Step2 CK Notes

No t e b o o k: Cre at e d: Exam Threads 3/10/2013 2:26 PM Up dat e d : 4/5/2013 2:12 PM

CARDIOVASCULAR Prolonged QT interval: Cause: Hypocalcemia, toxins, hypothermia, medications, SAH if <1/2 RR usu. safe. May cause torsades de pointes -> Mg Jugular Venous distention: JVD>7cm above sternal angle, RA Pressure Kussmauls sign (JVP with inspiration): RV infarction, post op cardiac tamponade, tricuspid regurgitation, constrictive pericarditis LVH + ST >1mm ANY reason -> precludes routine stress testing, use nuclear imaging Cor Pulmonale - Pulm HTN -> RV hypertrophy, dilate -> peak P wave, right axis dev, R in V1-V3, S in V6, ST-T changes AF+ risk factor (stroke, TIA, HTN, LV dysfunction, CAD, rheumatic MV disease, prosthetic valve, diabetes, thyrotoxicosis) -> warfarin (INR 2-3) **prosthetic valve: INR 2.5-3.5 SVT: Adenosine (short t1/2. initial dose 6mg->12mg minutes later if need) work for 90% if not cured - BB, CCB (only diltiazem/verapamil), Digoxin VT due to cardiac ischemia -> Amiodarone *(1) may cause HYPERthyroidism(2) ankle edema WPW: avoid BB, CCB, digoxin Mgmt acute: stable - procainamide, amiodarone, unstable - immediate sync cardioversion Mgmt long term: ablation may try adenosine BNP: brain-natriuretic peptide sensitive to LV dysfunction (>500) CHF: avoid NSAIDs (retention + vascular contraction) cilostazol (medication for claudication, phosphodiesterase inhibitor, increase exercise tolerance) contraindicated for increasing HR K+ and Digitalis compete for myocardial binding site -> K+ increase in blood = digoxin activity Peripartum / postpartum cardiomyopathy: last trimester or <6mo after delivery, most common 1mo before/after delivery of pts recover completely mortality 20-30% avoid future pregnancy ACEI contraindicated in pregnancy Cardiomyopathy Tx Dilated Hypertrophic Restrictive ACEI, BB *NO CCB! BB CCB ICD most effective to prevent sudden death Palliative only Heart murmur with preload (valsalva) : (1) Hypertrophic cardiomyopathy (2) MV prolapse Prinzmetals angina: Definitive Dx: Ergonovine during angiography -> trigger vasospasm Tx CCB (prevent recurrent vascular spasm) or Nitrates Sumatriptan is vasoconstrictive and containdicated NSTEMI: Troponin I, Troponin T or CK-MB begin to @4h Clopidogrel: loading dose 300-600mg then 75mg daily ACEI not used within 24h of acute MI to avoid shock Streptokinase: allergenic should not be given repeatedly

Post MI arrhythmias: *bradycardia (sinus) common after M, caused by vagal tone -> atropine *VT caused by cardiac ischemia -> amiodarone *slow V tach, R60-100 develops in 25% post MI -> benign Lifestyle change - HDL is most sensitive in cholesterol board Thiazide cause K+ and uric acid in the blood 2nd dyslipidemia: DM, hypothyroidism, obstructive liver Dis, Chronic RF, medications 2nd HTN: Cushings syndrome, Conns syndrome (hyperaldosteronism), Aortic coarctation, Pheochromocytoma, stenosis of renal arteries Labetalol for HTN emergencies not to be used on asthma pt, for 2 blockade Echocardiography is sensitive and specific for pericardial fluid CCB + BB = bradycardia, contraction disturbances ACEI may worsen R failure in renovascular HTN, azotemia, not in angioneurotic edema pt. NSAID weakens BP effect of ACEI Coxsackie B virus is the most common cause of pericarditis in North America Prophylaxis of infectious endocarditis(IE): Hx of previous IE Pt with prosthetic heart valves Pt with unrepaired congenital cyanotic heart disease Pt with prosthetic graft not yet endothelialized (<6mo) One time screening for AAA: 65-75 yo, male, with any history of smoking Severe MVR + pulmonary edema -> use vasodilator (ACEI) , LV afterload to anteflow Pt had DVT during pregnancy and on heparin: continue for 6 weeks LWMT or warfarin Enoxaparin: 1mg/kg bid subcutaneous Aneurysm >5.5 cm - surgical repair ASD - fixed split S2 Warfarin + TMP-SMX: warfarin effect cause bleeding Rheumatic fever: 5 major criteria: chorea, carditis, erythema marginatum, subcutaneous nodules and migratory polyarthritis. Fever is a minor criterium Bifid pulse - Hypertrophic cardiomyopathy Pulsus alternans - severe CHF Pulsus paradoxus - constrictive / restrictive heart disease or pericardial disease Wide pulse pressure - aortic insufficiency DERMATOLOGY Type I hypersensitivity reactions: IgE mediated first and fast - diphenhydramine Eczema - risk of asthma Reiters syndrome: a type of reactive arthritis happens in reaction to a bacterial infection in the body. Characterized by arthritis, urethritis and conjunctivitis Seborrheic dermatitis - Pityrosporum ovale; symptom worsen in Winter suspect HIV in severe young pt. Tx can use both steroid or antifungal, coal-tar shampoo Psoriasis common exacerbating factors: stress, medication, injury of skin 1st line tx: high potency steroids i.e. fluticasone (w/o joint involvement) Topical calcipotriene (avoid face and mucous) Urticaria: acute- bugs, drugs, food; chronic: pressure, cold, vibration (idiopathic in most cases) Systemic antihistamines: loratadine, fexofenadine, cetirizine Erythema Multiforme: red rings (small) DDx: Lyme dis -red rings larger than 5cm, multiple Tx: symptomatic only, usu, resolve in 4-6 wks Behet's disease - genital ulcer + oral ulcer + uveitis -> fatal due to vascular aneurysms False +VDRL: erythema nodosum or SLE

Celiac sprue: IgA. - osteopenia, Iron Deficiency Anemia, Type I DM, protein Tx: Dapsone sulfones or sulfonamides Can have rice/corn (gluten free) Impetigo can cause nephritis but not rheumatic fever Tx. topical bacitracin or mupirocin, or oral dicloxacillin /cephalexin Strawberry tongue: in scarlet fever or Kawasakis Fungal infections: best initial test - KOH, most accurate test - fungal culture (4-6wks) Emp Tx: no hair/nail - topical ~conazole hair/nail - topicals dont penetrate - oral terbinafine or itraconazole Onychomycosis - nail fungus infection - terbinafine 6 wks hands 12 wks feet HAIR-AN syndrome: subset of PCOS: hyperandrogenism, insulin resistance, acanthosis nigricans Lichen Planus: may appear suddenly, intensive pruritic, low-grade fever Basal Cell Carcinoma - low risk cancer, no metastasis Melanoma: malignancy related with the thickness of lesion, unpredictable metastatis Mycosis Fungoides (cutaneous T-cell lymphoma) a rare type non-Hodgkins Photopheresis: FDA approved for T-cell lymphoma Buffy Coat + platelets separated from blood, chemically treated with 8-methoxypsoralen, exposed to UV, returned to Pt Photochemically demaged T-cell -> induce cytotoxic effect on T-cell formation Rash on palms and soles: consider (1) rocky mountain spotted fever tick is the vector, recent camping Hx fever + myalgias + macular rash with petechial lesions (2) 2nd Syphilis (-) fever, (-) myalgia Drugs can cause urticaria erythema multiforme SJS TEN penicillin, sulfa, allopurinol, rifampin (rifampicin) Acne: Benzoyl peroxide (topical cleanser) Retinoic acid Add topical erythromycin / clindamycin Switch to oral minocycline Switch to oral accutane, isotretinoin (teratogenic) Granuloma annulare - self limited, not contagious, inj. corticosteroids (oral not effective) ENDOCRINOLOGY DM - gastroparesis common; scintigraphic gastric emptying study worsen by amylin analogue (pramlintide) and glucagon-like peptide 1 (exenatide) Monofilament test for neuropathic foot ulcers Bariatric surgery for BMI >35 usu. resolves DM Metformin - 1st line DM type 2 Tx TZD contraindicated in CHF (cause fluid retention), relative contraindicated in pregnancy Exenatide not for elderly Metabolic Syndrome: LDL>4.13mmol/L and 2+ risk factors = Tx required Low TSH level >65yo risk of hip/vertebral fracture TSH<10mu/l no symptoms subclinical TSH receptor immunoglobulins Graves TSH R-blocking Ab Hashimotos Propylthiouracil usually cause mild leukocytopenia no need to discontinue. Rarely cause agranulocytosis (infection) monitor CBC and differential Liver injury possible, renal injury not associated

Choice for woman may become pregnant Methimazole - preferred in Men or non-childbearing age women TPoAb (thyroid peroxidase autoantibody) exist in 90-95% autoimmune hypothyroidism Levothyroxine 500mcg bolus+50-100mcg/d lead to TSH risk of hip fracture Prolonged use of phentoin osteoporosis ( hepatic metabolism of Vit D) Long steroid Tx users (>3mo, >5mg/d) Vit D + Ca + bisphosphonate therapy Canadian Recommendation: Age >50 - daily Vit D 400 IU Vit D deficiency low serum Ca2+ elevated iPTH (1) alkaline phosphatase (2) normal ionized Ca2+ Hyperparathyroidism - Lab Hypercalcemia, hypophosphatemia, hypercalciuria If Ca in urine suggest other etiology Cushing reflux: trial of HTN, Bradycardia and Resp. depression, in Pt with ICP Adrenal Insufficiency: Cortrosyn stimulation test Hyperaldosteronism HTN: esp diastolic aldosterone/plasma renin activity ratio (if >30 strongly suggest) Ambiguous genitalia - check newborn for congenital adrenal hyperplasia - immediate fluid resuscitation and salt repletion Incidental adrenal mass: if >1cm 1st step determine functioning or not serum metanephrines (pheochromocytoma) dexamethasone suppressed cortisol (Cushings) EPIDERMIOLOGY Intranasal live, attenuated influenza vaccine is an option for healthy, Non-pregnant 2-49 yo Screening in CAN: M/F>65 yo or F 50-64 with risk factor of fracture DEXA screening Preschool speech screening: insufficient evidence to support or against Chance corrected agreement : Kappa =(P0-Pc)/(1-Pc) P0: observed agreement; Pc: chance agreement GASTROINTESTINAL Gilberts syndrome: BIL (indirect) impaired glucuronyl transferase activity Dubin-Johnson Disease: Benign liver disease - Direct BIL In adult, lower esophageal sphincter is the most common site for impactions Glucagon may relax smooth muscle allow pass Tetracyclines esp. doxycycline associate with esophagitis in elderly ( peristaltic clearance) Achalasia - no pain swalling Barretts esophagus - <1% risk of esophageal adenocarcinoma, endoscopy dont risk of death Route-en-Y operation may lead to iron/VitB12 deficiency Diarrhea DDx: (1) incontinence of stool (2) rectal urgency (3) incomplete evacuation (4) bowel movement immediately after a meal Travellers Diarrhea: E Coli Mg, NSAIDs, Antibiotics, HTN drugs, Arrhythmia drugs may cause diarrhea Campylobacter Jejuni: the most common etiology of infectious diarrhea Tx Erythromycin Clostridium Difficile: Pseudomembranous Tx PO metronidazole or vancomycin Entamoeba Histolytica: History of endemic visit - NO steroids! may cause fatal perforation Carcinoid syndrome: 5-HIAA >100mg/24h very specific diagnostic (normal <8mg/24h) IBS: rarely awaken pt from sleep; uncommon vomiting, sig. weight loss, constitutional symptoms Sigmoid volvulus: sigmoid scope decompression is therapeutic Strep. Bovis is associated with colon cancer Ogilvie Syndrome pseudo obstruction: elderly M>F parasympathetic dysfunction associate with trauma/ surgery+bed rest

Tx: naso-gastric tube to decompress stomach, relieve vomiting, surgical decompression with flexible colonoscope Bloody stool in elderly colon cancer until proven otherwise; CEA more useful to follow up Colon cancer: depth of invasion is important for prognosis; Rad Tx usu. for rectal cancer recur PUD is responsible for 45% of upper GI bleeding CD and UC: noncaseating granulomas only on CD no barium on acute UC - risk of perforation avoid antidiarrheal agent in UC - toxic megacolon Risk factor for cholesterol gallstone: F>M, Age , Obesity, Pregnancy, OCP or hormone tx, Rapid weight loss, Crohns disease, TG Primary biliary cirrhosis: antimitochondrial antibody test - sensitive and specific if >1:40 Pancreatic necrosis high level of c-reactive protein Alcoholic Ketoacidosis (AKA): (1) Chronic alcohol abuse + binge drinking (2) little or no recent food intake (3) had persistent vomiting (AG : Na -(HCO3+Cl) >12) Mainstay Tx: hydration with 5%Glucose in normal Saline Megestrol for appetite stimulation may result in adrenal suppression Hepatic adenoma: rarely ruptures or cancerous, common seen in childbearing age using OCP HEMATOLOGY Heparin overdose: PT/aPTT not sensitive; anti-factor Xa can be measured in renal failure pts Warfarin does not cause depression UFH in DVT bolus 7000-10000 then 10000-1500/h Clumped platelet in Lab - change anticoagulant and re-test Use DDAVP: restrict fluid to avoid hyponatriemia Heparin induced thrombocytopenia: NO heparin (even low molecule), NO warfarin (skin necrosis / venous gangrene); Use lepirudin TTP following virus infection - most resolve spontaneously Anemia: in elderly, most common reason is chronic disease Howell-Jolly body in RBC smear - asplenia (sickle cell anemia) Sickle cell disease - indication of a 2nd dose pneumococcal polysaccharide vaccine in children May cause avascular necrosis SCD+fifth disease(parvovirus B19) - aplastic anemia Thalassemias - Schistocytes not likely to be seen, normal RDW With -thalassemia major, increased hemoglobin 2 With -thalassemia minor, normal Hb electrophorosis PCV (polycythemia vera): erythropoietin 2nd polycythemia: erythropoietin Normal or Needle aspiration biopsy is insufficient to diagnose suspected lymphoma Tumor lysis syndrome: K, Phos, Uric Acid ; Ca Multiple myeloma: age mean = 61; bone pain at REST raise concern of malignancy Mesothelioma exposure to asbestos Hemochromatosis: Dx Serum transferrin saturation Vit K reverse warfarin (fast: fresh frozen plasma) Protamine sulfate reverse heparin 1st year in cardiac transplant: mortality/ morbidity due to infection INFECTIOUS DISEASE 4mo-4yo pneumonia - RSV - wheezing + rhinorrhea, winter Palivizumab given to specific child in RSV season: <2yo, chronic lung disease that required medical therapy within 6mo before RSV season. RSV Tx: supportive care

S. Pneumoniae is the most common pathogen for asplenic pt pneumonia Nursing home acquired pneumonia: Emp. antibiotics - levofloxacin Outpatient community acquired pneumonia: macrolide, doxycycline or fluoroquinolone. If pt was treated with antibiotics in 3 mo - use quinolones Tubercular Meningitis: chloride low Meningococcal vaccine is not effective for B type (30-40% of infection) PCP: prophylaxis when CD4<200. Lab: methenamine silver stain -> cyst like structure Chlamydia test for cure is NOT recommended now other than pregnancy (3-4 wafler tx) yearly test for chlamydia is recommended for <25yo, risk, new/multiple sex partner, pregnancy Tx: Doxycycline 100mg PO BID * 7 days or azithromycin (for pregnant) 1g po *1 day EBV: infectious mononucleosis - resume contact sports when physical exam is normal Rocky mountain spotted fever - tick bites face usu. spared creatinine risk of death, tx: doxycycline Splinter hemorrhage: emboli from subacute bacterial endocarditis Diarrhea pathogen: cryptosporidium and Giardia cysts are resistant to chlorine Diarrhea/food poisoning Staphylococcus: vomiting is major, 4h after eating Salmonella: beef, poultry, eggs E.Coli: O157:H7 improper hamburger - watery - bloody stool starts 3-4 d, last 1wk Giardia: Travellers d -ground water - fecal-oral - mild bloody stool - start 2-3d - last 1wk Paronychia: chronic- 95% candida albicans Rabies prophylaxis - ALWAYS immunoglobulin + vaccine MUSCULOSKELETAL De Quervains tenosynovitis more common in (1) pregnancy (2) after trauma (3) pt with RA wrist region (radial), Tx: steroid injection Supracondylar fracture of humerus risk of compartment syndrome Colles fracture: cast - flex, pron ulnar position Gamekeepers thumb: avulsion of attachment of the ulnar collateral lig - surgical repair, splint is not adequate ACL: most frequent injured lig in the knee Meniscal tears: medial > lateral Prepatellar bursitis knee swelling Bursitis of medial collateral ligament tenderness of median aspect of knee Anserine bursitis: pain esp. at night, medial knee to the upper tibia, can be bilateral Osteoarthritis: Normal CBC/ESR, (-)RF, (-)ANA. Pain reduce with muscle strengthening Fibromyalgia --> may have sleep disturbance, no muscle weakness, no objective lab findings Tx: Antidepressants (SSRI/CA) comb. have efficiency i.e. amitryptyline Steroids/NSAIDs dont help Gout: elderly differ from usual presentations. young: podagra Gout Pseudogout M>F M=F middle aged M postmenopausal F older acute onset acute or insidious needle shape neg. birefringence pos. birefringence rhomboid shape monosodium urate calcium pyrophosphate dihydrate NSAIDs, Steroids, Colchicine, allopurinol NSAIDs, Steroids Polymyositis: old (50-70yo) EMG- potential with fibirllations, biopsy necrotic m.fibre +inf.infiltrates Duchennes muscular dystrophy (X-recessive) young (2-4yo)

Both CK , proximal muscle SLE: ANA sensitive Anti-Sm Anti-dsDNA specific Scleroderma Anti-Scl-70: poor prognosis Sjogrens syndrome is associated with high risk of non-Hodgkins lymphoma Rheumatoid arthritis: no rash Capsaicin, topical substance P depleting drug can relieve pain RA compare with OA (1) thumb squaring (2) Heberdens nodes (distal) (3) Bouchard's nodes (proximal) Rotator Cuff Injury: Rest, pain control, acetaminophen or NSAIDs if not improved 3-6mo under supervised rehab program: consider surgery Polymyalgia rheumatica: C-protein , CK normal (CK strongly suggest other etiology) Duchenne Muscular Dystrophy (DMD) 1. young (3-5yo) 2. Gowers maneuver Transient synovitis of Hip: a postinfection condition Bier Block anesthesia: indicated for fracture of forearm, wrist or hand, NOT for fracture above the elbow Tibial nerve injury: paralysis of the plantar flexors of foot affects flexion of ankle(L4) and toes (L5) Anterior Drawer Test: integrity of ACL Stress fracture: No cast, NSAID not recommended for delaying healing. Activity can continue as long as it does not cause pain Little League Elbow - located over the medial epicondyle (apophysitis) Iliotibial band syndrome: common, lateral knee / thigh pain Patellofemoral syndrome - discomfort moving patella Facet joint syndrome - low back radiate to thigh or knee NEUROLOGY Limbic system - associate with emotion HTN is the most powerful risk factor for stroke Brocas area - inferolateral frontal lobe L parietal lobe damage Gerstmanns syndrome R-L confusion difficulty writing or maths R parietal lobe damage contralateral neglect, difficulty in making things, draw, deny deficits Crossed hemiplegia: brain stem hemorrhage or lesions Chronic subdural hematoma may cause a reversible form of dementia Headache warning signs: - onset >50yo, very sudden onset, frequency / severity, with signs of systemic disease, focal neurologic symptoms, papilledema, headache after trauma Migraine Headache: Ergotamines older than triptans, but much less expensive. VitB12 showed some effect, Biofeedback might be useful as alternative tx Cluster Headache: always unilateral Tramadol has potential to cause seizure (rare) Phenytoin related with osteoporosis, may worsen acne Toxicity sign: ataxia Tonic-clonic seizure, prolactin test within 20 min Tx: first line valproic acid 2nd line phenytoin and carbamazepine Topiramate not to be used with history of kidney stone or taking high dose of Ca/VitC MS - use MRI, CT doesnt show, Std Tx interferon beta GBS - or absent deep tendon reflex Leading cause of permanent bilateral visual loss >55yo is macular degeneration Risk factor: HTN Essential tremor of hand: propranolol, topiramate or primidone Newborn: tear start to be produced after 3 weeks of life Propoxyphene is NOT recommended to manage chronic pain in elderly nursing home pt Restless leg syndrome: carbidopa / levodopa

Related with Iron Deficiency, check ferritin level Cerebellopontine angle tumor - of 8th cranial N. benign. CM corneal reflex & hearing loss OBSTETRICS melasma / chloasma: common, 70% pregnant women affected hypermelanosis of face, symmetric distribution, UV worsens the condition Quad screening: AFP neural tube defect Initial visit (prenatal) - discuss Tay Sachs if Jewish ancestry. HIV needs consent Chloramphenicol - grey baby syndrome parvovirus B19 in mother Hydrops Varicella zoster: first pregnancy period cutaneous / bone defects, chorioretinitis, cerebral cortical atrophy,hydronephrosis 3 spontaneous abortions (SABs) in 1st trimester - chromosomal consult Epidural anesthesia mother: hypotension common NST not reassuring -- BPP Even if BPP 8-10, mind early decelerations Engagement : biparietal diameter through pelvic inlet Chlorpropamide (sulfonylurea) - contraindicated in type 2 DM with pregnancy or gestational DM (may cause prolonged symptomatic hypoglycemia) MgSO4 - monitor Cr, reflexes (knee) and resp. 1st sign of Mg - deep tendon reflex disappear Preeclampsia: 1 control BP 2 prevent seizure 3.induction or C-section (indicated>34wks) Atenolol related with fetal growth delay Placenta previa - transvagina US acceptable but NO vaginal exam! IUGR - chronic HTN is the most common reason Normal pregnancy: S/D ratio (doppler) with pregnancy avance Symmetric IUGR look for congenital abnormalities Sinusoidal pattern of FHR severely affected Rh- isoimmunized fetus, or mother medication Saltatory pattern: episodes of brief / acute hypoxia usually seen during labour Erb palsy C5-6 limpy extended arm internally rotated Klumpke paralysis C7-T1 hand paralyzed Shoulder dystocia - obstetric emergency - call for help Amnioinfusion - effective for severe variable decelerations and meconium stained fluid Premature Rupture of Membranes (PROM) Risk factors: low socioeconomic condition, STDs, Previous preterm birth, vaginal bleeding, smoking Prolonged latent phase - meperidine (demerol) IM Tocolysis: indomethacin / indocin may cause oligohydraminos nifedipine low BP, monitor Ritodrine/terbutaline tachycardia, hypotension, pulmonary edema MgSO4 high dose cause respiratory and cardiac depression Twins delivery (1) vertex/vertex (2) vertex/breech Bacteroides fragilis resistant to penicillin and gentamicin use clindamycin Sheehans syndrome affected hormones - FLAT PiG FSH, LH, ACTH, TSH, Prolactin, Growth Hormone During pregnancy, high level of estrogen inhibits lactation Umbilical artery *2 deoxygenated blood to the placenta Sulfa drugs in 3rd trimester may cause kernicterus Obstetric conjugate: shortest - promontory of sacrum and symphysis pubis -10.5cm not clinical Diagonal conjugate: lower margin of symphysis - sacral promontory True conjugate: top of symphysis - sacral promotory

Episiotomy: 1 D tear: vaginal mucosa, perianal skin , 2D tear: subcutaneous tissue 3D rectal sphincter affected 4D tear extend to rectal mucosa Ctst of ovarian during pregnancy mostly benign, 14-16w is best time to operate Antiphospholipid antibody syndrome in preg - risk of embolism, fetal loss, thrombocytopenia Misoprostol for induction or cervical ripening, NOT ind. in prev. uterine surgery or active labor Crown-rump length - accurate in 1st trimester Biparietal diameter - more accurate in 2nd trimester Intrahepatic cholestasis of pregnancy (ICP) - severe pruritus in 3rd trimester, absence of primary skin lesion + bild acid GYNECOLOGY Female thelarche adrenarche (pubic hair) growth spurt menarche Hot flushes: Tx SSRI effective Injectable medroxyprogesterone acceptable as HRT not linked with thrombotic cases Inability to conceive after 1yr sex life - infertility Copper IUD main action is spermicidal Ovulatory disorder: most common cause for female infertility Constitutional growth delay: can watchful wait and observe Medication cause hyperprolactinemia amenorrhea: (usu. <100ng/ml) -Benzodiazepines, SSRIs, TCA, Phenothiazine, buspirone, sumatriptan, valproate, ergot derivatives, estrogen/contraceptives, atenolol, verapamil, reserpine, methyldopa 1st Dysmenorrhea prostaglandin synthetase inhibitor trail OCPs suppress PG release and menstrual fluid volume Endometriosis most common location other than pelvic organs: GI tract Atypical or adenomatous hyperplasia hysterectomy Heavy bleeding: estrogen 25mg every 4h until bleed abates (high dose) Ambiguous Genitalia 1st step is physical exam screen congenital adrenal hyperplasia PCOS - estrogen in blood (+progesterone challenge test), a risk of endometrial Ca Trichomonas: Tx single dose metronidazole 2g or tinidazole. If fail, metronidazole 500mg bid *7 if fail, metronidazole 2g *3-5 days Toxic shock syndrome: tampons or diaphragms in body >24hrs AGUS - cervical intraepithelial neoplasia is the most common histologic Dx Vulvar cancer - long standing pruritus Ovarian Ca - pregnancy, breast feeding and OCP all decrease risk Breast development in pregnancy - progesterone Health Exam: Screen chlamydia for all sex active women <25yo or older at risk PAP at least every 3 yr, sex active + have a cervix Hep B: recommended for pregnant women Spironolactone can improve post menstrual syndrome PEDIATRICS Breast milk lacks Vit D, Cow milk lacks Iron Most common reason for visual loss in child: amblyopia Baby sleep on back risk of sudden death Child safety seat: : rear facing until 9kg(20lb) forward facing 9-18kg booster seat 18-36kg belt for >36kg, >145cm or 8yo SBS - may have long bone fracture or soft tissue injury Eisenmengers syndrome: maternal mortality 50%, L to R Pulm HTN R to L PGE1 iv maintain PDA - in transposition or F4 Lithium Ebsteins anomaly Retinoic acid bilateral microtia anotia

Decreased Folate spina bifida ACEI renal dysgenesis Ted spells - diminish R to L shunting by systemic vascular resistance Androgen insensitivity - X linked recessive Meconium aspiration patchy atelectasis Hyaline membrane disease homogeneous opaque infiltrates with air bronchograms Downs syndrome 14% pt atlantoaxial subluxation Noonan syndrome: autosomal dominant, M/F symptom similar to Turners PKU: autosomal recessive 1st child PKU 25% later chance CF: - nasal polyps Bleeding of diverticulum (Meckel's) mostly due to ectopic gastric mucosa acid induced bleeding Croup: parainfluenza. moderate: IM steroid single dose (help with glottic edema) Epiglottis: Hib, Strep or viral Pertussis incidence is in Canada Tx: Erythromycin or azithromycin; TMPSMZ 2nd line Hand-foot-and-mouth disease: Coxsackie A; supportive care Serum bilirubin: Age(hrs) Consider photox photox exchange transfusion if photox fails 25-48 >=12 >=15 >=20 49-72 >=15 >=18 >=25 >72 >=17 >=20 >=25 Newborn mass:50% renal origin, usu. benign myelomeningocele - anaphylactic shock from latex allergy RDS tx: L/S <2:1 maternal corticosteroids Cerebral palsy: frequent seizured perinatal period - asphyxia Reyes syndrome: rash, vomiting and liver disease Most common posterior mediastinal tumor in children: neuroblastoma Osteosarcoma: no radiation Lead poisoning: wobbling gait. Normal blood lead <10ug/dl Asymptomatic proteinuria in children/adolescent: 60% orthostatic Henoch-Schonlein purpura (HSP): generalized acute vasculitis of unknown cause involving smal blood vessels. Purpura + arthritis of large joints, gastrointestinal symptoms, colicky abd. pain vomit melena PSYCHIATRY Psy functional inquiry: MOAPS: Mood, Organic(substances), Anxiety, Psychosis, Safety Fluoxetine less likely to cause discontinue symptoms - long t1/2 long-acting metabolism Fluoxetine early side effect: loss of appetite Fluoxetine is the only FDA approved med for 8-17 yo Night terror: No nightmare, (-) REM, Tx. Diazepam improves condition OCD - Tx SSRI, SNRI (venlafaxine) not the choice. TCA (clomipramine) can be used Acute stress disorder <4wks PTSD: SSRI (Quetiapine) HIV+ dementia: usu CD4<200 Picks disease - 25% of dementias early personality changes, social improper mood changes pick body (intracellular inclusion) and pick cells (swollen neurons) Benzodiazepine in elderly - potential for delirium

Major depression Disorder - depletion of norepinephrine and serotonin Tx: last >6mo after first episode ECT: methohexital (anesthetics), complication w recent cerebral Hemorrhage, stroke or ICP ECT safe in pregnancy Switch phenelzine to paroxetine (MAOI to SSRI) - allow 2 weeks wash off time avoid serotonin + cyproheptadine for serotonin syndrome SSRI withdrawal 2d lightheadedness, headache Nortriptyline: curvilinear Imipramine: sigmoidal (pharmacodynamics) Citalopram is least involved in P450 system MAOI - avoid tyramine metabolism Dysthymia: strongly associate with other disorders,(major depression, personality disorder, social phobia, MS, AIDS, CVS, premenstrual, hypothyroidism) Tx: mood stabilizer(lithium), anticonvulsive med. (valproic acid), antipsychotics, antianxiety (benzo) CBT, IT, Group Tx Valproic acid: carnitine to prevent increase ammonia level Lithium most common side effect: tremor. Maintain bipolar: lithium, lamotrigine, aripiprazole or olanzapine Narcissistic: medicine Tx no use. Psychodynamic psychotherapy Psychosis: loss contact with reality Schizophrenia: 20% drink excessive water Phenobarbital - likely to cause Tardive dyskinesia Childhood disintegrative disorder: apparent normal development <2yo clinically sig. loss of prev acquired skills before 10 yo Retts disorder: By age of 5, microcephaly or disordered gait Fetal alcohol syndrome: small eyes, short palpebral fissures, thin upper lip and a smooth philtrum Sleep disorders: cognitive-behaviour therapy zaleplon is short acting vs. zolpidem zaleplon may induce sleepwalking, binge eating aggressive outbursts night driving etc Narcolepsy modafinil sleep attacks Somatoform disorder Dont need to have Hx of depression / anxiety Conversion disorder: la belle indifference - dont concern regarding apparent extreme decline of health Triazolam (benzodiazepines) short term (<10d) tx for insomnia, may cause amnesia PULMONARY Acute asthma: ipratropium added to b2 blocker better than b2 blocker alone systemic steroids recommended to all admission to hospital pts. COPD inhaled steroids - controversial review (+risk of pneumonia, improve quality of life, no effect on mortality) Non-caseating granulomas can be seen in Crohns but not UC Nitrofurantoin - may cause acute hypersensitivity pneumonitis, fever, chills, cough, bronchospasm. CBC leukocytosis with @ of eosinophils Pleural effusion: CHF usu. right side Echinacea - used to treat upper resp. infection - no proven effect Air-fluid level in superior segment of right lower lobe - pulm. abscess - anaerobes Pneumonia 23 valent vaccine: 2-64 yo -DM, cirrhosis, CHF, Chronic lung dis.(COPD), - not Asthma Pulmonary hemosiderosis: X-ray, diffuse fluffy infiltrates, may assos. w milk allergy (heiner syndrome)

RENAL/GENITOURINARY UTI in childhood - 80-90% E Coli Thiazides may decrease renal clearance of Ca2+ exacerbate hypercalcemia asso. w hyperparathyroidism Fanconi syndrome: proximal renal tubules do not reabsorb back excessive drinking, excessive urination, glucose in urine, untreated: muscle wasting, acidosis, poor condition Kidney stone (ureteral stone) adequate analgesia is critical Acute tubular necrosis ATN: FeNa>2 Atheroembolic renal failure warfarin risk factor, CF: derm findings, digital cyanosis, refractile plaque in retinal artery Nephritic syndrome: PRO<1.5g/d Nephrotic syndrome: PRO>3.5g/d Inguinal hernia in child - dont close spontaneously Hydrocele - usu resolve itself<12-18mo Epididymitis: if MSM, or >35yo, E Coli is most comon Tx: ofloxacin 10d or ceftriaxone 1 dose + doxycycline 10d Orchitis is viral Finasteride(proscar) falsely decrease PSA level Testicular cancer dont FNA!!! can cause spread. Use ultrasound Incontinence: Urge - detrusor instability , anticholinergic: oxybutynin(ditropan)/tolterodine(detrol) side effect - retention, delirium, etc. Overactive bladder - Kegel exercises Stress - pseudoephedrine(sudafed) weight loss, surgery Overflow - residual >200ml, (normal <50) life style, catheterization, Tx underlying cause, cholinergic drugs (bethanechol) SELECTED EMERGENCY MEDICINE Unstable cardiac Pt: chest pain, shortness of breath, confusion Asystole - vasopressin better than epinephrine Blumbergs sign - rebound pain Methamphetamine addiction Tx: Cognitive Tx (difficult to treat) Flumazenil - dont give on benzo overdose, may cause status epilepticus in dependents Common symptom caffeine discontinue - headache Cocaine withdrawal - crush Heroin withdrawal - craving Alcohol dependence relapse prevention: Naltrexone/ disulfiram Charcoal : not useful for iron, hydrocarbon, acid/alkali erosion Perioperative cardiovascular risk: elective operation, 6mo after acute MI Postoperative fever: 1d atelectasis 3d UTI 5/7d DVT 5/7d wound infection 7-10d abd abscess Sigmoid volvulus: sigmoidoscopy decompression (tx) Activated protein C (APC) survival in septic shock GCS: Eye Open 4 verbal 3 pain 2 no 1 Verbal oriented 5 confused 4 inappropriate 3 incomprehensible 2 no 1 Motor obey 6 local pain 5 withdraw 4 flexion 3 extension 2 no 1 Sepsis - norepinephrine is preferred vasopressor Bariatric surgery leading cause of death: PE

RAPID REVIEW Murmur VSD: holosystolic at mid left sternal border Murmur Aortic Insuf mid left sternal border Impetigo - S Pyogenes and S aureus Echovirus - cause aseptic meningitis