previously)
Varicella (chicken pox) vaccine (If it was not administered previously)
Ensure that immunization status is up to date


2. A 5 yr old child brought for a routine visit just before joining the school.
A: Measure and plot on a standard chart the height, weight, and weight for height. Share the information with the parent. As part of the complete physical examination, the following should be noted:
Caries, developmental dental anomalies, malocclusion, pathologic conditions, or dental injuries
Evidence of neglect or abuse
Assessment of risk of high-dose lead exposure
Vision screening (Vision screening guidelines appear in appendix F)
Hearing screening
Assessment of risk for hyperlipidemia
Annual tuberculin test (PPD) if any of the following risk factors are present:
-Low socioeconomic status
-Residence in areas where tuberculosis is prevalent
-Exposure to tuberculosis
-Immigrant status
Blood pressure screening
Perform tuberculin test (PPD) once before school entry at four to six years of age
Ensure that immunization status is up to date
Administer once before school entry at four to six years of age: Diphtheria, Tetanus, Pertussis (DTP) Vaccine #5 (The acellular DTaP Vaccine may be substituted)
Oral Poliovirus (OPV) Vaccine #4
Measles, Mumps, and Rubella (MMR) Vaccine #2
 
3. Peds - 1 year old baby in respiratory distress with history of asthma in the family. On closer inspection it is a foreign body aspiration.

4. Diabetic - A 30 yo diabetic male in routine office visit. Involved patient education, hypertension control, and lipids control.

5. Cardiac - A 32 yo woman with SOB and chest pain on exertion. Involves stress test and prescription for a anti-anginal along with anti-hypertensive agent.

6. Gyn- A 25 yo sexually active female with vaginal discharge. This is a lady with cervicitis and requires out patient treatment with abx. Doxycycline PO and ceftriaxone IM.

7. Renal Cell Carcinoma - An obese 45 yo black female comes to clinic with fatigue and anemia. Studies revealed RCC.

8. PUD - A 28 yo black female comes to clinic with hx of NSAID use for back pain. Rectal shows hemoccult positive stool. Prescribe ppi and refer to EGD.

9. Aortic Aneurysm Case - A 58 yo woman with chest pain.C-Xray reveals widened mediastinum. Hypertensive and in excruciating pain. Start Nitroprusside to lower BP and vascular consult nailed the case. Don't forget to get other tests to r/o mi etc.

SCREENING TEST BREAST 
1) age18 : self breast exam every month
2) age 18-35: clinical breast exam every 3 yrs and self breast exam every month
3) age 35-40: Baseline mammogram with clinical breast exam every 1 yr and self breast exam every month
4) age 40-49: mammogram every 2 years, clinical breast exam every 1 yr and self breast exam every month
5) age50 : mammogram every 1 year, clinical breast exam every 1 yr and self breast exam every month

NOTE: For Women considered to be high risk (1st degree relative with breast cancer) move the schedule up by 10 yrs.


FINAL WORDS

** In CCS cases, they usually throw the common cases you encounter in your training as a doctor. In approaching a case you first assess the situation. If the patient is seen in the clinic and complaining of extreme abdominal pain, it may be prudent to transfer to ER right away before ordering test. As per ordering labs, think of what the particular test is going to contribute in arriving at a particular diagnosis before ordering it. If there are 2 or more equally sensitive tests, pick the readily available and cheaper one (these is also true on mcqs). Always try to re-assess the patient on follow-ups (i.e. check abnormal PE findings seen initially if it's still there). If the computer does not prematurely closes an in-patient case and patient seems stable, arrange for discharge and follow-up as out-patient. Change all IV meds to oral just like in real practice when the patient is getting better. (eg. IV Ceftriaxone to oral cefixime in patient hospitalized for pneumonia once WBC count has fallen and patient is afebrile). Counsel the patient always when you have the chance.


** Please pay close attention to time management.

** MCQs are basically long questions. A lot of them are psyc. and peds questions and a few ob/gyn. A lot of questions are on glucocorticoid administration in pregnancy. A 35-50 ER question.

** I should say there is no point in taking this exam without being excellent in hypertension and DM. Think all the premutations and combination of diseases with HTN plus the drug interactions of each HTNsive and how you treat. peds was also extensive but most of them about viral illness. 

** Study immunization schedules as well as indications and contra indications of vaccines.