UWORLD

notes
Cardiology
1. Decreasing LDL is more imp to prevent CAD than stopping smoking, DM control, HTN
control or exercise. DM is the second most important.
2. Pt with CHF on amiodarone comes with desaturation and basal crackles- probably chronic
interstitial pneumonitis, or organizing pneumonia due to amiodarone. Its a cumulative
dose effect, and not dependent on blood levels. Other adrs are liver, lungs, thyroid, BM
toxicity and skin changes including Photosensitivity. Steroids can be used for severe pul
disease.
3. Young patient with sec HTN, most common finding is abdominal bruit( 50%). Tachycardia
if pheochromocytoma, but is less common.
4. In a patient with HTN, in absence of any known CAD, baby aspirin is useless.
5. All pts with stable angina should undergo stress EKG for risk stratification. High risk
patients, ie those with failure to inc BP with exercise, inability to complete stage I of
Bruce protocol,, or appearance of downsloping or horizontal ST segment during exercise
>1mm, should undergo cor angiography, and thallium scan to see viable salvageable
myocardium before PTCA or CABG.
6. Pt on warfarin is started on amiodarone- dec the warfarin dose by 25%
7. In a pt with h/o angioedema with ACEI, ARB are not the choice drugs- B blockers are,
because ARB still have low risk of causing angioedema. Especially if the pt has no
compelling indication to use ACEI, like Diabetic Nephropathy.
8. Stress Echo is always more sensitive than stress ECG, and can show wall motion
abnormalities, but stress ECG is still the first choice for risk stratification in pts with stable
angina. In patients who cannot exercise, eg due to OA, use dopamine stress EKG or Echo.
Probably can use adenosine and dipyridamole stress EKG/Echo too.
9. Adenosine thallium/sestamibi scan, Dipyridamole thallium perfusion/viability scan both
are c/I if the pt has COPD or asthma. These are used to see hypoperfused myocardium
during stress.
10. Pharmacological stress testing (and probably radionuclide scan) are done in those who cant
exercise eg due to OA or MI or unstable angina, and in those with abnormal baseline
ECGs like LBBB, LVH, baseline ST changes, WPW, externally paced heart, etc.
11. Aortic sclerosis and ESM are normal finding in old patients.
12. Pt with CHF is given ACEI even in asymptomatic stage, ie if Echo shows low EF; B
blockers and diuretics are added only if symptomatic. Isosorbide Dinitrate if evidence of
pul edema. Low sodium diet and diuretics if pt has some fluid retention.
13. Orthostatic hypotension means fall of 20 mm in systolic and 10 mm in diastolic
14. Verapamil, quinidine, amiodarone and spironolactone can cause digoxin toxicity, so for eg a
pt on digoxin comes with nausea, vomiting, confusion after starting verapamil.
15. In a pt with high LDL and TG, the first step is always targeting LDL with statin, then add
fibrates if statin doesnt decrease the TG. Cholestyramine can increase TG so is
contraindicated.
16. Post CABG angina, with permanent ECG changes- do radionuclide perfusion imaging and
not stress EKG or even stress Echo, as we cant interpret the Echo with previous wall
motion abnormality due to previous MI or ischemic cardiomyopathy.
17. Inc fibrinogen >2.7 7 puts patient at high risk of MI; and lovastatin and atorva both
increase fibrinogen. So if the patient has elevated levels of fibrinogen, change to either

prava or simvastatin, as they have no effect on fibrinogen.

18. Wt loss is the single most imp measure to dec BP, more than stopping smoking, or dec salt
or alcohol consumption or exercise
19. Preop cardiovascular risk assessment; age above 70 yrs 5 points, MI<6 mo ago 10 points,
MI>6 mo 5 points; angina on walking 1-2 blocks 10 points, angina at rest 20 points, and
critical aortic stenosis 20 points
20. Drug lupus with hydralazine, mdopa, CPZ, IFN a, diltiazem, minocycline, penicillamine,
procainamide, INH- starts with flu like symptoms, fever, malaise, arthralgia and facial
rash.
21. Asymptomatic hypoNa in CHF patients- water restriction is the TOC, even if NA <115;
hypertonic saline only for symptomatic pts. Isotonic saline and oral salt tablets are
contraindicated as they will increase the fluid overload.
22. Pt with unstable angina 2 weeks back- sent home from Er- do straightaway cor angio and
then intervention. No need for stress testing.
23. If stress testing shows no change in EKG and we still suspect CAD, do stress perfusion scan.
24. MRI is the inv of choice for coarctation, not TTE. TEE is inferior to TTE for aorta.
Coarctation is usually associated with bicuspid aortic valve and ESM murmur.
25. Lone AF, without any cause found, aspirin is the treatment. Warfarin if prosthetic or
rheumatic AF, ticlopidine, dipyridamole and clopid if allergic or intolerant to aspirin.
Ticlopidine causes neutropenia.
26. Monomorphic nonsustained VT- usually either MVPS/DCM/LVH or CAD; do Echo and
Stress test.
27.
Long QT syndrome, hypomag, hypokal, they cause polymorphic VT.
28.
Pt on warfarin with increased INR upto 5- withhold warfarin; if between 5 and
9- give a small dose of vit k oral, if more than 20 only then give iv vit k or FFP.
29.
External pacemaker means temporary one. Mobitz II needs permanent
transvenous pacemaker insertion.
30.
Multifocal atrial tachycardia in COPD, dec K or Mg, aminophylline or
isoproterenol- P wave of 3 or more morphology with narrow complexes, variable PR and
RR- always check pulse oximetry first too rule out hypoxia; correct underlying cause, then
if it doesnt subside give metoprolol. In COPD pts, give verapamil instead of metoprolol
31.
HTN crisis can present with flash pulmonary edema. Administer morphine,
oxygen and lasix, then start iv nitroglycerine or nitroprusside for the HTN. Since many
heart diseases like acute MR or AR can present with flash PE, echo should be performed.
If recurrent episodes of flash PE and HTN, then do renal duplex scan, esp in young
patients.
32.
A case of postop inferior MI with significant bradycardia (ie symptomatic, for
eg causing pul edema)- start atropine first, and if it is recurrent do transvenous pacing.
Dont do pacing initially as the brady is usually transient. Dont use dopamine or norepi
as they increase cardiac oxygen demand. Thrombolysis or heparin cannot be given upto 2
weeks postop. DONNO ABOUT PTCA.
33.
AF with hemodynamic instability- synchronized cardioversion. Also for VT.
Asynchronised for VF and Torsades. In chronic AF or stable AF, rate control with
metoprolol or diltiazem is preferred. Using iv load of digoxin then regular digoxin was the
idea of the past. Stable AF can also be cardioverted either with defibrillation or chemically
with class III drugs. Prior anticoagulation needed for cardioversion of chronic AF.

34.
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37.

38.
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40.
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45.
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47.

Diltiazem is preferred as it has fast OOA and low DOA, except if CHF or heart block,
where digoxin is needed. The problem with even iv digoxin in acute cases of AF is that it
takes hours to act.
ACEI is the DOC in CCF, even more so in elderly with dementia, in whom
digoxin and spironolactone etc can cause delirium.
Elderly with multiple risk factors coming with an episode of syncope should
be admitted for continous ECG monitoring, to assess for possible ICD placement to
prevent SCD, as arrhythmia is usually the cause. Also do cardiac enzymes to rule out
CAD, Echo to see left ventricular function.
Young patient with acute MR and flash pul edema, is either due to IE or
trauma or idiopathic rupture of chordate tendinae, the last being the most common re, esp
if he has features of EDS like pes planus, hernias, cigarette paper scars on the skin due to
easy bruisability, and rubber man syndrome with skin and joint hyperflexibility. Marfan
usually causes chronic progressive MR and not acute one.
Diffuse ST elevation and PR depression are the hallmark of acute pericarditis
postMI. Dressler syndrome is autoimmune pericarditis and pleuritis after weeks of MI or
cardiac surgery. NSAID in former, steroid in latter, tho steroid has been shown to increase
LV aneurysm formation.
CABG TOC for multivessel disease or lt main disease, esp if DM coz in them
the chance of restenosis with PTCA is very high.
Thrombolysis- within 12 hrs of symptoms if ECG shows ST elevation >1mm
in 2 contiguous leads, after nitroglycerine is given to rule out coronary spasm. Also in pts
with new LBBB. No benefit in NSTEMI. C/I with BP>180, recent surgery or ischemic
stroke. ST depression occurs with ischemia, strain, digitalis, hypokalemia and
hypomagnesemia, so is not an indication, unless it is due to posterior MI.
Poor R wave progression- if the R remains same through V1 to V4. Seen in
COPD, RVH, LVH, ant infarction, blocks and cardiomyopathy.
Prolonged QT means more than half of RR, seen in antiarrythmic drugs, TCA,
hypokalemia, seizure and stroke.
Metformin should be stopped before coronary angio or other dye related
procedures that can harm kidney and cause lactic acidosis. Also in renal or hepatic failure,
CCf, sepsis and alcoholics.
Aspirin should be stopped 7 d before most procedures, but neednt be stopped
for coronary angio or cath.
TCA overdose is treated with sod bicarb. Lidocaine is the DOC for any vent
arythmia that occurs. Procainamide, disopyramide and quinidine are membrane stabilizer,
hence increase TCA toxicity re. Also ppnl is contraindicated, as it dec conduction and inc
arythmogenic potential of TCA re.
Pt can resume sexual activity 6 weeks after uncomplicated MI- ie if he
recovers without any post MI chest pain, CCF or arythmia.
Severe symptomatic AS (area <1cm2) is treated with valve replacement, as
balloon valvulotomy is associated with transient efficacy and high procedural morbidity.
Radionuclide ventriculography (RVG) or Angiography (RNA) or MUGA
(multigated cardiac blood pool imaging) is done before and after chemo with
anthracycline to detect early cardiotoxicity, before and after cardiac transplant and in
severe CCF. 2D echo in children instead to prevent nuclear exposure, but less accurate and

operator dependent.
48.
CCB have no use, and infact are harmful in patients with acute MI- only
indication is when there is intolerance of b blockers, postMI angina refractory to b
blockers or nitrates.
49.
Torsades: prolonged QT caused by liver, renal failure, dec Mg or K, sotalol,
macrolides, pentamidine, cotrim, antipsychotics, TCA, terfenadine, astemizole. TOC is
asynchronised defib, as the patients are almost always unstable, then followed by MgSO4
whether or not the Mg level is low. That is because we cannot measure ionized Mg.
Transvenous pacing if refractory to Mg. Lidocaine and isoproterenol are second line drugs
if pacing is unavailable.
50.
Adenosine perfusion imaging with thalium or adenosine Echo or ECG is
always the choice in patients with CAD who cannot exercise. Dipyridamole can be used.
But in patients with COPD or asthma, both cant be used, so use dobutamine. In unstable
angina, however, directly go for coronary angio.
51.
INR in mechanical aortic and mitral valves should be in 2.5 TO 3.5; If
superadded AF more than 3.5, and if embolism occurs even on warfarin, then add aspirin
and increase INR above 3.5.
52.
WPW: PR<0.12; QRS>0.12; Verapamil and b blockers are contraindicated as
they will slow down the AV nodal conduction, thus causing increased conduction in
accessory pathway, which can lead to VT.
53.
Acute arterial embolism suspect- first thing to do is iv heparin.
54.
Cardiac tamponade: Becks triad of hypotension, muffled sounds and elevated
JVP; ECHO shows diastolic collapse of both rt atrium and ventricle, cardiac
catheterization shows equalization of pressure in all chambers, and ECG shows low
voltage with alternating sizes of QRS, aka electrical alterans.
55.
Elderly patient comes with DCM and CCF, first thing to do is Cardiac stress
test to rule out IHD, as it is the most common cause.
56.
ACEI has shown survival benefit when given for several weeks following MI,
usu 6 wks, but not indefinitely.
ENDOCRINE
1. Only symptomatic subclinical hyperthyroidism needs treatment, or those with AF or low
bone densities or MNG who have subclinical hyperthyroidism. Else, an asymptomatic pt
needs only follow up with TFT.
2. Asymptomatic subclinical hypothyroidism on the other hand doesnt require treatment. Do
antibody profile first. Treatment is warranted if antibodies are present, if lipid profile is
abnormal, or if menstrual irregularity or TSH>10.
3. Immobility is a common cause of hypercalcemia, esp in adolescent and those with pagets
disease, who have high bone turnover, due to uncoupling of bone turnover, ie more
resorption and less formation. Subsequent hypercalcemia will suppress PTH, and low PTH
in turn suppresses D3 levels. Biphosphonates can be used in these patients to prevent this.
4. For every 1 g/dl decrease below 4 of serum albumin, add 0.8 mg to the total calcium level.
5. Paraproteinemia can increase the bound calcium, hence the total calcium in the serum.
6. Hypoglycemia with high C peptide can be both due to insulinoma and sulfonylurea
overdose. History and context is imp. To differentiate, measure serum proinsulin levels.
Also checking for sulfonylurea level in urine and plasma can be helpful.
7. Autoimmune hypoglycemia due to insulin antibodies which bind to insulin receptors, or

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11.

12.

13.

14.
15.

16.

17.

18.

release excess insulin into circulation

Diabetic for planned CS section- dont stop regular dose of insulin night before, to prevent
ketoacidosis, even if she is npo. Then start insulin infusion during the surgery, with
D5,1/2NS and KCL. Insulin requirement will drop following delivery of the placenta.
Switch to scheduled sc dosage as soon as the patient starts tolerating food.
DKA management- continue NS and insulin till blood glucose is 250, then change to DNS
with KCL, and decrease the insulin infusion dose. Dextrose infusion is very imp to
decrease ketone levels. Start KCL regardless of serum level. Switch to oral feed and sc
insulin only after the anion gap has corrected, HCO3>10m and precipitating factor like
infection is corrected. But always start sc insulin 1 hr before discontinuing iv insulin, as sc
insulin needs time to act, so otherwise it might precipitate DKA again if we dont overlap
the insulin.
Pt with hyperthyroidism with chief complaints of palpitation- treatment is ppnl
and not PTU
Preop patient for emergency surgery like CABG for unstable angina is found
to have hypothyroidism- its not a contraindication for surgery, tho there is higher risk of
ileus, hyponatremia and oversedation with narcotic. Only after the surgery, start with low
dose T4 as the patient has CAD.
DM pt on metformin develops anion gap acidosis, and there is no leukocytosis
or hyperamylasemia- implies its probably lactic acidosis and not DKA- so do ABG and
blood lactate level, instead of ketone level and urinalysis, or instead of starting DKA
treatment.
In patients with thyroid cancer in remission, T4 supplementation should be
used to suppress TSH below normal range (ie between 0.1-0.3). If distant mets, even
lower, to undetectable levels, tho that increases the risk of AF and bone loss. T3 is only
used short term and never used for long term management of hypothyroidism. Hormone
supplement should be taken on empty stomach.
Mental state change in elderly- always do TFT for diagnosing apathetic
hyperthyroidism.
A pt on prednisone for RA develops infection and then hypotension- acute
adrenal insufficiency. Administer fluid and dexamet, as it is long acting and doesnt
interfere with measurement of serum cortisols. Then do cosyntropin test.
Mineralocorticoids arent used, because, one- they are not deficient, two- they take a
longer time then just simply infusing saline.
Amiodarone- monitor patients TFT 6mthly; if it causes hypothyroid, no need
to stop amiodarone. Just give larger dose of T4, as amiodarone prevents peripheral
conversion of T4 into T3. But check TSH first. If hyperthyroid, it can be either due to
induction of Graves disease, which is treated with PTU or methimazole, or it is due to
induction of destructive thryoiditis, in which case the treatment is steroids.
Female on HRT for hot flashes develops DVT- should stop HRT, then give
warfarin for 3 mo as this DVT has a precipitating cause and is the first episode. DVT
without precipitating cause, or subsequent episode should get warfarin for 6 months.
Increasing anticoagulation for continuing HRT is not justified, neither does tamoxifen
help with postmenopausal symptoms.
Urinary metanephrines and catecholamines are better test then VMA for
pheochromocytoma. Alpha blockade should be started only after the test, as it can falsely

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21.
22.
23.
24.

25.
26.
27.

increase the level of the CA. Only after biochemical confirmation we do CT/MRI to
confirm location. Both have equal sensitivity, but MRI is useful for extraadrenal foci, and
also to differentiate benign from malignant ones. MIBG scan can be used if either of the
above three tests are equivocal and we still suspect pheo, or one test shows pheo but the
other doesnt. Treatment is with alpha blockade, only then start beta blockade. Long
acting phenoxybenzamine is used before surgery, along with liberal salt and fluid intake to
increase the intravascular volume. The common complication after surgery is
hypotension- use normal saline bolus and infusion. Dopamine doesnt help as the alpha
blockade will blunt the response to vasoconstrictors.
Pt with Hashimoto develops rapidly enlarging thyroid and SVCO- probably
thyroid lymphoma. Treatment is RT.
Long acting sulfonylurea induced hypoglycemia- treat with D50 bolus, then
D5 infusion is required to prevent rebound hypo due to the D50 induced insulin release. If
refractory to this treatment, start octreotide sc. Somatostatin is iv and is short lived so not
used. Giving D10 or D50 infusion for long time is not recommended as they can cause
thrombophlebitis. Glucagon is also not recommended as it is short acting, plus increases
insulin release causing reboud hypo. Glucagon is hence only used in acute mgmt of hypo
with mental obtundation, and the patient is given readily absorbed carbo after gaining
consciousness.
Pt on amiodarone can have inc T4 and low T3 due to decrease in conversion
from T4 to T3. Ppnl also does that, but not atenolol. Aspirin displaces T4 from albumin,
so dont use it as an antipyretic in the treatment of thryotoxic storm.
AF due to Grave disease is treated like any other AF- with b blockers and
anticoagulation. So antithyroid drug or RI ablation is not the answer.
Effect of tight glycemic control on microvascular complications is proved, but
not macrovascular. It reduces the incidence of neuropathy, but there are conflicting
evidence for reversing previous neuropathy.
Fahr syndrome: pseudohypoparathyroidism, with Albright hereditary
osteodystrophy (short stature, round facies, short metacarpals and short neck); they have
hypocalcemia with hyperphosphatemia, latter causing basal ganglia calcification and
cataract. Their PTH is also elevated. Patients with hypopara will have low ca, high
phosphorus and also low PTH. Vit D deficiency causes low ca and phosphorus both, and
inc PTH. Acute hyperphosphatemia like with rhabdomyolysis, seizures, ARF can cause
decrease in calcium, but no basal ganglia calcification and cataract like in chronic
hyperphosphatemia.
Hypercalcemia due to sarcoidosis- , due to 1a hydroxylase enzyme, vit D
increases, PTH is suppressed, hence urinary calcium is increased. Treatment is
glucocorticoid and not pamidronate.
Exercise increases non insulin mediated glucose uptake by muscles, so can
cause hypoglycemia in a patient on insulin. Avoid insulin injection to the exercising limb,
and lower the dose of insulin.
Medullary Ca thyroid, post surgery rise in calcitonin level indicates residual
metastatic disease- first step is HRCT of neck and chest with HRUSG of neck, with
surgical resection if possible. If these dont show any lesion, HRCT abdomen and bone
scan, or iodine 111-octreotide scan and PET may be required. Total body iodine scan is
for follicular and not medullary cancer, as the parafollicular cells dont take iodine.

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Thallium scintiscan is also nonspecific.

Dont take thyroxin with calcium or iron over the counter supplements.
Pt with amenorrhea, low FSH and LH with high alpha subunit, high prolactin
and a pituitary mass- probably has gonadotroph adenoma, with lack of functioning beta
subunit. Increase in prolactin is probably due to compression effect. Treatment is surgery
as bromocriptine works only with GH or prolactin secreting tumor. RT is never the first
choice due to delayed risk of hypopituitarism. Octreotide is also not much effective.
Pituitary incidentaloma with no symptoms shouldnt be treated, only followed
up with regular MRI.
To diagnose spurious hyperthryroidism due to external intake and to
differentiate it from primary thyrotoxicosis, do the thyroglobulin level. It is decreased in
external thyrotoxicosis. RAIU study doesnt help, as the intake is decreased also in
different thyroiditis, iodine or amiodarone induced thyrotoxicosis.
Subclinical hypothyroidism- treat if TPO AB present, as they have high rate of
conversion to overt hypothyroidism. Also treat if symptomatic subclinical (ie inc TSH but
normal T4).
HTN with hypokalemia- do aldosterone to renin ratio to differentiate hypo and
hyperreninemic hyperaldosteronism. In Conns syndrome, the ratio is >30, with high
aldosterone level also needed for diagnosis, as essential HTN can also suppress renin.
Patients present with polyuria and polydipsia due to hypokalemia induced DI. If
hyperreninemic, then do MR angio of renal arteries, with fibromuscular dysplasia giving a
beaded appearance, and is the most common cause of RAS in young patients. Suppression
of both renin and aldosterone in a pt with hypokal and HTN is probably due to apparent
mineralocorticoid excess (AME), so obtain a serum cortisol level.
Pt with DM, NASH due to hyperTG, and obesity- TOC is metformin, as it
causes wt loss,, and helpful in hyper TG and NASH. Glitazones are contraindicated as
they cause wt gain, partly due to fluid retention, as well as they are hepatotoxic.
Subacute thyroiditis- thyrotoxicosis with painful thyroid enlargement. Tt is
NSAID and beta blocker, and steroid rarely if severe. Since preformed thyroid hormones
are the cause of the problem, antithyroid drugs and RI are not effective. Its not difficult to
differentiate from bacterial suppurative thryoiditis, as in the latter case, people arent
usually thyrotoxic as it involves the center of the gland, as well as USG will show multiple
abscesses.
Hyperthyroidism in pregnancy- PTU is the TOC, as methimazole is
teratogenic. If PTU doesnt work, or cause neutropenia, surgery is indicated, else she can
have thyroid storm during the stress of childbirth.
Asymptomatic thyroid nodules: first step is to, do TSH- if normal, and if
<1cm need f/u with yrly USG, >1cm need FNAC. If TSH is decreased, then RAIU studyif hot nodule, only observation. If symptomatic, then antithyroid drugs.. RAIU is
seldom used in management of thyroid nodule, as most of cold nodules are benign, though
most of malignant nodules are also cold. Since most of the nodules are benign, all nodules
dont need surgery, only FNAC is enough. Still, if we have done RAIU, then all cold
nodules must be biopsied. IF the nodule is toxic or if there is carcinoma on FNAC, then
the patient needs surgery.
CT of neck is less sensitive than USG for nodular thyroid diseases.
If pt has papillary cancer on FNAC, then he needs NTT- near total

40.

41.

42.
43.
44.
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thyroidectomy, and then RI ablation therapy for residual tissue and mets, then RAIU study
to see for remaining mets, then lifelong Thyroxine to suppress TSH. Also thyroglobulin
can be followed up as a tumor marker. TSH should be suppressed below the normal range,
tho this can risk AF and bone loss. Doing only subtotal thyroidectomy is ineffective, as it
is difficult to ablate the remaining gland with RI, and we cant also use thyroglobulin as a
marker when lot of thyroid tissue is still left in the body.
If medullary cancer, first test for RET to see for MENII syndrome, or do urine
metanephrine/CA or abdominal CT to diagnose any concomitant pheochromo. Then start
the pt on alpha blockade for a few weeks before surgery then beta blockade only after
alpha blockade (else there will be vasomotor crisis), then do surgery- total thyroidectomy
with central neck dissection.
DM with autonomic dysfunction, gastroparesis- its difficult to adjust insulin
because due to delayed gastric emptying, pt will be hypoglycemic just after meal. Plus
problems of postprandial bloating and constipation. Treatment is metoclopramide, or
cisapride or erythromycin, and small frequent, low fat meals. Cisapride is especially
shown to be beneficial, tho it is not freely available due to incidence of QT prolongation
and Torsades. Last resort is feeding jejunostomy. Metoclopramide cant be used for long
due to side effects and tachyphylaxis, so cisapride is the TOC re. High fiber diet will
increase the constipation.
Octreotide can be given in intractable diarrhea in DM gastroparesis patient.
DM neuropathy- amitryptiline is the DOC, but since most patients have heart
disease also, beware- use gabapentin instead.
Erectile dysfunction with normal morning erection- its psychological
impotence. Erectile dysfunction is never a normal part of aging, so dont tick that.
Pt of hypoparathyroidism- Tt is high dose of vit D( calciferol) and calcium;
high dose because conversion to calcipotriol is defective. We dont use calcipotriol as it is
expensive. Calcipotriol has a rapid OOA, and can be used in hypercalcemic crisis, or if pt
is refractory to calciferol. Pts thus treated with vit D and Ca for hypoPTH usually develop
high urinary excretion of Ca, due to lack of PTH, which can lead to nephrocalcinosis. So
adding THIAZIDE not only helps reduce urinary calcium, but also increases the serum
calcium effectively.
Hypercalcemia with high PTH- can be either primary hyperPTH, lithium
toxicity or familial hypocalciuric hypocalcemia. If hyperPTH, surgery is indicated if
Bone mineral density is less than 2.5 SD (ie T score below -2.5), overt bone disease or
fracture, kidney stone, reduced creatinine clearance, Ca level more than normal by 1,
urinary calcium >400 mg/d, or if young than 50 years. For eg a postmenopausal woman
with T score of -3 comes with hypercalcemia and high PTH, then she probably needs
surgery. Alendronate is not as effective as surgery in preserving the BMD.
Those with hyperPTH who dont need surgery are managed with periodic
msmt of ca, Cr, and BMD. Pt can continue their vit D and Ca supplement, as research
hasnt shown any aggravation on calcium level with those.

48.
Acromegaly:
COD is cardiac- LV dysfunction, asymmetric septal hypertrophy, CAD, HTN and
myocardial fibrosis; these changes may be reversible with treatment. Also increased risk
of colon cancer.

49.
Offspring of
mother with DM I has 3% risk, if father then 6% risk of having DM I.
50.
A patient
with unknown goiter undergoes cardiac cath, then develops thyrotoxicosis- its iodine
induced thyrotoxicosis. Treatment is b blocker, or Antithyroid drugs or KCLO4, but RAIU
doesnt help, as the iodine uptake is reduced in the gland.
51.
Pt with inc
TSH following say, pneumonia, with normal T4 but dec T3, its not subclinical
hypothyroidism, its EUTHYROID SICK SYNDROME (low T3 syndrome). Just followup
with TFT in a few weeks. No treatment needed, and no investigations for antibodies too.
52.
T score in
DEXA is calculated in comparison to healthy adult of age 25, while Z score is calculated
in comparison with similar aged adults. WHO classifies T between -1 to -2.5 as
osteopenia, and below that as osteoporosis. In a pt with osteoporosis, do CBC/Ca and PO4
levels for secondary causes; can do urinary calcium, SPEP, PTH, TSH, N telopeptide for
bone resorption and AlP for bone formation. Pts with T score< -2, with low wt, smoking
patient, or with fragility factures irrespective of T score, need antiresorptive therapy with
alendronate or risedronate, in addition to vit D and Ca. Etidronate is old and not used,
Pamidronate iv is used if pt cannot tolerate oral alendronate due to esophagitis. Calcitonin
is not very effective, teriparatide (PTH) is very effective but needs daily injection and is
expensive. HRT has fallen out of favor since 2002 due to report of inc MI, DVT, Stroke,
and breast cancer. Pt who doesnt respond with biphosphonates, has constitutional
symptoms and pallor should be strongly suspected to have myeloma. Myeloma cells
release OAF( osteoclast activating factor).
53.
Medical
therapy is the TOC in prolactinoma even if large and has effect on vision.
54.
Pt with
Addisons disease develops diabetes I- its autoimmune polyglandular failure type II
(Schmidts syndrome), which also has Graves, pernicious anemia, premature ovarian
failure, vitiligo and celiac disease.
55.
Postpartum
patient on heparin for DVT comes with osteoporosis discontinuing breastfeeding can
help re, increasing dose of vit D and Ca isnot as much helpful.
56.
Old male
comes with hip pain- XR shows thick outer cortex with sclerosis, and Tm scan shows
increased uptake- its Pagets disease. Biphosphonates are indicated if intolerable pain,
involve wt bearing bones, hypercalcemia, or CCF. Calcitonin and steroids are not useful.

HAEM/ONC
1.
Pt of NHL comes with epidural spinal cord compression( radicular pain)- give high
dose steroid, obtain an MRI to confirm diagnosis, then start RT. If only back pain due to
vertebral mets, only RT. If saddle anesthesia or bowel bladder involvement, immediate
decompressive surgery.
2.
Patient comes with metastatic ER/PR + cancer with occult primary in breast- no
need for multiple core biopsy of breast or RM- only do chemo and hormonal therapy.
Tamoxifen is preferred, with fulvestrant in those not responding to tamoxifen.
Trastuzumab (HERceptin) in Her + ones.
3.
Pt with AML gets multiple platelet transfusion, still the platelet count doesnt
increase- its called platelet refractoriness, due to alloimmunisation (formation of antiplatelet antibodies). If initial increase in platelet and then decrease within 24 hrs, think
DIC or sepsis or active bleeding or antiplatelet drugs.
4.
Pt with lung tumor with FEV1 and contribution of each lung given- the best next
thing to do is still to do CT staging. PET/ bone scan can be used too. CT is best as it gives
mediastinal and chest wall invasion, mets to adrenal and liver, and can also help in CT
guided biopsy.
5.
SVCO: dyspnea, persistent cough, hoarseness, dysphagia, syncope, chest and neck
pain, cyanosis, collateral veins in thorax, ocular proptosis, lingual edema- best thing is CT
with contrast. MRI only if dye cant be used.
6.
If imatinib is not in the choices, then BMT is the TOC for CML, aka HCT(
hematopoietic cell transplantation.) IFNa will lead to cytogenetic and not molecular
remission. CPS is used to prepare for BMT to prevent GVHD.
7.
HIT usually presents as thrombosis- very tricky- type I is less severe and occurs
early, type II more severe and occurs after 4-10 days, due to heparin-platelet factor 4
complex antibody, decreases platelet upto 30,000, can lead to limb gangrene, mesenteric
ischemia, cerebral sinus thrombosis. Prevention of HIT is by using LMWH or danaparoid,
or using heparin for less than 5 days; while treatment is using DTI like lepirudin or
argatroban. LMWH are not the treatment of HIT, as they can also rarely cross react with
the antibodies and increase the problem.
8.
Prostate cancer post treatment- f/u with PSA. If rising PSA or if skeletal complaints,
do bone scan.
9.
Pts on tamoxifen should be screened for endometrial hyperplasia with annual Pap
and detailed history. TVS has a lot of false +ve leading to unnecessary endom biopsy, so
not recommended.
10.
Plt transfusion are useless in ITP, as they will also be rapidly destroyed. Only use in
life threatening emergencies as intracerebral and massive GI hemorrhage. Steroid are the
TOC in most cases, with IVIG in severe cases ( IVIG is not the first answer).
Plasmapheresis is for HUS and TTP.
11.
Alcohol and colon cancer are strongly linked than remote smoking history, so beware
if the pt is smoking currently. NSAID and hormone replacement are protective. Alcohol
probably causes the risk by interfering with folate absorption.
12.
Among inherited thrombophilia, factor V leiden is the most common, dont tick
antiphospholipid syndrome, that is not inherited. Methyl tetrahydrofolate reductase gene
mutation is related to homocystinemia, and is another risk factor. Any patient with
inherited thrombophilia and spontaneous thrombosis should be on lifelong warfarin. Also

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26.

those with life threatening VTE like massive PE, or unusual site like mesenteric or
cerebral venous thrombosis should also be on lifelong warfarin.
Primary vs secondary polycythemia- WBC and platelet count will also increase in the
former. If secondary cause is suspected, eg in a pt with COPD, first test is pulse oximetry
after minimal exertion, and sleep study to determine nocturnal desaturation.
Pt with RA has pneumonia and found to have anemia- ferritin is high ( can be due to
both infection or due to ACD), transferring and TIBC are low (can be due to both IDA and
ACD). In these patients, do BM biopsy to differentiate ACD and IDA.
Pts requiring frequent transfusion might develop antibodies to RH, Kelly and other
antigens, causing acute transfusion reaction. Rx is hydration, stopping transfusion.
Dopamine and osmotic diuresis can be used.
Of all the features of Pancoast syndrome, chest movement asymmetry with
asymmetric lower leg DTR is the most dangerous, as it signifies phrenic nv involvement
with possible iv foramina invasion and imminent cord compression.
Pt of CRF comes with esophagitis and massive bleeding- Desmopressin is the TOC as
it releases VIII/VWF from the endothelium, after that dialysis. Cryoppt can be used but
associated with infections. Estrogen can be used too.
Pt with prostate cancer comes with back pain due to mets- TOC is hormonal therapyLHRH analogue with flutamide to counter the initial flare, if back pain is unresponsive to
this, then EBRT followed by chemotherapy. Radionuclide bone scan is the most effective
diagnostic modality. DES reduces LHRH release from the hypothalamus too, but increases
MI, PE and stroke.
SCC skin- surgery first line, RT if pt refuses surgery, and 5FU is the third line
treatment.
Pancoast: RT with surgical resection is the TOC, but if there is evidence of distant
mets, or brachial plexus involvement, or positive bone scan, then RT alone.
AIDS with PCNSL- best therapy is HAART itself, tho RT and corticosteroid help,
they dont increase life expectancy. The most important prognostic factor is the increase in
CD4 count.
CholangioCa, even if Klatskin- if with mets, is inoperable, so the treatment is ERCP
and stenting for the pruritus and jaundice. PTC only if ERCP fails. Ursodeoxycholic acid
doesnt help as it doesnt relieve the obstruction.
Pt comes with diarrhea, sclerotic bone lesions, eosinophilia and peptic ulcer- Systemic
mastocytosis.
Lobular CIS of breast- it is multicentric and bilateral, so the best treatment is close
observation, annual mammogram and tamoxifen which has shown dec risk of progression
to overt carcinoma. Surgery, If at all, has to be bilateral prophylactic mastectomy. Local
excision is useless.
Pt with ACD- low iron, high ferritin, normal or low transferring and transferrin
saturation. BM is diagnostic, and shows normal or increased iron in macrophages, and
decreased no of sideroblasts. Do EPO level, if it is low, EPO is the treatment. If EPO is
already high, then periodic blood transfusion is the treatment. Plus treatment of the
underlying disease with close f/u might be the right answer.
Pt with ESRD and ACD, doesnt respond to EPO- first thing is to do iron study to rule
out iron deficiency. Then see for folate deficiency, systemic inflammation and Al toxicity.
Avoid BT in them, as that can risk causing allogenic graft rejection after kidney

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transplant.
Advanced gallbladder Ca with neuropathic pain in right thigh- for sharp pain, DOC is
carbamazepine, second line being valproate or gabapentin. For dull pain, desipramine is
the DOC. Not narcotics.
Pt treated for SCLC comes with features of acoustic neuroma, its probably not
neuroma but mets. Contrast MRI showing the multiple well circumscribed mass with local
edema is the investigation of choice.
A pt with normocytic anemia- first thing to do is retic count- if high, its hemolysis, if
low its hypoproliferative Electrophoresis and Coombs for earlier, BM for the latter.
Myaesthenic syndrome means Lambert Eaton- treatment is plasmapheresis and
immunosuppressive therapy. Electrophysiological studies confirm incremental response
with repetitive stimulation. DTR are lost unlike in myasthenia gravis or polymyositis re.
Breast cancer metastasis to brain- stereotactic surgery if single, EBRT if multiple.
Chemo dont penetrate, steroid help, and prophylactic anticonvulsant are not indicated.
Sickling crisis- during mens, alcohol, nocturnal hypoxemia- mainstay of treatment is
hydration. Morphine or iv ketorolac for pain.
Sickling crisis with splenomegaly- beware of splenic sequestration- dramatic fall in
hemoglobin causing hypovolemic shock. So CBC should be monitored in these pts. CXR,
blood and urine culture are followed by iv antibiotics esp if the pt wasnt on prophylactic
penicillin. Avoid contact sports.

GASTRO
1. If polyps are found in sigmoidoscopy, next thing to do is colonoscopy to see for
synchronous lesions and remove them. Double contrast enema is inferior, plus doesnt
allow intervention also.
2. TPN: average need is 30Kcal/d and protein 1g.kg.d, but in malnourished or critically ill
patients, its 35-40 and 1.5 respectively. Overfeeding leads to hyperglycemia,
hyperinsulinemia, inc TNF. PEG (percut gastrostomy) should be considered if pts need
TPN for a long time.
3. LGIB: urgent colonoscopy is the procedure of choice due to diagnostic and therapeutic
advantage. IF there is poor visualization due to bleeding, then do Tm tagged RBC scan,
which is better than angio to localize the site. Vasopressin is inferior as bleeding recurs
after stopping, and it can cause ischemic damage to organs and arythmia. Octreotide
works only in variceal bleeding. Urgent colectomy might be needed, but only after
localization of the site of bleeding.
4. Chronic pancreatitis: low fat diet is the most effective method to stop steatorrhea, while
enzyme supplement is inferior.
5. Mallory Weiss tear that has stopped bleeding needs no intervention. Hiatal hernia is a very
frequent predisposing factor for the tear, and can occur during blunt abd trauma, CPR and
endoscopy too.
6. Mesentric angina- duplex USG is the screening test done first, as it has a high negative
predictive value. Angiography is the gold standard, but is done only after duplex.
7. Mild pancreatitis- manage with pain control and iv fluid, npo, ng aspiration to prevent
further pancreatic stimulation. Hypoechoic mass in pancreas doesnt mean abscess unless
there are systemic signs. Antibiotics have been shown to be useful prophylactically only in
severe pancreatitis (Ranson criteria), or necrotizing pancreatitis or large peripancreatic

8.
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10.

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fluid collection. Imipenem or cefuroxime penetrate pancreas well. No indication of daily

CT scan or CT aspiration unless features suggestive of infected necrosis. Surgical
debridement if severe necrosis, biliary pancreatitis, lack of response to therapy or
complications. ERCP if concurrent dilatation of biliary system or elevated LFT.
If the patient with pancreatitis develops fever, then take blood culture and start imipenem,
piperacillin, quinolones. IF pt fails to improve after 1 week of antibiotic therapy, a CT
guided aspiration of the tissue for C/s is done.
Acute HepB needs only supportive treatment, as most resolve on their own. Only chronic
active hepatitis needs lamivudine and adefovir. Conversion to chronic stage depends on
age- 90% if perinatal, 20-50% if below 5 and <5% if adult. Interestingly, if PT remains
normal during the acute infection, then the infection will likely resolve with no sequelae.
Isolated gastric varices without esophageal varices in a pt with chronic
pancreatitis is due to splenic venous thrombosis. It may also present with noncirrhotic
portal HTN, ascites, massive splenomegaly and hypersplenism. Portal vein thrombosis is
similar, but will have esophageal varices also.
Hepatic venocclusive disease is due to occlusion of terminal hepatic venules
and causes postsinusoidal portal HTN, with hypatomegaly, jaundice and ascites. This is
similar to Budd Chiari, but in the latter there is thrombosis of major hepatic veins.
Pseudomembranous enterocolitis suspect: rapid immunoassay for C difficile
toxin is very popular, but its sensitivity is low, so that if one is negative, repeat it if the
pretest probability of infection is high. Stool cytotoxin test and stool culture are outdated.
Culture is useless also because many nontoxigenic strains of C Difficile exist. Tt is metro.
IF relapse, again metro, coz relapse is due to inadequate treatment more than resistance.
Vanco if more than one relapse.
Febrile transfusion reaction can be prevented by washing the cells, using
leukocyte depletion filter, and preferring packed RBC to whole blood.
First test in chronic diarrhea is stool examination for leucocytes, parasites,
blood, fat, ph, osmotic gap.
Duodenal endoscopic biopsy is needed for diagnosing celiac disease, showing
villus blunting and increased lymphocytic infiltrate in the mucosa. Avoid wheat, rye and
barley. Can take soyabean, rice and corn and potatoes. Plus might need to supplement
iron, folate and calcium.
Chronic constipation- bulk laxative like psyllium, methylcellulose and dietary
fiber is the mainstay of treatment. Magnesia is c/I in CRF, castor oil and bisacodyl are
laxatives and cause electrolyte imbalance. Docusate is a softner but not used long term.
Triple therapy for H pylori failed- give quadruple therapy. Best way to see
eradication is urea breath test or fecal antigen test 4-6 wks after therapy. Fecal antigen test
is best. Early testing might produce false negative, as Helicobacter can transform into
urease negative coccoid form. Serology is uselss coz it doesnt differentiate past and
present infection. Endoscopic biopsy is not warranted to document care.
Complete resection of a <2cm polyp which proved to be dysplastic, but with
cellfree margins, no vascular or lymphatic involvement- we dont have to do anything.
Screening colonoscopy every three years is safe in those with previous polyp. IF >2cm
sessile, or if poorly differentiated, f/u colonoscopy in 4-6 mon.
Scleroderma- atrophy of muscle layer with fibrosis on HPE, dec peristalsis
wave and dec LES tone. Achalasia: dec peristalsis but inc tone, and hypertrophied muscle

20.
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24.
25.
i.
ii.
iii.
iv.
v.
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in HPE. Diffuse spasm: inc peristalsis and inc tone.

Kava can cause hepatitis and cirrhosis. Gingko can cause platelet dysfunction.
Ginseng can cause SJ syndrome and psychosis.
Pt of celiac disease not improving with gluten free diet must be suspected to
have intestinal T cell lymphoma. It can be nodular or ulcerative, leading to perforation
peritonitis. Pain, wt loss, diarrhea are typical, with malabsorption and anemia. Tt is
surgery and chemo, but prognosis is poor.
Post chole: no change in diet is needed, not even low fat diet. Giving CCK is
useless, as it is already produced by duodenal mucosa.
ALS pts need PEG gastrostomy, and not TPN, as it is irreversible. It is better
than NGT as it doesnt interfere with breathing and speech, and it doesnt cause sinusitis;
tho risk of aspiration is the same with both.
Protease inhibitors can be used to prevent ERCP induced pancreatitis.
Child Pugh criteria:
Albumin- <2.5, 2.5-3.5 and >3.5- score 1, 2 or 3 accordingly
Bilirubin- <2, 2-3 and >3
Ascites- None mild and moderate
Delayed PT- <15 sec, 15-17 and >17 sec
Encephalopathy, none, stage 1-2, or stage 3-4
Liver transplant if score is >7, ie class B or C in child pugh classification. Class A is <7

RESPIRATORY
1.
Large cell ca of lung- peripheral mass; SCC- cavitary mass inside bronchus
2.
SIADH- treatment is water restriction, with or without salt administration. Diuretics
can be used but watch for hyponatremia- should usually be given only with hypertonic
saline or salt tablets. If these fail, then demeclocycline, which is preferred to lithium due
to less side effect, tho it is nephrotoxic.
3.
ARDS- diagnosis criteria: PCWP <18, PaO2:FiO2 <200, and bilateral infiltrates,
with clear lung fields on exam re. Treatment is mechanical ventilation with high flow
oxygen, low tidal volume <6ml/kg and low plateau pressure<30 with PEEP of 5-10 (5 is
physiologic peep, so should be more than 5 here). Low tidal volume limits the
barotraumas. Steroid are not effective in acute phase, but useful in reducing
fibroproliferative phase of ARDS. NO and prostacyclins are not much helpful. Should be
weaned as soon as possible to prevent oxygen toxicity and atelectasis. Decrease FiO2
gradually to keep SaO2 at 90 and PaO2 above 60, and a slightly acidic pH (ie permissive
hypercapnia) confirmed by ABG. When FiO2 reaches 30% and patients neurologic status
is improved, then extubate.
4.
Indications for IVC Greenfield filter- recurrent VTE, c/I to anticoagulation, chronic
PE with PHTN.
5.
IVDU can present with septic pulmonary embolism from either septic
thrombophlebitis or tricuspid endocarditis. XR shows multiple round lesions in both lung
fields. Mgmt is blood culture and antibiotic.
6.
Asymptomatic sarcoidosis needs no treatment, including erythema nodosum or hilar
adenopathy. Steriods are used if other skin lesions, fever, hypercalcemia or decreased
pulmonary function to prevent fibrosis.
7.
Postop pt on heparin develops dyspnea- ECG and CXR should be done before going

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12.
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14.

15.
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for VQ or CT angiogram. CXR is done first also because VQ cannot be interpreted if there
are any previous lung pathology like COPD. Heparin followed by warfarin, to prevent
skin necrosis if only warfarin is given. Thrombolytics if hymodynamically unstable.
Warfarin is given for 3-6 mo for PE that occurred in the setting of reversible risk
factors, like OCP or immobilization; 6 mo atleast if idiopathic, atleast 12 mo ifmalignancy
or anticardiolipin syndrome; indefinitely if recurrent or continuing risk factor like
antithrombin deficiency.
VQ is the first investigation in suspected PE; esp if pretest probability is high like in
immobilized, cancer patients, OCP, etc; if it is negative and suspicion is high, then do
lower limb Duplex to calculate the pretest probability of PE before jumping to CT
angiogram. Pul angiogram is the gold standard, but not done usually. D dimer has high
negative predictive value, so some say it should be done first of all.
OSAS: first rule out hypothyroidism, esp if there are suggestive symptoms in a
patient, then refer for sleep study (polysomnography). MRI and nasopharyngoscopy
before uvulopalatoplasty.
Sarcoidosis- hypergammaglobulinemia, depressed CD4: CD8 ratio ie depressed cell
mediated immunity and activated humoral immunity, and cutaneous anergy is common.
BAL however shows high CD4. Hypercalciuria is much more frequent sign then
hypercalcemia, and can cause nephrocalcinosis and CRF
Wedge shaped infarcts seen in subsegmental PE are seen as Hamptons hump in XR.
Peripheral lung nodule- risk of malignancy is high if >3 cm, irregular or speculated
border, reticulate, punctate or eccentric calcification (vs regular, concentric, laminated,
central, diffuse homogenous or popcorn calcification of pul hamartoma). Doubling time of
benign lesion is either less than 20 days in acute conditions, or more than 450 days,
anything in between is malignancy, so checking for previous XR is always the first step. If
no earlier XR available, and current XR is inconclusive, HRCT has to be done, which can
show the morphology and the mediastinal node involvement. If high suspicion for
malignancy after this, then VATS and excisional biopsy is the TOC for peripheral nodule.
FNAC is less sensitive, while PET scan has high sensitivity but low specificity.
Think carcinoid if nonsmoking patient comes with recurrent postobstructive
pneumonia. Fiberoptic endoscopy with lavage and /or biopsy is the next best step. Sputum
cytology is very insensitive. Other causes of nonresolving pneumonia are CEP( chronic
eosinophilic pneumonia), alveolar proteinosis, bronchiolitis obliterans organizing
pneumonia (BOOP).
Magsol is no more recommended for asthma.
Asthma patient develops fatigue, diaphoresis, confusion, use of accessory muscles
with sterna retractions, marked tachy, pulsus paradoxus, PaCO2>40, PEFR <25% of
personal best: indications for intubation and ventilation.
Pts with PE can have fever and neednt be treated, unless very toxic, or with inc WBC
with bandemia.
ABPA criteria: underlying asthma, skin test reactivity, serum antibodies to
Aspergillus,, inc IgE and eosinophil in blood, lung infiltrate and central bronchiectasis.
Cough, fever, sputum, wheezing are typical symptoms. First thinkg to do is skin prick test
as it has high NPV. If it is positive, measure total IgE and antibodies to Aspergillus.
HRCT is last to detect bronchiectasis. Steroid is the TOC to prevent bronchiectasis and
lung fibrosis.

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LTOT: PaO2<55 on room air, or SaO2<88. Or if PaO2<60 but with cor pulmonale,
RHF or HCT>55. So before deciding for LTOT, ABG should be done, as PaCo2 has
prognostic value also.
Primary PHTN; all pts need anticoagulation because of increased risk of pul
thromboembolism, due to slow pul blood flow and dilated rt heart. Also vasodilators like
CCB are used, but before that should do vasoreactivity test, because using dilators who are
not reactive to NO or CCB show acute cardiopulmonary decompensation if oral
vasodilators are used. The commonest complication of PPHTN is cor pulmonale.
Stable COPD need only hx and ex preoperatively, and dont need PFT, ABG or
spirometry. These are needed if lung resection is planned, or if c/e shows airflow
limitation or suggests that the patients are not at their baseline lung functions.
CEP (Chronic Eosinophilic Pneumonia)- Xr shows peripheral infiltrate that are the
photographic negative of pulmonary edema is very characterstic. Pt comes with symptoms
of asthma, and can have allergic rhinitis. BAL shows eosinophils. ANCA is negative, but
antibodies to aspergillus may be positive (doesnt mean its ABPA). Churg Strauss
syndrome is similar, with asthma and rhinitis, plus peripheral neuropathy in most of the
patients, and involvement of other organs like kidney. Glucocorticoids are the treatment in
all three conditions, ie CEP, ABPA and Churg strauss. Loeffler syndrome presents with
migrating pulmonary infiltrates.
Lymphangioleiomyomatosis is a rare condition in women, presenting with dyspnea,
chest pain and reticulonodular infiltrates on XR, plus effusion and pneumothorax might be
there.
LT antagonist like zafirlukast are associated with Churg Strauss. They also cause BM
suppression and idiosyncratic hepatitis, so monitor LFT.
Silicosis- glasswares or pottery, small nodules in upper lung, with eggshell
calcification in hilar LN. Annual PPD testing and INH prophylaxis in the condition of
seroconversion is important, as silicosis is highly associated with TB.
Diagnosis of sarcoidosis- biopsy of parotid or superficial LN should be preferred to
hilar LN biopsy.
Asthma with PEFR 25% lower than the patients baseline: after beta inhaler, oral
steroids are the next step. Admit if PEFR is 40-50% lower. Intubate if danger signs or
PEFR <25% of normal.
Cough induced by forced expiration is very suggestive of asthma, ie bronchial
hyperreactivity.
Recurrent pneumonia- first do CXR to rule out a mass, if inconclusive, then do
HRCT, then only bronchoscopy, as it is an invasive procedure.

INFECTIOUS DISEASES
1. Rabies can be transmitted by aerosols from bats in caves. It is universally fatal once patients
are symptomatic.
2. HIV prophylaxis indicated for exposure to genital fluids and blood, but not urine, sweat,
sputum, tears or saliva.
3. TSS- treatment is heavy fluid loading, with clindamycin with or without nafcillin to prevent
recurrence of TSS
4. Human bite- Strep, Staph, Eikenella corrodens( main one, GNB), hemophilus, bacteroides,
peptostreptococcus, actinomyces and fusobacterium. Treatment is ampicillin-sulbactam

after cleaning thoroughly. Pasteurella multocida in cats and dogs bites.

5. Elderly in nursing home presents with pneumonia, and XR shows right lower lobe fluffy
infiltrate, its probably aspiration pneumonia.
6. Erysipelas as a consequence of sinusitis- beta hemo strep, but these days penicillin resistant
strep and staph are increasing, so the TOC is shifting from iv penicillin to anti-staph
penicillin.
7. HRCT and DLCO measurement are highly useful for pneumocystis, but still bronchoscopy
and BAL is the diagnosis of choice, with or without transbronchial biopsy to increase the
yield. Treatment is oral cotrim if mild, and iv cotrim if moderate to severe, with steroids,
to prevent hypoxic resp failure. Giving only antiretroviral can worsen the resp failure due
to immune reconstitution phenomenon. Steroids indicated if A-a gradient>35 or if
PaO2<70.
8. Type I necrotizing fasciitis is polymicrobial, seen in DM and PVD patients, and microbes
include Staph, Bacteroides, E coli, GAS, Prevotella. Type II is associated with laceration,
IVDU, blunt trauma or surgery, and typically caused by GAS (pyogenes). Severe pain in
the absence of significant skin change is the initial presentation, with later bulla formation
and systemic toxicity. Staph alone is not associated with NF.
9. Treatment for type II NF is iv clindamycin, with surgical debridement.
10.
Meningoencephalitis, splenomegaly, pneumonia triad in immunocompetent
host is Chlamydia psittaci UPO, esp if vet, poultry or bird breeders. Presents like culture
negative endocarditis, confirmed by serology. Treatment with doxycycline. Admit if
danger signs, hypoxia, old aged or immunocompromised.
11.
Pt on antiepileptic- avoid imipenem, monobactam, penicillin, cephalo and
quinolones as they can cause seizures. Esp if pt has old age, renal insufficiency,
preexisting CNS disease.
12.
Gingko biloba- used in intermittent claudication, ARMD and Alzheimers; can
cause diarrhea, seizures, irritability but more importantly bleeding, esp if pt is on
anticoagulant. Its bcoz it inhibits PAF.
13.
Saw palmetto acts like finasteride in BPH. Kava is used for anxiety and
insomnia, and is sedative and hepatotoxic. St Johns wort for depression, and each has
been proved to be effective than placebo. Garlic for lipid disorder- and can cause platelet
dysfunction like Gingko. ST John wort can cause GI distress, dry mouth, anorgasmia, etc.
Chinese wt loss herbals have artistolochic acid which is nephrotoxic.
14.
Glucosamine used for OA can cause problem with glucose control in diabetics.
PREVENTIVE MEDICINE
1.
Person exposed to active TB should immediately get baseline PPD, then repeat PPD
at 3 wk- 3 mo to see conversion. If conversion occurs, then CXR- if CXR negative,
monotherapy with INH prophylaxis, and if CXR is positive, then DOTS.
2.
Close contact of meningococcal patients should receive rifampin to eradicate
pharyngeal carriage, for eg woman working in a nursery. But if she can take rifampin coz
she is on OCP, then a single dose of cipro is sufficient. Health care worker exposed to
such cases, however, dont need it.
3.
Fasting glucose to screen for DM is advised in everyone after 45 yrs, 3 yrly, or yrly
if risk factors like f/h, metabolic syndrome, African or Hispanic or PCOD is present, or if
h/o IGTT or gestational DM.
4.
Total cholesterol >200, first step is to order a complete lipid profile, which will give

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HDL and TG. Calculate LDL by TC-(HDL+TG/5). Primary goal is always treating LDL,
so use ator even if TG is much higher than LDL. Only if the statin cant control TG with
LDL, then add fibrates. In a pt on HRT and high TG, however, the first step is stopping
the HRT.
Influenza vaccine- above 50 yrs (65 since 2005 due to low budget), chronic diseases
like COPD, asthma, CRF, DM, HIV, malignancy; nursing home residents, 2-3 trimester,
healthcare worker, household member of person at high risk of developing complicated
influenza, like if children have CF, 6-23 mo child, or older if on long term aspirin
treatment, household contacts of <6mo child. Young normal individuals dont need
vaccine, as even if they contract influenza, it is not going to be complicated. C/I if egg
allergy.
Abrupt cessation is preferred to gradual decrease in smoking (cold turkey), with
nicotine patch as the first choice, and then bupropion if needed.
Children who have high lipid( TC>240) or CAD in family should have TC screening
at 2 yrs of age, then fasting lipid profile if TC is high, or directly fasting profile if there is
h/o CAD in family. Repeat 5 yrly. Below 2, no use of screening as the diet is rich in fat at
that time.
A decrease of BP by 5 mm decreases the risk of stoke by 40%. Neither aspirin or
statins or diabetes control or smoking cessation are as effective as control of BP.
Screening for prostate cancer with DRE and PSA should be done in males 50-70 yrs
of age. Begin at 45 if high risk, ie African or with f/h of 2 or more first degree relatives).
Repeat annually.
FAP: ideal is total colectomy before the age of 20 yrs.
Smoking cessation has far better effect on preventing osteoporosis than exercise or
dec alcohol. HRT is not preferred these days due to risk of breast and endo cancer and
cardiovascular diseases.
Wellness examinations- should counsel about safe sex, vaccines, importance of
screening, seatbelt, exercise, wt loss, alcohol, smoking and drugs. Chlamydia screening in
all women below 25 who are sexually active, or above 25 with multiple or new sexual
partner, or pregnant below 25 yrs. Gonorea is very uncommon these days, so no need of
screening.
Colonoscopy is preferred to FOBT, and should be started at age 50, 40 if f/h of colon
cancer, 25 if lynch syndrome and 15 if FAP. (not sure.) repeat 10 yrly, or 5 yrly if
sigmoidoscopy.
Self breast exam has no benefit, clinical breast exam alone also has no benefit, but
should be combined with mammogram, after 40 yrs of age, till 70 yrs. After that the
probability of dying from other causes is higher. Repeat 1-2 yrly. Breast lump after the age
of 35 should be evaluated with mammography.
Pts with antitrypsin deficiency should be f/u 3 monthly with spirometry. Enzyme
replacement therapy only if radiological evidence of panacinar emphysema or if the
patient is symptomatic.
Baby born to HBV positive mother- HBIG and vaccine at 12 hrs, then at 2mo, then 6
mo, then test for antigen and antibody at 9 mo to see if he has gone into chronic hepatitis,
or if the vaccination has to be repeated again.

17.
ETHICS

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Truck driver with DM on metformin drinks alcohol- what will you say? Dont drink
alcohol is paternalistic, and total abstinence is not required either with DM or in patients
on metformin; Total abstinence is preferable only if f/h of alcoholism, pancreatic or liver
or heart disease or hyperTG or previous alcohol related problem. You can drink, but in a
moderate manner is wrong as this justifies drinking which can cause many complications.
Best response is we must talk about your drinking and how it affects your driving. He
must be screened for alcoholism, as it predisposes to hypoglycemia, which is specially
dangerous in his profession. Those on metformin and with liver, renal or cardiac
compromise, or old than 65 yrs should avoid alcohol to decrease the risk of lactic acidosis.
Medical care for braindead patients is important till he is transported to transplant
center to keep the organs viable- so pt should be kept euvolemic, normotensive,
normothermic (not hypothermic), and shouldnt be hypoxic or hypercapnic. Pt should be
kept in ICU. Hypotension is common due to loss of sympathetic tone, fluid loss and DI, so
fluid replacement, and if necessary pressors and inotropes are needed.
Send to hospice if life expectancy is six months or less, also in patients with end
stage COPD, pul fibrosis and cardiomyopathy.
Patient is taking unknown herbal medication on which no adequate research has
been done- say dont take the medicine, as its benefit has not been proved, and it might
cause harm as a physician duty is to protect from harm. If known herbs like ginseng,
which has adr, obtain a written agreement which releases the physician from any liability,
but continue to follow the patient up to identify and treat any complication.
Eg, ma huang is the Chinese name for ephedra used for wt loss.
Be the patients advocate- an old woman unable to care for herself, has serious
illness- advise her against living alone. If no relatives where she can live with, send her to
nursing home. Even if she refuses, adult protective services can prohibit her from
returning home alone.
If a cometent adult woman says that her husband will sign the consent to any
surgery for example, let it be- she has a right to choose her surrogate. Means surrogate are
not only for end of life decisions.
PT who is diagnosed with life threatening diseases like Huntington and Tay Sachs
refuses to tell his family, putting other family members and siblings at jeopardy- you
neednt inform the family, but make the patient sign the refusal document.
If multiple first degree relatives disagree on the treatment of an unconscious patient,
go to hospital ethics board, and then if necessary to court.
A specialist is fed up with the drug seeking patient who slaps nurses and wants to
leave him- he cant do that without prior notice and arrangement to transfer him to another
specialist. Nobody can leave a patient, however difficult, in the middle of a treatment.
A dehydrated depressed elderly is probably abused- first thing to do is admit to
distance from the abuser and to rehydrate, then inform the adult protection services.
Braindeath- absence of respiratory drive off ventilator for a duration that is sufficient
to produce hypercarbic drive (PCO2 of 50-60). Body temp above 94, EEG isolectric for
half hour, no cerebral circulation on Doppler, and 24 hrs in observation with anoxic or
ischemic brain damage with negative drug screen. Braindead patients can still have leg or
arm movements due to spinal reflex, and this should be explained to the family.
Health care proxy or surrogate have the right to know all information of the patient,
but if they call, talk only briefly and ask her to come in for personal visit.

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Tell the truth not only to the patient, but also to the insurance company- else it will be
insurance fraud.
15.
Jehovas witness is refusing exchange transfusion to a diseased neonate which might
develop kernicterus- since it is not emergency but is urgent, consult the hospitals ethics
committee about seeking court injunction to mandate exchange transfusion.
16.
A patient refuses basic life support and cardioversion in case he goes into arrhythmia
during surgery, and signs the advance directive- its ok to transfer the patient to another
specialist, due to nonreconciliable difference between the physician and the advance
directive- it is incorrect to proceed with the surgery, as it has the possibility to harm due to
patients refusal of basic life support. THIS IS NOT THE SAME AS END OF LIFE
SUPPORT.
SURGERY
1. A pt involved in MVA couldnt be extricated from the car, is unconscious and he started
coughing up blood- first thing to do is secure the airway without spinal manipulation by
jaw lift manuver. Only then suction and stabilisation of neck. Intubation is not needed as
the patient has spontaneous respiration.
2. Thompson test in Achilees tendon rupture: no foot plantarflexion on calf muscle
compression.
3. Cholangitis: ampigenta or monotherapy with imipenem or levofloxacin. If not responsive,
do decompression with ERCP.
4. MVA pt after intubation doesnt have satisfactory oxygen saturation, and on examination
has hypoventilation on one side of the chest. The first diagnosis should be bronchus
intubation. So try to check the ETT placement, and withdraw it a few cm. If that doesnt
help the oxygen saturation, then think about pneumothorax, and do a needle
decompression.
5. Pt with acute colonic ischemia are not due to embolism like mesentric ischemia, but due to
hypotensive state. IT presents with lateralised abdominal pain (periumbilical pain in
mesentric ischemia), and with hematochezia.
6. Pt who die due to lightning strike usually have asystole, so if they dont respond to CPR,
then epinephrine should be tried, atropine comes next. Defibrillation will not help in
asystole patients.
7. All animal bites should be thoroughly cleaned with NS, debrided, Xred to see the presence
of foreign body or bone involvement, and shouldnt be primarily closed (except if dog bite
on face, due to its vascularity infection and nonhealing is not common in the face). Also
puncture wound, cat and human bites shouldnt be closed primarily.
8. Only TT if contaminated would and <5 yrs since vaccination, or clean wound and >10 yrs
since vaccination, no TT if clean wound and <5yrs since last dose, TT and ATS if
contaminated and >10yrs since last dose, or if vaccination history is not known.
9. Scrotal trauma with hematoma formation on examination, surgical exploration should be
done immediately, and not USG as USG has not been shown to be reliable.
10.
Inhalation injury without any surface burn- the most dangerous complication is
supraglottic edema. Fibreoptic laryngoscopy should be done, and intubation if necessary.
11.
Laparoscopy can be used to evaluate tangential gunshot wound, but
perforating GSW needs laparotomy. Exploration under local anaesthesia for stab wound.
12.
Compound clavicle fracture should be repaired by ORIF
13.
MVA patient with bradycardia, bradypnea and HTN has cushing reflex- and

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the first thing to do is secure an airway with ETT to prevent respiratory arrest.
Hyperventilation to reduce ICP is contraindicated in those with head injury and ischemic
stroke, as it can worsen the neurological injury due to vasoconstriction.
Polytrauma patient with shallow breathing, tachycardia, chest bruises, cyanosis
with intact Breath sound probably has flail chest- hypoxia is caused due to associated pul
contusion and inc work of breathing due to muscle spasm.
Pt comes with knife sticking in his head- first thing to do is not CT but
coagulation profile and blood match and cross match.
Aortic injury is the most common cause of sudden death in steering wheels
injury, and occurs in the area of lig arteriosum, aortic root and diaphragmatic hiatus.
Pt who underwent lidocaine injection for PIVD came with fever, and leg
paralysis and anesthesia- he has epidural abscess. First step is MRI with gadolinium
contrast. CT myelography is an alternative. Antibiotic should be started, guided by CT
aspiration or biopsy culture. Immediate surgical exploration is needed.
Pneumatic compression alone is not sufficient in high risk patients to decrease
risk of DVT, because they can still have pelvic vein DVT.
<5mm renal stones pass spontaneously. Removal is mandated if small but
causing persistent pain even after analgesics, or if urosepsis or renal failure. ESWL is
preferred for small proximal ureteric calculi, while ureteroscopy with laser lithotripsy for
large >1cm proximal stones.
Post communicating artery aneurysm- diplopia, ptosis and anisocoria. PICA
aneurysm- ataxia and bulbar dysfunction.
Scaphoid fracture on presentation- first thing to do is not casting, but CT or
bone scan to rule out fracture. If fracture is really present, then thumb spica cast with wrist
in slight radial deviation and neutral flexion. Most common complication is nonunion and
not AVN.
Sister cannot be considered legal guardian of a child- so in emergency if
parents are not around, we should treat the child anyway, and we dont take the sisters
consent.
Elderly with BPH comes with protruding rectal mucosa with bluish
discoloration and fraibility- its rectal prolabpse with strangulation and gangreneimmediate surgery (rectosigmoidectomy) is needed. If not strangulated, can try digital
reposition under sedation, or application of granulated sucrose to decrease the edema.
Reflex sympathetic Dystrophy, aka Complex Regional pain syndrome
(CRPS)- immobilisation after sprain or fracture, causing allodynia, hyperalgesia, some
edema, changes in skin blood flow and sudomotor activity (sweatin), later leading to
atrophyof tissues. This is due to SMP (sympathetically mediated pain), causing
vasoconstriction and ischemia. Early treatement with a blockers like phenoxybenzamine,
chemical or surgical sympathectomy within 3 months and early physiotherapy helps to
reduce its incidence.
Plica syndrome- crepitus, snapping and effusion related to prominent medial
plica of synovium which gets trapped in the knee joint, presenting like torn medial
meniscus or maltracking patella.
PSA over 4 needs urology referral for biopsy.
Proximal nonmetastatic rectal cancer can be treated with sphincter sparing
surgery, while distal can be locally resected only if mobile, small and nonulcerated. Big

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tumors can be given neoadjuvant chemoradio to make them resectable.

Smooth, round, soft, mobile, mildly tender breast mass implies cyst and not
fibroadenoma- so the best step is FNAC, if pt refuses it, then mammo if over 35 yrs of
age, or USG if under 35.
Silicone breast implant havent been associated with any connective tissue
disease, any problem in fetus or in breastfeeding. Only problem is contracture of the
capsule, pain and sometimes rupture needing extraction. It also doesnt affect the
mammogram criteria, though the calcifications along its capsule can rarely lead to a false
positive result. It doesnt obscure mammogram or decrease its sensitivity.
Multinodular thyroid in a patient with short neck can be retrosternal and cause
symptoms of dysphagia- treatement is surgery. Iodine or thyroxine dont help, as there is
already considerable fibrosis in the gland. RAIU and Antithyroid drugs can infact cause
initial enlargement of the gland, so are contraindicated.
Undescended testis, or varicocele can cause infertility due to the effect of
temperature on the spermatozoa, but not hypogonadism as the Leydig cells are not
affected.
Pt with bilateral or right sided varicocele, or varicocele that doesnt disappear
in the supine position, should be investigated for clot or tumor obstructing the inferior
venacava. Varicoceles are common in the left side due to the drainage of veins.
March fracture: XR can be unremarkable for 2-4 wks, so do bone scan or MRI
Pt showing multiloculated cyst in pancreas on Ct- no need to do CEA and CA
19-9, as they are very nonspecific. Directly send the patient to surgery.
Barometric surgery- if BMI >40, if decreased quality of life, eg OA and sexual
dysfunction, OSAS, movement limitation or brittle diabetes. Benefits of gastric bypass or
gastric banding include better DM control, better lipid levels, sleep improvement,
depression decline, etc.
Pt with hard nontended scrotal mask suspected to be tumor- FNAC or biopsy
are contraindicated. Referral to urology for radical inguinal orchiectomy is the TOC.
Before that, CT of abd and pelvis to detect LN metastasis, and tumor markers can be done.
Testis usually descends spontaneously within 6 mths, else surgery is indicated,
at most before 2 yrs. Even after surgery, the risk of malignancy is still high, but it makes it
easier to examine the testis. Orchiopexy does decrease the risk of infertility.
Breast lumps can be examined 4-10 days after menstruation for regression in
size, which implies fibrocystic disease. If palpable and patient is anxious, FNAC should
be done, and fluid sent for HPE if bloody. Reexamine in 4-6 wks for any regression or
recurrence.
Congenital hernia due to persistent processus vaginalsis should be repaired as
early as possible to decrease the risk of incarceration.
CT or nuclear scan to see for remnant thyroid tissue is needed before Sistrunk
operation for thyroglossal cyst, else we might remove the only functioning thyroid tissue
inside the cyst. CT is preferred.
Epididymitis: mild pain, (severe in orchitis), usu due to Chlamydia these days,
cremasteric reflex is absent, Prehns sign positive (ie pain subsides on elevation), testis is
high riding, transillumination usually shows unilateral hydrocele due to reactive effusion,
Doppler USG if equivocal, and treatment is xone and doxy.
Recurrent abdominal or thigh superficial tumor with mild pain is desmoid

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tumor. Excision with a wide margin of resection is the TOC.

ESWL for gallstone if only 3 or less stones, ursodeoxycholic acid if small
stones with functioning gall bladder, electrohydraulic lithotripsy is very cumbersome, and
surgery is the TOC.
Dumping syndrome: high protein diet in small doses and frequent interval is
the TOC, low carb diet, alprazolam helps for neurovegetative symptoms (dizziness,
sweating and dyspnea), metoclopramide increases gastric emptying and exacerbates the
problem.
Retrograde ejaculation is the most common complication of TURP. Urinary
incontinence and erectile dysfunction are the complications of nerve damage due to
suprapubic radical prostatectomy, which should be done if the TURP specimen shows
evidence of malignancy, even if only adenocarcinoma in situ ! It should be done with LN
dissection following sentinel LN sampling using technetium radiolabelling. Chemo,
bicalutamide antiandrogen therapy and radio are reserved for advanced lesions.
Raloxifen (SERM) used for osteoporosis, can cause hot flashes and more
importantly DVt. So should be stopped 72 hrs before any elective surgery.
Klinefelter syndrome predisposes to male breast cancer, but not testicular
cancer, tho the testis undergo atrophy.

GYNAECOLOGY
1. Shoulder dystocia- first thing is to tell mother not to push, then reposition the fetus, and
then suprapubic pressure. If it fails, McRoberts maneuver, ie flexing the mothers knee
towards the abdomen; or Rubin or Woods maneuver or delivery of posterior arm first.
Zavanelli maneuver is replacing the fetus head in the pelvis before performing a CS.
2. Lesbians- have lower risk of contracting all STD, including cervical cancer. They should
still be given HBV vaccine.
3. After the first baby of a twin is born, then positioning and heart rate of the second should be
assessed with USG. If labor is halted, start oxytocin. Forceps is c/I if second amniotic sac
is intact. Internal podalic version can be done to revert breech into cephalic position
re
4. HELLP syndrome- treatment is again Magsol, to prevent seizure. Plasma exchange
transfusion in persistent HELLP.
5. LSIL on Pap- do colposcopy. IF colposcopy is satisfactory (ie entire lesion and
transformation zone visible), expectant management with repeat cytology 6 mthly or
HPVDNA testing at 1 yr. If the lesion is persistent after 1 yr, or there is progression, or if
colposcopy is unsatisfactory, or if HSIL, treatment with either ablation or excision is
needed. Ablation can be cryo or laser, and excision can be knife or laser conisation or
LEEP (Loop Electrosurgical Excision procedure). LEEP is the most favored procedure.
Ablation is done in low risk lesion, without evidence of invasion and satisfactory
colposcopy.
6. Condyloma are not c/I for vaginal delivery, as long as they are not large enough to cause
obstruction. HSV is an contraindication however.
7. Risk of repeat preeclampsia is atleast 7 times higher, or even more if the previous
preeclampsia occurred earlier, or pt has chronic renal disease or HTN.
8. Most effective strategy for severe preeclampsia is delivery, tho the next best step is magsol,
as preeclampsia has other complications besides seizures, and magsol only controls the

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seizures. IV hydralazine or labetalol for BP control. Even after eclampsia occurs, magsol
is more beneficial than phenytoin in preventing seizure. Diazepam if magsol is c/I, eg due
to myasthenia.
Retinal hemorrhage is considered the most ominous sign of preeclampsia. Also PGI2 dec,
TXA2 inc, NO dec, Endothelin inc.
Fasting glucose target in GDM is 60-90 and postprandial <120. If higher, start
NPH at bedtime, with regular or lispro before meal. Glargine is contraindicated as it is
teratogenic.
Postpartum endometritis- TOC is clindamycin and gentamicin, as metron is c/I
in breastfeeding women, and ampigenta dont cover lactamase producing anaerobes. The
most important risk factor for endometritis is route of delivery, not PROM.
Pap should be started only 3 yrs after assuming sexual life, or at 21 yrs of age,
as HPV needs 3-5 yrs to cause SIL
No consent needed from parents in treating a minor for STD, pregnancy,
abortion !!, contraception, drug use and emotional problems like anorexia and depression.
Menorrhagia is the most common complication of norplant, others being TTP,
vaginal spotting (less common), DVT, PE, stroke, MI, and breast cancer.
Postmenopausal women- start vitd and Ca supplement, HRT has fallen out of
favor due to cardiovascular risk. Use raloxifen or alendronate only if documentation of
low BMD, or history of fragility fractures.
HGSIL on pap- do colposcopy with endocervical curettage- if this confirms
HGSIL, then ablation or excision.
ASCUS on pap- best next step is HPV testing. If it shows high risk HPV, then
colposcopy, else f/u in 1 yr. Some recommend accelerated pap for ASCUS, every 4-6mth,
if second pap is abnormal, then colposcopy, but this requires greater no of visit and delays
diagnosis.
PPH- first thing to do is pelvic examination for retained placenta, then
bimanual massage, if this is not effective, only then oxytocin.
Athletes having amenorrhea due to low GnRH can result in osteoporosis,
vaginal and breast atrophy and infertility. Treatment is improving caloric intake, and if
this doesnt help, then vitD/Ca and OCP.
Levonorgestrel is preferred to combined estrogen/prog for after morning pill,
valid upto 120 hrs. If after 120 hrs, use copper T.
Absolute c/I to OCP- h/o of thromboembolism or stroke, active liver disease,
h/o estrogen dependent tumor, pregnancy, DUB, smokers> 35 yrs, hyper TG. Relative c/I
are migraine, poorly controlled HTN and anticonvulsant therapy. Diabetes and f/h/o
malignancy are not c/i.
20% women with CF are infertile, due to thick cervical mucus and amenorrhea
due to malnutrition, 95% of male are infertile due to impaired development of Wolffian
duct, and poor sperm transport.
Annual pap is recommended even in lesbian, tho the interval can be increased
to 2 or 3 yrs after 3 or more consecutive normal pap.
Trichomonas in postpartum period- give 2g single dose of metron, and
withheld breast feeding for one day. Also treat the partner. Local vaginal therapy are less
efficacious coz it doesnt reach the urethra and the periurethral glands.
Stress incontinence- alpha agonists like amitryptiline can help by increasing

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the sphincter tone. Anticholinergic like oxybutinin and biofeedback are for urge
incontinence.
UTI in pregnancy- cephalexin, amoxicillin or nitrofurantion. Even
asymptomatic bacteriuria has to be treated to prevent preterm birth and neonatal sepsis and
endometritis, and risk of progression to pyelonephritis. After treatment, eradication should
be documented with urine culture. Pyelonephritis is treated with 10-14 days xone or
ampi/genta, followed by low dose nitrofurantion or cephalexin prophylaxis for the
remainder of the pregnancy.
If Pregnancy is detected early in first trimester in HIV patients, its better to
withheld HAART. If in second trimester already, continue HAART. HIV patients
shouldnt breastfeed, even if on treatment.
In pregnancy or if on OCP, the dose of Thyroxine has to be increased due to
inc TBG in the body, plus increased body mass and VOD in pregnancy. Monitor TSH and
try to keep it at normal level.
Subchorionic hematoma are diagnosed by USG, and should be observed with
repeat USG in 1 week. The most common complication of such hematoma is spontaneous
abortion. Preterm birth and IUGR are also possible.
Gabapentin and valproate are safe to be used in pts on OCP- other
antiepileptics will decrease the efficacy of OCP.
Pregnancy is still possible in Turners, tho the chance is very small.
A lady with hemophiliac husband is worried and asks what is the risk of her
child having hemophilia? The answer should be none, as the child will be only a carrier
if a female, and normal if male.
Hyperreflexia is an ominous sign of severe preeclampsia and heralds
eclampsia- treatment of severe preeclampsia is hydralazine or labetalol, plus magsol.
Physiologic changes of skin are the commonest cause of general body pruritus
in pregnant wome. Other cause is herpes gestationis, aka pemphigoid gestationis, which
manifests are urticarial veriscles around umbilicus, and is not due to viral infection.
PUPPP (popular urticarial papules and plaques of pregnancy) is another and involves the
stria gravidarum. Treatment is antihistamine, topical steroid, emollient, etc. Topical
steroids are the DOC.
Contraindication of exercise in pregnancy are pul or cardiac disease, cervical
incompetence, twin, abruption placenta, placenta previa, Premature labor, preeclampsia.
Scuba is c/I as it can cause decompression sickness in the child
Limb reduction defect associated with CVS depends mostly on the age- higher
risk with earlier age.
Weight reduction is the TOC for PCOD infertility. After that is clomiphene,
and if it doesnt work, then gonadotropins. Metformin is not studied enough, so is usually
not the answer.
Adolescents dong comply with OCP mostly because of concern over wt gain,
tho there is no hard evidence.
Testicular feminization- pt has breast development but no axillary or pubic
hair, unlike in constitutional delay, where such asynchronous delay is not found.
Laparoscopy is always the first step in suspected endometriosis, to rule out
other pathology, and to see the extent of the disease, plus it can be therapeutic too with
bipolar coagulation.

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Unilateral nipple discharge is cancer UPO, so do mammogram, even if it is

serous. It can be f/by FNAC or biopsy, and cytology of the discharge if it is bloody.
CVS doesnt help with detecting NTD, as it is only for cytogenetic studies and
doesnt measure AFP levels.
NTD needs immediate surgery to prevent infection of CNS, followed by
orthopedic evaluation to correct patients posture and promote ambulation.
All pregnant women should be screened for Chlamydial infection in the first
prenatal visit, and repeat in third trimester if the patient is below 25 yrs of age (donno
why)- coz it can lead to endometritis, chorioamnionitis, conjunctivitis and pneumonia in
the baby, preterm delivery, PID, ectopic. If positive, treat mother with erythromycin base
(estolate is c/i)or amoxicillin for 7 days; and father with azithro single dose.
The MCC of postmenopausal bleeding is atrophic vaginitis, then endometrial
ca, while cervical cancer is a very rare cause.
Rosette test can be done to detect fetal RBC in mother in cases of
isoimmunisation, and if present, then quantify how much fetomaternal bleed has occurred
by Kleihauer Betke test. Adjust the dose of anti RH globulin accordingly.
Sickle cell disease- OCP are not preferred due to thromboembolic risk,
progesterone pills cause breakthrough bleeding and aggravate anemia, IUD also increases
bleeding, so the best contraceptive is DMPA or norplant. Almost half of pregnancies are
complicated by either acute crisis, endometritis, pyelonephritis or thromboembolism.
Pt on antiepileptic becomes pregnant- never change the drug. Add folate
(though benefit has been shown only in animal studies) and offer screening for NTD with
serum fetoprotein, amniocentesis and USG, and termination if affected. Also antiepileptic
is not a c/I to breastfeeding, though Phenobarbital and diazepam can be stopped for a few
weeks if the child becomes irritable or sleepy.
Eisenmenger syndrome is absolute contraindication to pregnancy- elective
termination of pregnancy should be advised. The sudden drop in systemic vascular
resistance with delivery will cause cyanosis in the mother. Also higher risk of spontaneous
abortion and preterm delivery. Only treatment is heart lung transplant, or lung transplant
with intracardiac repair.
Gestational transient thyrotoxicosis (GTT) has mild increase in free T4 and
only slight decrease in TSH, due to the effect of hCG on thyroid stimulation. If TFT are
normal, and pt has typical symptoms of hyperthyroidism, she probably has anxiety
disorder or something else. Subacute lymphocytic (postpartum) thyroiditis causes only
transient hyperthyroidism, and shows reduced RAIU test.
DMPA is the contraceptive of choice in pt with VWD or hemophilia, as it
decreases the menstrual flow, unlike IUD or minipill which increases bleeding. It also dec
risk of PID and endometrial cancer, and is useful in those with fibroid.
Downs diagnosis- increased nuchal translucency on USG in 10 wks, PAPP-A
in the first trimester, quadruple testing ( with dimeric inhibin A) in second trimester, and
karyotyping with CVS in 10 wks and amniocentesis in 16 wks.
A pt recently started on OCP comes with spotting, just reassure her that is
normal breakthrough bleeding, and nothing needs to be done. Just continue the OCP.
Some patient may complain that there is no withdrawl bleeding. That is normal too,
initially. Advice her to use condoms if she forgot to take her pill for 2-3 days.
Clonidine is useful for hot flashes, esp if there are any c/I to the use of HRT.

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Progestin has also been shown to be effective for hot flashes, but causes mood
disturbances.
Any preterm labor- always administer prophylactic penicillin for GBS. Also
betamethasone if between 24 to 34 wks.
Intrahepatic cholestasis of pregnancy is associated with still birth, so in a ICP
suspect, do LFT to rule out other causes, and then undergo fetal testing and early delivery.
Elderly with burning, dyspareunia and a butterfly like atrophic white lesion on
the vulva, has lichen sclerosis. Treatment is potent topical testosterone !!
Breastfeeding suppresses estrogen release from ovary, and that can result in
vaginal dryness and dyspareunia.
Air travel is c/I after 36 wks, or if h/o HTN, preterm delivery, poorly
controlled DM or sickle cell anemia.
A pt comes with primary amenorrhea, no other symptoms like abd pain, and
normal secondary sexual characteristics. This is probably uterine agenesis and not
imperforate hymen (Mayer Rokitansky Kuster Hauser syndrome)
Meigs syndrome- TOC is unilateral oophorectomy and not TAHBSO, as it is
caused by a benign ovarian fibroma. Tricky.
Regularly timed but heavy periods imply adenomyosis, endo hyperplasia or
polyp or fibroid. Anovulatory DUB is characterized by irregular cycles.
If a pt comes with PROM at say 28 wks, then expedited delivery is not
warranted, tho prophylactic antibiotics can help prevent amnionitis. Delivery should be
delayed until sign of infection develops to promote further fetal growth and development.
c/I to daily aerobic exercise in pregnancy are significant heart disease, HTN,
preeclampsia, preterm labor and PROM, restrictive lung disease, incompetent cervix,
twins, placenta previa.
A pt with normal mens hx comes with abnormal bleeding. It is most probably
due to pregnancy, and not anovulatory bleeding. PREGNANCY always comes first in d/d.
Pt comes with severe pv bleeding, hypotension and anemia- Tt is iv estrogen,
vasopressin if needed, BT, followed by oral estrogen which is gradually tapered. If above
35 yrs, do endometrial sampling before starting estrogen to rule out endometrial
hyperplasia or Ca.
Rapid onset virilisation with clitoromegaly and frontal balding- its probably
ovarian or adrenal androgen secreting tumor and not PCOD. So the first investigation is
USG pelvis.
LH:FSH ratio is not a very sensitive test for PCOD re. Amazing.
Below 40 yrs, breast lump if dismissed as having no abnormality by USG or
mammo, has 1% chance of malignancy, so nothing needs to be done. But if more than 50
yrs, it has >40% probability of being cancer, so even if mammo is negative, still have to
do biopsy or fine needle aspiration.
Postpartum telogen effluvium is common after 2-6 mo of delivery.
The preferred therapy for inpatient PID is iv cefoxitin and iv doxy, +/-metron
if vaginal smear shows trichomonas. Alternative is iv clinda and iv genta. Beware of
options with oral doxy. Admission is needed in pts with peritoneal signs, n/v precluding
oral treatment, pregnancy, etc.
All SSRI are excreted in breast milk, so only short acting ones should be used
in postpartum period, so that patient can refrain from breastfeeding till the drug is in her

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Shoulder dystocia and obstructed labor- first thing to do is call for help. Then
McRoberts maneuver by pushing the mothers leg as far back as possible. Then epi,
supriapubic pressure, Woods corkscrew manuvre, heel knee position, and finally pushing
back the fetal head and CS if everything else fails.
IUD protects against endometrial cancer
HRT increases HDL and lowers LDL, thus dec cardiovascular mortality long
term, but it has been shown to increase coronary event in the short term.
After the first trimester, advise not to exercise in supine position, as it can
compress IVC, dec CO and cause uterine hypoperfusion.
Fragile X is a X linked dominant syndrome due to triple repeat expansion,
which is a type of mutation. If the permutation is transmitted from the mother, it has a
higher chance of expansion than if from father. Huntington on the other hand is autosomal
dominant.
Breastfeeding is usually successful after reduction or augmentation
mammoplasty or breast implant.
If a pt is profusely bleeding pv, D&c gives a faster response to stop the
bleeding than iv estrogen.
Screening for DM starts at 45 with three yearly RBS, for lipid disorder starts at
45 if no risk factor, but as early as age 18 if has risk factor like f/h of MI.
A pregnant mother is diagnosed with sec syphilis in her second trimester. The
baby will be born with ? snuffles, rhagades and neurosyphilis (features of early congenital
syphilis), not saber shin/Hutchinson teeth, as these are manifestation of late congenital
syphilis. Also can have meningitis, hydrocephalus, optic atrophy.
Maternal obesity increases the risk of NTD, tho the reason is not known. It
also increases the risk of GDM, macrosomia and stillbirth, so wt loss before conception is
advised.
Tubal ligation: failure rate is 5% and not 0.1%, 5-20 % pts regret later doing
the ligation.
The presence of endocervical cells on Pap is regarded as adequate sampling. If
these cells are absent, then in a no risk patient, repeating may be deferred till next years
Pap. If it is high risk patient, then repeat immediately.
After an episode of pyelonephritis in pregnancy, the pt should be put on
prophylactic antibiotic for the rest of her pregnancy.
A pt comes with IUGR, ie <10th percentile, then the first thing to do is Doppler
velocimetry of the umbilical artery. If the flow is absent or reversed, then immediate
delivery is warranted, else not.
ER+ breast tumor needs tamoxifen for 5 yrs to reduce recurrence after surgery,
chemo and radio. Lifelong tamoxifen is not used as it can cause endometrial cancer.
Pregnant women shouldnt consume too much fish, due to risk of mercury
poisoning, and ACOG has actually set limits on the amount of fish in a week a pregnant
woman can take. Also carnivorous fishes like shark are c/i.
In a patient with partial spinal cord transaction, the biggest threat during
pregnancy is developing autonomic dysreflexia. It can manifest with malignant HTN,
brady, arythmia, sweating, resp distress, uteroplacental vasoconstriction, etc. Patients are
unaware of labor due to absence of pain, and only way of knowing is abd or leg spasm and

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SOB that accompanies labor.

Cranberry juice prevents UTI by inhibiting E coli from adhering to the urinary
epithelium.
None of the radioimaging are c/I in pregnancy except for radioactive imaging.
The modality with highest exposure to the fetus is a barium enema, then a CT abdomen.
Ondansetron is effective only if given before chemo. For late onset emesis,
metoclopramide is more effective.
No alteration in sexual practice is needed during pregnancy, except if pt has
PROM, placenta previa or premature labor history. Even supine position is not c/I re.
Chronic vestibulitis is a cause of chronic vulvar pain and extreme tenderness.
Tt is low dose amitryptiline.
IF a HIV elisa comes positive, the most important factor of the test that
concerns the patient is the PPV of the test, ie how many with positive test actually have
HIV.
Tt of condyloma in pregnancy is TCA. Podophyllin is c/I in pregnancy. IFN
and laser ablation in case of resistant infection.
Bicornuate uterus needs no treatment before pregnancy. Septate uterus needs
hysteroscopic excision of the septum, and didelphys needs reunification process.
Dysuria with low level WBC in urine, low bacteruria and negative leucocyte
esterase is consistent with urethral syndrome. Interstitial cystitis has a normal
examination of urine. Traumatic cystitis occurs sex, diaphragm use or catheterization, and
presents with hematuria without pyuria.
pt with Anticardiolipin Ab can present with livedo vasulitis in the lower limb,
which presents with painful purupura in the lower limb, which ulcerate and heal leaving
atrophic scars, livedo reticularis with telangiectasia, erythema and hemosiderin
hyperpigmentation. Livedo can occur with hep C, protein C deficiency also. Treatment is
low dose aspirin, nifedipine, dipyridamole, pentoxiphylline or mini dose heparin. Heparin
is preferred in pregnancy, with one dose every 2-3 days.
A pt with menarche comes with heavy bleeding and shock- its probably not
DUB but VWD, so do ristocetin cofactor assay. Tt is OCP, desmopressin, antifibrinolytic
and VWF concentrates.
Pt with bac vaginosis on pap dont need treatment if they are asymptomatic,
even during pregnancy, as the treatment hasnt been shown to be effective. Metronidazole
is okay for 2nd trimester use.
Gestational thrombocytopenia is one of the commonest cause.
DMPA is the best contraceptive in a pt with sickle cell anemia, as it has shown
to decrease the pain crisis. Estrogen is relatively c/I as it increases the vasoocclusive crisis.
IUDs are also not good, due to high rates of infection.
80 yr female with stroke develops incontinence. Post void residual volume is
70ml (normal). This is functional incontinence due to impaired mobility so that the pt
cant go to toilet. Best treatment is communicating with caregivers about accessing the
toilet.
Young woman on ACEI should be using contraceptives.

DERMATOLOGY
1. In pt with alopecia, if the hair shows split ends, aka trichoclasis, then it signifies traumatic

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alopecia, due to trichotillomania, or chemicals.

Psoriasis is treated with potent local steroid, and low potency steroid like hydrocort if on
face or intertriginous area. Systemic steroids are not used as they can induce pustular
psoriasis. Extensive disease is managed with UVB with or without coaltar (Goeckermann
regimen). Severe or psoriatric arthritis is treated with MTX.
Pressure ulcers are treated with moist saline soaked gauze packing. Dry gauze is not used as
the fluid is thought to contain growth factors needed for reepithelialisation.
Topical metron is the TOC of rosacea, with or without oral doxy, mino, erythro, tetra like in
acne. Topical isotretinoin in popular or pustular lesions, and permethrin has shown to
help, as demodex mites are frequently found in the lesions. Rosacea can be associated
with conjunctivitis, keratitis, chalazion and scleritis.
Erythrasma caused by corynebac minutissimum, reveals coral red fluorescence in Wood
lamp.
Photoaging causes coarse deep wrinkles (fine and superficial only due to aging), actinic
keratosis, telangiectasis and brown liver spots. Treatment is isotretinoin, which will
remove the brown spots also. Smoking exacerbates photoaging.
Tattoo removal- deramabrasion, laser, cryo, cautery- laser can cause scarring and
hypo/hyperpigmentation.
Wearing protective clothing is more important than sunscreen since childhood to decrease
the risk of melanoma. Sunscreen with SPF 15 have shown to reduce the incidence of only
BCC and SCC, not melanoma.
Oral Terbinafine 6wks for fingernails and 12 for toenails are the TOC for tinea unguium.
Itraconazole can be used. Oral fluconazole is once weekly and easy to take, but is not as
effective.
Lindane used for scabies was found to cause aplastic anemia and seizures, and
hence is replaced by permethrin.
A pt went hiking, was bitten by insect, and scratched with a wooden stick,
followed by draining lesion- its sporotrichosis, as it is the only fungus which can get
inoculated. Blastomyces and Coccidiodes both have to be inhaled.
Minocycline doesnt cause photosensitivity, but can cause lupus like
syndrome, pseudotumor cerebri, vertigo and tooth discoloration
NSAID and hydration are the treatment for sunburn, whether induced by drugs
or otherwise. NSAID also limits the damage to the skin. Diphenhydramine for itchng, and
topical steroids can be used
Oral Isotretinoin can cause hyperTG,so monitor LFT and lipid profile, and
stop if severe hyperTG, as it can cause pancreatitis.
Psoriatic lesions are exacerbated by beta blockers, ACEI, lithium, NSAIDSstop the medicine and replace from another group.
A pt on OCP with chronic HCV comes with painless blisters on hand, and
hyperpigmentation, hypertrichosis and fragility of skin. Its porphyria cutanea tarda. Dx is
by inc urinary uroporphyrins. Treatment is phlebotomy or hydroxychloroquine, or IFN
alpha in those with HCV infection.
Mild acne is treated with topical retinoid. Moderate( or refractory mild) with
topical retinoid and either benzoyl peroxide or topical antibiotic. More severe with all
three of them, or systemic antibiotic with topical benzoyl peroxide or retinoid. If no
response in 3-6mo, start oral isotretinoin. Microcomedones need 8 wks to mature, so wait

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for 2 months for any therapy to work before switching. Pregnancy is c/I with even topical
isotretinoin, though no LFT and lipid monitoring needed with topical therapy.
Microsporum canis ectothrix infection is fluorescent in Woods lamp, unlike
the endothrix infection with T tonsurans.
Trichotillomania is characterized by bizarre pattern of broken hair strands of
varying length.

PAEDIATRICS
1.
DTaP vaccine c/I if anaphylaxis of encephalopathy within 7d. If high fever, shock,
inconsolable crying and seizure within 24 hrs, then give under caution. There are no
contraindications to pneumo, polio or Hib vaccines.
2.
MMR c/i- severe febrile illness, anaphylaxis to neomycin or gelatin, severe
immunodeficiency (not just HIV status), thrombocytopenia after first dose, previous IVIG
administration within 3-11 mo, as it decreases the efficacy of the vaccine, pregnancy. f/h/o
seizures, breastfeeding, TB, PPD conversion, asymptomatic HIV infection, allergy to
mercury (thimerosal) and egg are not considered contraindications.
3.
Chemoprophylaxis for PPD conversion following contact with MDR TB- if resistant
to only INH, give rifampicin 4mo or RZ 2mo, if resistant to H and R, give ZE or Z with
quinolone for 4 mths.
4.
If neonate at birth has polycythemia in capillary heel blood test, then repeat in
venous blood- if still elevated, repeat in 12 and 24 hrs, as it resolves on its own. If it
persists, and the child develops drowsiness, jaundice, hypoglycemia, apnea, hypotonia,
poor feeding, cyanosis, then hydration and exchange transfusion is needed.
5.
Children need 1300 mg calcium daily, so apart from diet, 1gm calcium
supplementation should be done in all. Adults typically need less, while the requirement in
old age again increases.
6.
Strawberry aka capillary hemangioma in places other than face can be left to regress
by themselves, while face can be treated with laser for cosmetic reason. Steroid and
interferon sc have also been useful in large hemangiomas.
7.
Kawasaki disease- TOC is Aspirin and IVIG. HSP- supportive, steroids if severe.
HUS supportive and IVIG, peritoneal dialysis. TTP- plasmapheresis. ITP- mild cases are
self limiting, steroid short course for severe cases, and IVIG for very severe cases.
8.
Diaper rash is due to overhydration and friction, eg following diarrhea, treatment is
to keep dry by frequent change of diapers, and barrier creams like petrolatum and ZnO, or
low potency steroid. Candidal infection involves skin fold, is painful, and is persistent
after the above treatment. Bacterial superinfection presents with fever, pustular drainage
and lymphangitis.
9.
Flexible kyphosis is commonly seen in adolescent, and is correctable by voluntary
extension and prone extention test, and doesnt need treatment. If there is sharp angulation
seen on forward bending, it is structural kyphosis, aka Scheuermann disease, and needs
Milwaukee brace if angle <70-80, or surgery for more severe angulation, pain or neuro
abnormality.
10.
Dx of CHPS aka IHPS is by usg, or second choice is barium meal showing double
track sign.
11.
Mother found bat in the room of her child, but the child has not been bitten- PEP with
Ig and rabies vaccine is needed, immediately unless the animal can be captured and

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observed for signs of rabies or sacrificed and autopsied. PEP should be given within 5
days, or with head and neck bites, within 3 days (72 hrs)
Xone is not used in neonatal sepsis as it can displace bilirubin and aggravate sepsis
induced cholestasis. Same for cotrim. So TOC is ampicillin for Listera (tho uncommon in
US) and cefotaxime.
Child comes to Pediatrician with epiglottitis- first thing to do is arrange for ambulance
to send to ER, for possible intubation
In immunocomp patients, herpes zoster might resemble HSV, so diagnosis needs PCR
or IF of scraping, else tests are not needed for diagnosing zoster.
Nocturnal surge in LH and enlargement of testes are the first signs of puberty.
Delayed puberty is diagnosed if >14 yrs of age. It can be constitutional if positive family
history, and bone age is lower than true age, and other systemic illness are absent. Pt with
Klinefelter has normal puberty, but then he develops testicular atrophy and hypogonadism.
Constitutional puberty delay can be managed with testosterone mthly im injection for 3-6
mo (short therapy doesnt affect bone growth), esp for psychological reason. HCG with
HMG can be used in central hypogonadism like kallmans syndrome- or GnRH pump.
Child with diarrhea should be given normal diet, with limited sugars and fat, which
increases osmolality. Clear liquid like juice has sugar. Loperamide can cause paralytic
ileus, toxic megacolon and CNS depression.
Normal Tympanic mb with decreased mobility signifies effusion, and can persist for 3
mo after an episode of AOM. So watchful waiting only is needed, unless if the effusion is
bilateral, or has persisted for longer. First line therapy for AOM is amoxy, second line is
clavam, cefuroxime axetil or im xone, tympanocentesis or myringotomy with culture if
second line also fails. Hearing evaluation should be done if effusion lasts for more than 3
months.
Lead levels>44 needs oral chelatoin, and >70 needs hospitalization and iv chelation.
Less than 44 needs only environmental and behavioral interventions. Blood lead levels are
more sensitive than erythroporphyrin levels.
Criteria for admission of pts with anorexia nervosa- dehydration, electrolyte abn,
brady, hypotension, hypothermia, acute food refusal, wt<75%of average, arythmia,
psychosis, seizure, suicidal ideations and pancreatitis.
Enuresis normally resolves by 5-7yrs, so nothing needs to be done till then (right
answer is to assure that the behavior is normal!). Behavioral modifications can be used to
increase chance of success. Only after that investigations like USG to see residual urine,
VCU to see if obstruction or neurogenic bladder (latter appears as trabeculated bladder
with Christmas tree appearance), cystoscopy and urodynamic studies.
Erythro oint or sulfa drops are TOC for bac conjunctivitis, quinolones for contact lens
wearers and corneal ulcer to cover Pseudomonas. Keep at home till discharge is cleared, or
if not possible, atleast 24 hrs after starting antibiotics.
Sydenhams chorea can present after 2-8mo with pronator drift, delayed patellar
reflex, dec tone, crying or laughing inappropriately, facial jerking, etc. treatment is again
penicillin re.
If there is microcephaly, it cant be due to IUGR, has to be due to intrapartum
infections.
Childhood Absence Epilepsy (CAE), has a good prognosis, good response with
treatment and remission with age, esp if GTCS are absent. JME (juvenile myoclonic

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epilepsy), by contrast has absence episodes with myoclonic activity, and life long seizures.
A lean and thin patient with secondary amenorrhea, with dec axillary and pubic hair,
myalgia, asthenia, amenorrhea, axillary freckling,- its probably not anorexia but Addisons
disease. Lack of pubic hair points toward hormonal imbalance. Hyponatremia,
hyperkalemia, acidosis, hyperchloremia are present in aldosterone deficiency also, but the
hyperpigmentation and amenorrhea points to Addisons.
VCUG is indicated in all children <5 with febrile UTI, any age with first UTI,
recurrent UTI or those who dont respond to treatment. USG, Renal Scintigraphy and IVP
are not routinely recommended.
Downs syndrome predisposes to endocardial cushion defect, duodenal atresia and
polyhydramnios, Hirschsprung disease, atlantoaxial instability and hypothyroidism, and
leukemia.
Benign premature thelarche is common in girls at 18-24 months age, not accompanied
by other features of isosexual precocious puberty like ht, bone age, pubarche, adrenarche
and menarche. Hypothalamic hamartoma secrete GnRh and cause central isosexual
precocious puberty, while adrenal tumors cause heterosexual precocious puberty in female
(virilisation), and isosexual precocious puberty in male. McCune Albright syndrome has
cae au liat spots, fibrous dysplasia and ovarian cyst producing estrogen causing precocious
puberty.
Parents can deny vaccinations to their child, the doctor should document and sign the
refusal. Thimerosal present in many vaccines were linked with autism, but no evidence
supports it.
NF1- axillary freckling, lisch nodules on iris, optic glioma, bone dysplasia, other CNS
tumors, developmental problems. IF we suspect NF1, first thing to do is ophtho
consultation, then MRI or neurosurgery as needed.
Always suspect child abuse if the child presents with new onset behavioral problem
like sleeping poorly or wetting of bed, esp if the parents are alcoholic or uses drugs.
Depression can be second possibility.
Erbs palsy has a 80% chance of spontaneous remission. Symmetric palmar grasp
reflex, even with asymmetric Moro, reflects that the lower roots are intact. Serious
complication is phrenic nerve involvement. Horner syndrome is seen with lower root
injury in Klumpkes paralysis.
Sickle cell disease rarely presents before 6 mo due to fetal hemoglobin. Splenic
sequestration is the most common complication, others being ischemic complications like
asplenia due to infarction, dactylitis and ischemic stroke. Hb electrophoresis is the DxOC.
Acute coronary syndrome in these patients may be difficult to d/d from acute chest
syndrome.
Alarm is more effective than medications in enuresis, esp if augmented by other
behavioral approaches, and also has lower rate of relapses.
Acute bronchiolitis- TOC is respiratory isolation with bronchodilators (albuterol,
epinephrine), hospitalization if hypoxic or unable to feed (ng or iv feeding). Dx is by rapid
antigen detection of RSV in nasal or pulmonary secretions using ELISA antigen capture
technology. Serology doesnt help as it detects maternal antibody. Pt has increased risk of
AOM, and asthma in the long run. Apneic spells are very common in bronchiolitis.
No increased recurrence of Turners is seen with women who had previously delivered
a Turner, nor is there any increased risk with increasing age like Downs or Klinefelter.

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Lumbar meningomyelocele is associated with increased bladder dysfunction,

ultimately causing renal dysfunction. Sacral involvement can cause fecal incontinence.
Dural ectasia is the most common finding of Marfan syndrome re, along with MVPS
which can cause acute MR and CHF, requiring valve replacement; Aortic root dilation
causing aortic dissection and ectopia lentis. If aortic root >4.5 cm, then aortic valve
replacement is indicated to prevent dissection.
Due to TSH surge in baby after delivery, T4/TSH should be routinely tested after 1 d
of delivery, and immediately treated if hypothyroid, to prevent neurologic defect. IF TSH
is found to be high in the screening done from heel prick, the next step is to do a regular
blood draw, only then start the treatment. They also need higher dose of thyroxine than the
adults!!
Only symptomatic patients with Giardia in stool should be treated. Asymptomatics
should be treated in special situations as outbreak control, prevention of household
transmission by toddlers to pregnant women, and those with CF and
hypogammaglobulinemia.
Symptomatic ITP with plt<30,000 should be treated with steroids, and IVIG if severe.
Platelet is useless.
Pt with abd pain and HCO3<15, suspect DKA.
Baby on honey and fruit juice develops poor sucking, constipation, lethargy and weak
cry- botulism. See for diminished gag reflex in examination, which needs airway
protection to prevent aspiration. Baby can also contract it from contamination with spores
in the soil. Most improve fully but need long hospitalization for months.
TTP- pentad of thrombocytopenia, MAHA, fluctuating mental status, ARF and fever.
Pt/PTT are normal, LDH is elevated. Both TTP and HUS are in the same spectrum, and
both need plasmapheresis emergently.
Viral encephalitis- commonly due to enteovirus or Arbovirus, like EEE, WEE,
California encephalitis, st Louis encephalitis, Colorado tick fever. Adenovirus or CMV
only cause meningoencephalitis in immunocompromised patients, while HSV are usually
seen only in adults.
Severe Malnutrition- lethargic, severe wasting, edema- needs hospitalization,
warming, correction of dehydration and electrolyties, and NG feeding, esp if vomiting,
impaired consciousness and painful oral ulcers. High calorie or protein shouldnt be
started early as it can lead to heart failure, and iron shouldnt be used in first week as it
can cause GI ulcer and oxidation injury.
2mo child presents with pneumonia, with interstitial pattern on XR, eosinophilia, and
inspiration between cough (staccato cough), its probably Chlamydia. Search for h/o
conjunctivitis in the neonatal period.
Breastfeed a newborn every 4 hrs, and watch for him to take his fingers to mouth to
know that he is hungry.
TBM should be treated for 12months, and upto 18 months if resistant strain.
Open TB patients are considered noncontagious only after 3 consecutive negative
sputum smears, and not based on duration of receiving therapy.
USG is the DxOC in CHPS, while AXR in duodenal atresia or malrotation.
Continuous nasoduodenal feeding can be used as an alternative in those who are poor
surgical candidates. Erythromycin use, eg in prophylaxis against pertusis, even if given to
the breastfeeding mother, has been shown to increase the incidence of CHPS

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Cellulitis is in between subcut tissue and fat, so local anesthesia will not be helpful, so
shouldnt be used.
IV cotrim is the treatment in PCP pneumonia in AIDS patient, later changed to oral.
IV pentamidine if intolerant to cotrim, and iv trimetrexate if intolerant to both.
Aerosolized pentamidine has low efficacy and shouldnt be used in treatment, only in
prophylaxis. Atovaquone can be used too.
FB ingestion- if it is lodged in any esophageal constriction, then immediate removal
by endoscopy or fluoroscopy guidance is indicated. If it has already gone to stomach, no
intervention is needed mostly. Pyloric obstruction can present with persistent vomiting in
some cases.
Febrile seizures in 6mo to 5yrs, temp>38, usu first day of fever- only reassurance to
the parents is needed. Lumbar puncture is indicated if <18mo of age to rule out meningitis.
Simple febrile seizure has no focal features, lasts <15 min, and is associated with mild
increased risk of epilepsy, tho there is significantly increased risk of recurrent febrile
seizures. Complex febrile seizure is accompanied by focal features like postictal paresis,
duration>15 min.
Transient aka toxic synovitis of hip- child has pain on passive motion of the hip, is
usually preceded by respiratory infection, USg is the diagnostic modality, and aspiration is
warranted if child has fever with hip effusion.
3 wk child comes with purulent conjunctivitis and pneumonia- its Chlamydia. Fever
and wheezing are rare, which helps differentiate it from bronciolitis. This is the reason
why pregnant women should be screened and treated for Chlamydia. (Erythromycin is the
treatment)
Neonate presents with hemolytic jaundice- Coombs negative, it is probably G6PD and
not abnormal hemoglobin states like sickle cell or thallassemia, as the latter dont present
early due to presence of fetal hemoglobin.
After starting Amoxycillin for AOM, if the pain and fever persists, then its treatment
failure- start coamoxiclav for drug resistant Pneumo. Tympanostomy and tubing is
indicated if OME persisting more than 3 months, severe AOM, or if recurrent AOM
despite prophylactic antibiotics with half dose amoxy or sulfisoxazole.
Prune belly syndrome- multiple urologic abnormality, constipation, weak cough.
FB in resp tract- back blows and chest thrusts after holding the baby upside down, if
<1yr old, Heimlich if more than 1 yr.
Acute severe anemia in sickle cell pt can be due to either splenic sequestration crisis,
or acute hemolytic crisis, or aplastic crisis. To differentiate, see the retics count.
Cleft lip- rule of 10 says surgery at 10 wks of age, 10 pound wt, and 10 g hemoglobin.
Recurrence risk in subsequent pregnancy is 50%.
Epiglottitis suspect- the first thing to do is not antibiotics, but to arrange for direct
laryngoscopy and intubation under anesthesia.
In any case of trauma to the nose, even if no external deformity, ant nasal cavity
should be examined to rule out septal hematoma. If it is present, it should be drained to
prevent infection and saddle nose due to cartilage destruction. Radiographs of nasal bones
are not indicated, as clinical examination is better to find displaced fractures, and if there
is undisplaced fracture, it doesnt need treatment.
Choanal atresia suspect- do axial CT, as it shows the atresia best, as the atresia is
oriented in a coronal plane. It is assoc with CHARGE syndrome, with coloboma, heart

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anomaly, atresia choana, retarded growth, genital hypoplasia and ear anomaly.
Intoeing usually improves on its own, and needs no investigation and treatemtn. It is
usually due to internal femoral torsion or metatarsus varus.
Adolescent well visit should include dietary history. Very imp. AAP doesnt
recommend routine drug screen.
OM in sickle cell pt- its probably Staph and not Salmonella, as Staph is overall the
commonest cause.
ELISA antigen test on stool is the test of choice for Giardia, as it needs 3 stool
examination is needed for visualization.
Spinal curves like scoliosis need attention only if they are rapidly progressive or
painful. Absolute coobs angle is not a criteria for intervention. 3-4 caf au lait spots dont
indicate NF, it needs more than 6.
Blunt trauma to the eye- always refer to ophthalmologist even if no apparent anomaly,
as he can have commotion retina, hyphema, retinal tears and lens subluxation.
Ca requirement is 500 for 4 yr child, 800 for 8 yr, and 1300 for 12 yr old
4 wk infant present with acute bronchiolitis like picture, and conjunctivitis- beware, it
can be Chlamydia pneumonia. It might even have hyperinflation and eosinophilia.
A child is brought with alcohol accidental poisoning- the biggest threat is
hypoglycemia. Also cerebral edema and seizure can occur. Hypocalcemia with
nephrocalcinosis occurs with antifreeze poisoning.
Mild diffuse gingival inflammation and swelling- its probably bad hygiene and not vit
C deficiency- prescribe regular brushing and dental flossing.
Abrasions over dorsal aspect of hands over knuckles signify bulimia, and the sign is
called Russell sign.
A 16 yr male comes with rhinorrhea, occasionally bloody, and c/e shows boggy
turbinates- its probably cocaine abuse.
Turner syndrome- if asked what is the most common complication, its primary
amenorrhea (100%) and not coarctation (only found in 20%)
Anorexia nervosa pts have brady, hypotension, hypothermia, constipation, but
overactivity and cold intolerance.
After starting iron in IDA, first sign is increase in retic count. Serum ferritin is the last
to change.
If a child is obese and short its usually endocrine disorder. In normal obesity, he
doesnt have growth delay, they enter puberty early and are tall.
Erythema infectiosum is not infectious after the appearance of the rash, so the child
can go to school , tho if his mother is pregnant, she should be warned of fetal death and
hydrops.
In girls, breast development precedes pubarche, so if pubic hair is at higher tanner or
sexual maturity rating scale, then there is a problem.
Copper deficiency can present as hypochromic anemia, neutropenia, esp in those with
TPN for a long time.
In any male presenting with gynecomastia, first thing to do is examine genitalia for
tanner staging.
Lactose hydrogen breath test is superior to stool test or clinical trial in diagnosing
lactose intolerance.
VZIg neednt be given to contacts unless they are immunocompromised. Isolation of

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contacts from immunocompromised relatives is required though.

A pt comes with thyroid nodule- first thing to do is FNAC, it is diagnostic if its a
solid lesion and therapeutic if its a cystic one. USG, I scan are not the best answer.
A 10 yr boy is diagnosed with ALL and has life expectancy of 6 mo. His parents
implore not to tell him. What to do? Ask the parents why they dont want to tell him,
listen to their fears, then say that telling him will make it easier for them to provide him
the best care. The pt must be told.
Tick bite- tick remains for days, and produces a papule with erythematous halo, or
can later produce foreign body reaction. It can also transmit Lyme and erythema
chronicum migrans can develop at the site of bite later. Relapsing fever, rickettsial
infection, babesiosis and tularemia are other associated conditions.
A child of 4 wks comes with a solid mass on his sternomastoid- which is slowly
growing. Its probably fibromatosis coli, which if not treated will cause congenital
torticollis. So stretching exercise is needed, or surgery with splinting can be offered if
exercise doesnt help. D/d is branchial cyst.
A pt comes from Haiti with complete immunization for well child visit. He has got
BCG also. He is asymptomatic, still he needs a PPD placed re.
In males<6mo and females<2 yr with fever without any apparent cause, urine culture
from suprapubic tap or catheterization should be done first, even in the absence of any
urinary symptoms.
A child who is throwing too much temper tantrum- TOC is to give him a choice- stop
the tantrum and you can go out for an icecream, or keep doing it and face the consequence
re. time out can be used, but not more than 5 min each time.
All close contact of a pt with Meningo meningitis must receive treatment, including
hospital staffs involved in intimate care like intubation or suctioning, and parents, but not
casual visitors or his frens.
A pt comes with mental retardation without any other systemic features, the
investigation with the highest yield is chromosomal study, as 25%of the time there will be
an anomaly.
A pt with mental retardation, obesity, short stature, muscle hypotonia, and
hypogonadism, excessive appetite and temper tantrums- think Prader Willi syndrome.
Most pts need growth hormone supplementation.
Hirchsprung suspect- the next best step in diagnosis is suction biopsy of rectum, and
not anorectal manometry re.
A baby is born with blueberry muffin spots, petechiae all over, cataract, deafness,
hepatospleno, osseous defects on XR, its congenital rubella syndrome, due to Togaviridae.
The blueberry spots are points of extramedullary hematopoeisis, also seen in those with
congenital toxoplasmosis, CMV, neuroblastoma, congenital leukemia, erythroblastosis
and twin transfusion syndrome.
In a child with c/f of sinusitis, transillumination and sinus XRs are not done, very low
yield as the sinuses arent developed that much. Start antibiotics straightaway.
Child comes with decreasing grades in class, behavioral problesm (neuropsychiatric
symptoms),
Until baby is 20 lbs, place the baby in a rear facing seat in the car, only after that in a
front facing seat. Dont use microwave to heat the milk, as it heats the milk unevenly, and
that can cause esophageal and tracheal burn. Hot water less than 120F will prevent any

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scald burn.
Child who received chemoradio in early childhood are at risk of developing premature
ovarian failure.
Downs child is at risk of atlantoaxial subluxation during horse riding and other things.
Also hypothyroidism.
Simian creases are found in 5% normal infants also, so without any other feature, it
doesnt demand any investigation.
Recurrent otitis media- myringotomy tube helps reduce the frequency and severity, plus
allows delivery of topical antibiotic. So in those with tube in place, only topical antibiotic
can be used first. Switch to oral or iv if no response only.
If the baby is having rotaviral diarrhea, AAP recommends that he can be sent to
daycare if his stool can be contained in his diapers and dont spill over. Careful
handwashing with ethanol is the prevention. Only boiling water wont help. Laundering
clothes will not help (its for scabies only). Vaccine was developed, but was associated
with intussusceptions.
A child who likes to be very neat comes with constipation. Ask about whether he
avoids school bathroom. Then do disempaction of stool, f/by balanced diet and behavior
modification. If its Hirschsprung, then the rectum will be devoid of stool, unlike in
functional constipation.
A pt is diagnosed with recurrent ankle sprain. On examination, there is a bony growth
along medial malleolus. This is talocalcaneal coalition. Initially the bar is unossified, but
after ossification it limits subtalar motion and causes heel pain. It needs CT to diagnose,
XR wont show. Oblique XR shows calcaneonavicular coalition however. Remember CT
for TC coalition.
A person with h/o sore throat comes with guttate psoriasis- do ASO and rapid strep
testing. Treatment with penicillin will limit the psoriasis also.
A pt with vit D deficiency and marked genu varum- he not only needs dietary
supplement, but also long leg wt bearing XR and ortho consult.
Nursemaids elbow due to radial head dislocation- tho many reduce it without any
investigation, its better to obtain an XR to document no other fracture like supracondylar
fracture or physeal separation is present.
PANDAS- pediatric autoimmune neuropsychiatric disorder associated with
streptococcal infection. It presents with OCD like syndrome and tics. Treatment is iv
antibiotic and IVIG.
Cradle cap in an infant is a type of seborrheic dermatitis- treatment is brushing with a
toothbrush to remove the scales, and daily bath with baby shampoo, and applying baby oil
or ointment before bathing to remove all the scales. Scales in eyebrows can be removed
with a cotton tip applicator dipped in shampoo and then rinsed with water. Dont use high
potency steroids like betamethasone. It can cause atrophy, telangiectasia, steroid acne,
glaucoma, cataract and systemic absorption due to high surface to volume ratio of the
infants.
A resident suspects child abuse and wants to speak to the child alone, but the parents
wont allow. What should you advise? Let the parents be there, that will ease the
examination. Then after hx and c/e, if abuse is suspected, then separate him from the
parent and contact the authorities.
IHSS- treatment in symptomatic case is with negative inotropes like verapamil or beta

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blocker, which slows the heart rate, which allows increased LV filling, and dec force of
contraction, which decreases flow velocity and consequently decreases the degree of
obstruction. Myomectomy of the septum is the last resort in case of severe heart failure.
Calcaneovalgus foot might be normal in early infancy, but if found at 2 yrs of age,
ortho referral is needed. By contrast, flat foot, metatarsus adductus, overriding 4th toe or
toe walking are all benign and dont need referral.
Neonatal gonococcal conjunctivitis- apart from topical antibiotics, systemic antibiotics
for both gonorrhea and clamydia should be given.
A pt comes with short stature, delayed puberty on examination, but normal growth
velocity (eg height velocity)- do wrist XR first to find if the bone age coincides with the
pubertal age (chronological age is not imp). If it does,then its only constitutional delay,
and the parents have to reassured that he will gain a normal adult height eventually,
depending on his parents final height.
A 6 wk baby with bilious emesis, slight distension of abdomen, dehydration- suspect
midgut volvulus. Usually the clinical picture is so classic that imaging is not needed, so
the TOC after rehydration is laparotomy. Delay in treatment will result in shortgut
syndrome, and TPN for the rest of life, with its resultant complications like liver cirrhosis.
If the pt is stable enough for evaluation, then a upper GI series with follow thru will
demonstrate the abnormal position of the ligament of trietz.
A pt with positive Barlow and Ortolani at birth- neednt do USG as it is a clinical
diagnosis, and USG can be negative falsely. XRs are useless before 4mo as the femoral
head is not ossified. So the TOC is putting the baby in a Pavlik harness, and then ortho
consult.
A child ingests a battery and is now stuck at mid esophagus level. IT should be
removed, as it has corrosives. Same for safety pin. If it is just a coin,then we can do f/u
XR to see its safe passage.
A toddler comes with hyperthermia, tachycardia, tachypnea, vomiting, diaphoresis, and
he has a minty smell in his breath. Its oil of wintergreen ingestion with salicylate
poisoning.
A child comes with pink eye, desquamation of hands and feet, strawberry tongue- its
Kawasaki disease. Thromobocytosis is an acute phase reaction seen in the blood.
A pt comes with acute bronchiolitis- the TOC is nebulised albuterol. Steroids help in
croup but not in bronchiolitis. Ribavirin is used only in those with underlying disorders
like bronchopulmonary dysplasia, prematurity or congenital heart disease. NS nebulisation
can act as an irritant and aggravate the condition.
Neonatal herpes- common in scalp and face area, can cause hepatitis, pneumonia,
coagulopathy, meningitis, paralysis, opisthotonus, and fatal if not treated. Dx Is by Tzanck
smear, or viral culture of skin lesion.
Wood lamp will accentuate the pigmentation of epidermal nevus, but not of dermal
nevus.
Congenital hydroceles only warrant observation- as most resolve by themselves.
Cat scratch disease- Bartonella; Tt is cotrim, or cipro or rifampin as alternative.
A child comes with cough during daytime only, worse on Mondays, without any h/o
allergy, and no response to medication, but is otherwise doing well- its probably
psychogenic cough (not exactly school phobia, as this is not a scientific term)
Rubella- evanescent rash that disappears within two or three days, post auricular and

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postoccipital LN. arthritis in many, ITP and encephalitis in some. Congenital Rubella
syndrome if contacted during the first trimester. Vaccination at 12-15 mo and then at 1112 yrs. Live vaccine, so c/I during pregnancy.
Incubation period between contact with TB patient and tuberculin skin test conversion
is 2-12 weeks.
Admission in burn in infants is mandated if BSA > 10% or 15% in older child, but also
in critical area involvement like face, hand, pubic area, perineum, and electric burn.
Remember all scald burns are not abuses- see if the pattern matches the history or not.
Pt with IDDM can deteriorate during his puberty due to different hormonal changes.
Honeymoon period refers to mth after dx before insulin is needed.
Human IG can be given for PEP to measles to children at special risk only.
Forscheimer spots are enanthem in Rubella.
A child comes with abdominal mass that seems to arise from inf venacava, its probably
wilms tumor. 11p13 deletion is the most imp cause. By contrast neuroblastoma is due to
mutation in Nmyc gene, and presents with fever, wt loss, abd mass, anemia and bone
mets.
A 12 yr comes with low grades in school, and language delay. He has microcephaly.
First thing to do is TORCH screen. Language delay can be due to both mental retardation
and hearing problems.
BP msmts are initiated after 3 yrs of age, or earlier if born with renal disease.
A child comes with scarlet fever- all other ill siblings should also undergo rapid strep
testing and treatment. No need to test asymptomatic siblings though. 24 hrs of antibiotics
is enough before going to school.
A physician is approached by a neighbor for an advice about his child, he advises for
free, and later the child deteriorates, and the neighbor decides to sue the doctor. The court
will hold the doctor liable, coz once you have given advice, you have entered a doctor
patient relation, and its your duty to fully examine the patient.
Pityriasis rosea- no treatment available, but UVB exposure can hasten the recovery.
These patients are very sensitive to irritants and friction, so only lukewarm bath and no
rubbing with towel.
Pregnant with Giardia can be treated with paramomycin.
First episode of concussion during sports- pt can get back to sport if asymptomatic for
15 min. second episode, he should return to sports only after a week.
Erythema toxicum neonatorum- HPE shows eosinophils accumulation around the
pilosebaceous follicles in the dermoepidermal junction. D/d are keratosis pilaris seen with
atopic dermatitis, and neonatal pustular melanosis which will show neutrophils, and leaves
a hyperpigmented macule with scales after the pustule ruptures.
Girl comes with a pedunculated lesion on her face for a month- bleeds with scratching.
Its pyogenic granuloma, and is a vascular reaction to infection. Treatment is destruction
with curettage or electrodessication, liquid nitrogen or pulse laser. It recurs after treatment
.
MOHS is used in melanoma if tissue sparing is a concern, if recurrence in a scar, or
location in planes of embroynal fusion.
Bullous impetigo, especially following other dermatoses or chickenpox, are caused by
Staph aureus. Treat with ether topical mupirocin or oral cephalosporin.
Azelaic acid can be used for hyperpigmented lesions like postinflammatory cases or

melasma. Hydroquinone also blocks melanogenesis, but prolonged use is associated with
yellow brown permanent pigmentation, called ochronosis.
151.
Cavernous hemangioma, even only cms wide, can cause DIC and consumption
coagulopathy with thrombocytopenia. Its called Kassabach Merritt Syndrome. So early
treatment is important with large hemangioma. Another danger is compression of vital
structures by rapidly growing hemangioma, like esophagus or trachea.
MISCELLANEOUS FROM KAPLAN QBOOK
1.
When a pt with RA comes with erosions on XR, then he needs DMARD- MTX is
the DOC, as it is cheap, but it can cause hepatotoxicity- so monitor LFT regularly and give
pyridoxine with it ! Low dose prednisone is used only if DMARD dont show adequate
response.
2.
Pts with chronic hep C shouldnt be given iron supplementation, as they are at risk
of hemosiderosis for unknown cause.
3.
Charcot foot in a DM pt with neuropathy starts initially in acute inflammatory stage
like cellulitis with warmth, erythema, edema which disappear on elevating the foot which
is pathognomonic. Then it goes into acute stage where there are periarticular fractures,
then joint dislocation, then comes subacute stage with bone resorption and finally fusion
in chronic or reparative phase. Tt is to limit wt bearing wth braces and cast. This can be
seen with tabes, and with pernicious anemia also.
4.
First thing to do in a new onset AF is TSH measurement.
5.
Inferior Mi patient develops brady and hypotension due to SA node suppression,
first thing to do is give atropine. If it doesnt help in 3 doses (total 2 mg), then temporary
pacemaker is indicated. Volume replacement and dobutamine if hypotension doesnt
correct even after correcting the bradycardia.
6.
Hyperprolactinemia and amenorrhea cant be due to anorexia- get a MRI.
7.
Azelaic acid inhibits tyrosine kinase, so can be used for hyperpigmentation or
melasma.
8.
Steroid for long time for psoriasis is not recommened due to side effect and due to
tachyphylaxis. UVA with either coaltar (Goeckerman regime) or antralin (Ingram
regimen) can be used, but if there are systemic and joint involvements, then the best thing
is to start MTX.
9.
Unstable angina is the dx if pt comes with chest pain and s/s of failure, like s4, rales,
edema, etc- starting heparin is the TOC. Before discharge, do a stress testing to quantify
the risk. Coronary angio is not indicated in all angina, only in those who report symptoms
despite aggressive management. Statins, aspirin, b blockers, ACEI, BP control and
smoking cessation have shown to increase lifespan in pts with angina, but not nitrates.
10.
Thyroid nodules that are not palpable but found on CT or USG need only f/u, no FNA
or f/u CT. thyroid scan is indicated only if hyperfunctioning nodule, not in asymptomatic
nodules.
11.
Pt with pancreatitis develops fever- promptly take blood culture and start antibiotics
(ampigentametro), only then do CT to see for any necrosis, if necrosis is present and pt is
febrile, then do CT guided aspiration for culture of the pancreatic necrotic material.
12.
Guttate psoriasis can occur after Strepto throat infection.
13.
A pt with quadriplegia cannot ask for voluntary refusal of fluid and food, he can be
force fed, coz quadriplegia is neither a terminal condition, nor a progressive one.

14.

ALT elevation asymptomatic, need only f/u after some months, other investigations
are warranted only if >3-5 times raised, if there are evidence of chronic liver disease, or
has persistent elevation on further testing. If no clear diagnosis after serology for viruses,
and autoimmune screen and USG, then we have to do liver biopsy.
15.
Hampton hump is the opacity due to intranecrotic hemorrhage seen in XR after PE.
16.
Asymptomatic sarcoidosis with only erythema nodosum and hilar LN need no
treatment.
17.
Nevus of Ota- oculodermal melanocytosis involving face and sclera on one half of the
face, esp along the branches of trigeminal nerve, has increased risk of melanoma of
choroid, brain, iris, skin and optic nerve. Fatigue, stress and mens has shown to increase
the pigmentation of the nevi.
18.
Immunocompromised pt develops pneumonia which progresses from interstitial
edema to necrotizing bronchopneumonia and then cavitation, its Pseudomonas. Pt
develops necrotizing skin lesion with blisters and pus discharge- its ecthyma
gangrenosum. No debridement is needed however, only iv antibiotics after skin biopsy
and blood culture are taken. It affects apocrine skin specially, ie in the glabrous parts of
body.
19.
Lichen planus, with white lacy streaks on buccal mucosa (Wickhams striae) in a
sexually active patient- do hepatitis panel, as it is associated with hep C infection.
20.
Offer HepB vaccine in all with STD, and also in gay men, dialysis patients and
household contacts of pt with chronic HepB.
21.
Pt with DKA may have hyponatremia due to ECF dilution due to water shift from
intracellular to ECF. So the hyponatremia needs no treatment.
22.
A court summons you to talk about your patient- what do you do ? first talk to patient
as to what information he wants you to divulge. If pt doesnt want any information to be
given, still appear in the court but dont say anything about the patient.
23.
A pt getting hydrotherapy for arthritis presents with itchy skin- its asteatotic
dermatitis, aka xerotic eczema- treatment is to avoid the hydrotherapy.
24.
Butcher develops bright red lesion due to an accidental cut on hand, with vesicles and
smooth shiny plaques, its Erysepaloid due to Erysipelothrix. Treatment is penicillin oral,
or Erythro with rifampicin if pt cannot tolerate penicillin. Debridement is not needed.
25.
Imipenem lowers seizure threshold
26.
Allergic alveolitis, aka acute Hypersensitivity pneumnitis, in a person who clears bird
cages- treatment is to avoid exposure. Psittacosis presents with similar clinical and
radiological picture, but has more systemic features like fever, and is treated with doxy.
27.
Necrobiosis lipoidica diabeticorum: erythematous papule, telangiectasia, atrophy,
ulceration, scarring, treatment is local steroid and not diabetes control.
28.
Arsenical keratosis in a patient who worked in smelting furnance, electronics industry,
preservatices or paints and pesticides- hyperkeratosis of palm and sole (like corn),
raindrop hyperpigmentation, exfoliative dermatitis, Mees lines, polyneuritis, peripheral
vascular disease culminating in blackfoot disease (gangrene), and cancer of skin (
BCC and SCC), and liver angiosarcoma.
29.
Pt taking isotretinoin for acne- 2 pregnancy test should be negative, should use 2
contraceptives, cannot donate blood upto 1 mo after stopping it, shouldnot wax skin upto 6
mo due to risk of scarring, and should be warned about myopathy and about driving in the
dark, as many have decreased night vision.

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48.

Pt receiving Radioiodine for Graves disease shouldnt have close contact with
children, eg in day care job.
Hyperthyriodism in elderly maynot have tremor.
Lanolin in different over the counter creams can cause allergic contact dermatitis.
Trichophyton tonsurans is the MCC of black dot tinea capitis in children, and the adult
can then contract the same on his skin from the child. M canis is less frequently seen these
days, and causes inflammatory patch in the scalp with broken hairs. Epidermatophyton
flocossum affects glabrous skin like in athletes foot.
Corynebac minutissimum causes erythrasma in glabrous skin, like groin and axilla,
and is known for coral red fluorescence on woods lamp.
Self breast examination is no more recommended, as it has no benefit.
Minimum screening age for cholesterol is 18, or 30 by most panels. Total cholesterol
panel is these days recommended instead of screening random cholesterol.
Hemoccult test positive in an elderly patient with hemorrhoid can still be due to
colonic polyp or malignancy- so colonoscopy is still indicated
A pt on alprazolam for anxiety for yrs comes with BZD overdose- flumazenil
shouldnt be used in pts with physical dependence as it can precipitate seizures.
Flumazenil is only useful in acute overdose cases.
Pt who is not braindead but who is certain never to recover his functions, and who can
never be weaned off ventilator, can be discontinued, on grounds of FUTILITY.
A PT on treatment for pyelonephritis doesnt respond to antibiotics- do CT to rule out
perinephric abscess.
Contact dermatitis- treatment is oral prednisolone, esp if hands and face are involved,
as you cant use potent steroid over those sites. Methylprednisone can be used in low dose
with acute taper, but shouldnt be repeated for fear of significant rebound flares.
Pt on risperidone, elderly, can cause chronic fecal impaction and overflow diarrhea,
treatment of constipation by fiber supplementation is the treatment of choice. Mineral oil
is c/I as it can cause lipoid pneumonia due to aspiration, as well as rectal leakage. Mag
salts can cause excess and dangerous fluid shifts in elderly.
Pt with recurrent outbreak of herpes genitalis, should be put on long term acyclovir
oral. After about a year, discontinue to see the frequency of outbreak, and if the frequency
has decreased considerably, then stop the drug. Lifelong treatment is not needed. Pt should
use barrier contraception to prevent transmission.
A pt with symptoms of pneumonia but has normal XR- rehydrate him and then repeat
the XR. The pneumonia might show up.
Data is given for effect of drug in lowering BP, with mean, median and SD. Then
asked to find the degree of benefit of a patient. If the mean is very different from median,
then it is a skewed distribution, so the rule of confidence interval doesnt apply, so the
answer would be cannot be determined from the given data.
Pt comes with postconcussive syndrome, olfactory hallucinations signifying temporal
lobe epilepsy- the best next step is to refer to a neurologist.
Mild concussion in a game, without LOC player can return to the game within 30
min if normal exam and without symptoms- vomiting or headache are not indications for
further investigations, unless they are persistent.
Chloral hydrate displaces warfarin from protein binding sites, causing overcoagulation
or hypocoagulation.

49.

In a pt getting methylprednisolone for multiple sclerosis, monitor his blood sugar,

keep him on insulin sliding scale, even if not a diabetic, and a diabetic diet should be used.
50.
Transient global amnesia is a cryptogenic condition without any treatment.
51.
In a pt with HIV and multiple stressors, if he comes with gait disorder but normal
neuro exam except for a wide based gait, its probably psychogenic gait disturbance.
52.
Stye needs only antibiotic drops and warm compresses- not IND
53.
In a meningitis suspect, first thing to do is starting antibiotic, then CT to rule out mass
lesion like abscess, and then only do LP.
54.
A pt comes with headache. Examination is normal. You consult a neurologist on
phone, he asks to discharge the pt on analgesic. Later the pt dies of aneurysm. The court
will indict the neurologist if he has directly spoken with the pt over the phone, coz that
will make them doctor pt in relation, else he has no liability.
55.
Wife caring for a demented husband- providing respite for the wife (with use of home
services or nursing home for a short period of time) can delay permanent admission of the
pt into a nursing home re.
56.
Donepezil is the DOC in Alzheimers due to least side effect. Gallantamine is c/I with
hepatic or renal impairment. Rivastigmine has caused severe vomiting and even
esophageal rupture. Tacrine can cause serious hepatotoxicity and is rarely used these days.
57.
Ultraviolet keratoconjunctivitis in pts who ski.
58.
A nursing home wants to use a test inmates for highest risk of developing
Alzheimers. For the test to include maximum patient s with risk of Alzheimers, the
nursing home should use the test with the highest sensitivity, and not highest specificity or
highest PPV. Think.
59.
Cerebral palsy usually occurs in baby with normal wt at birth, and normal POG. There
is very poor correlation with perinatal asphyxia or low APGAR scores.
60.
A pt who is undergoing CABG develops amaurosis fugax- should undergo carotid
ultrasound before surgery because these patients can develop stroke on bypass machine if
they have carotid stenosis.
61.
Daily metaxalone is useful for tension type headaches.
Some more
1. A pregnant patient comes with paralysis below the umbilicus, but reflexes are normal and MRI is
normal too. This is conversion disorder related to the stress of pregnancy. Best way is to
reassure the patient that it will get better on its own. Support is better than confronting the patient
with the diagnosis.
2. CT urogram ie with iv contrast is preferred over IVP nowadays for intial investigation of
asymptomatic hematuria (if pt has s/s of infection or stone, then detailed investigation is not
needed). Next step is cystoscopy and then urine cytology.
3. Clinda and genta is the TOC for postpartum endometritis, coz metro isnt to be used in
breastfeeding, tho it can be used in pregnancy with caution.
4. For condyloma acuminata, TCA acid and not podophyllin, coz the latter shouldnt be applied to
mucosal surface.
5. PMDD (dysphoric disorder) is the severe form of PMS- 15% are resistant to fluoxetine, in those
cases alprazolam is the second line drug.
6. LEEP is the TOC for HSIL or CIN II and higher. Ablation is less reliable than excision in high
grade lesions, thats why LEEP is preferred over laser/cryo or even cold knife conisation.
7. neonates to 1 year- N/4 saline, 1 to 4 yr- N/3 saline, 5- 10 yr- N/2 saline, >10 you can give NS.

ETHICS
8. Illegal immigrant with TB worries if he is reported to the health department, then it will
inform the immigration services and deport him. Tell him that health service department
doesnt need or send immigration status.
9. Pt in persistent vegetative stage and MODS- you are not required to do any treatment like
dialysis which you think is futile, even if it is against the familys wishes.
10.
Pt with syphilis has multiple sexual partners. Should the doctor inform the
partners? No, he should report it to the Department of Health Services, and DHS will
inform the partners by mail or phone that there is a public health threat, but it will never
reveal the name of the person. If the contacts call the doctor, the doctor is also not obliged
to tell them. Also the patient can refuse to give out the name of his contacts, and we cant
do anything about that.
11.
Any couple undergoing IVF can sell their sperm or ova, or donate them, but
cant sell the embryo- can only donate it.
12.
Employers have no right to order tests likeAPC gene without the consent of
the patient. So if a patient comes with such form to fill out, ask the patient if he wants the
test done and the result reported.
13.
You see a pt of CCF is not on beta blocker- the attending says to you,I am in
this business long enough to know.What to do? Report to the chief of staff.
14.
A pt comes with gunshot wound- report to the police even if the patient
disagrees, for the safety of the society.
15.
A pt is braindead- who should ask his family for organ donation? The organ
donation network, and not the physicians looking after him- as the latter will be conflict of
interest on our part.
16.
A pt has organ donation sticker in his drivers licence- he dies, but the family
doesnt consent to donation. What to do? Respect the wishes of the family, as the sticker
only shows the patients will but is not legally abiding, plus he could have changed his
mind after that. So its very important to tell your family about your organ donation
wishes.
17.
You work as a physician in a penitentiary- the warden calls you on the day of
execution to start a iv line as they cannot do it.What to say? Say you will not take part in
any of it. Even attending the execution is unethical. You cannot do things that will lead to
the patients death. You can give anxiolytic to the patient the night before to allay his
anxiety though.
18.
Gifts by patients can be accepted to maintain doctor patient relation. Gifts
under 100 dollars by pharmaceuticals are also okay, but not if they want something in
return.
19.
A severely mentally retarded person denies screening colonoscopy even after
explaining the benefits. Dont do it- he is still considered competent to decide about his
medical care.
20.
An unconscious patient in ER without any previous records is wearing a shirt
saying I am Jeovah's witness. He is in dire need of transfusion. What to do? Transfuse.
Consent is automatically implied in ER settings, unless overridden by will- and shirt isnt
considered as a will.
21.
A pt tried to kill himself by striking his car on a tree, and is now refusing
surgery to stop his bleeding. What to do? Do the surgery. A patient in acute stress, and

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who attempts to kill himself, is NOT competent to make his own decisions. Therapy can
change his mind later, so save him first. Thats the same logic why suicidal patients can be
detained against their will.
A pt is refusing to tell his divorced wife and kids that he has FAP. What
should you do? Inform the wife!! Confidentiality ends when sb else would be harmed.
A patient wanting romantic relation with you- say, I cant date you now,
maybe I can after you get a new doctor. Atleast the doctor patient relationship has to end
before you can date her.
A bus driver with sputum+ TB consistently refuses to take DOTS. What to do?
Remove the patient from his duty and incarcerate and treat him in the hospital till his
sputum is clear, as he is jeopardizing the health of others.
A pt has no healthcare proxy or living will and gets unconscious- there is no
agreement among the family members about the best step in management. What to do? Go
to ethics committee, and then to the court if necessary.
You donot have to agree with an adult patients wish, but you have to comply
with it!! Hmm nice.
Your patient refuses a treatment, and you are not comfortable with it- you can
transfer the patient to another colleague. Eg you are religious and oppose abortion, then
you can refer your patient to somebody who is comfortable with it.
Never postdate your note. If you find error in your earlier note, write a new
note with the correction.
A pt is unconscious and has no proxy or will- if the family members can be in
unison about the substituted judgement about the care of this patient, they can order
anything, and can stop any treatment.
DNR doesnt mean discontinuing ventilation, NG and fluids in an unconscious
patient.
A doctor unintentionally gives wrong dose to a patient- he is responsible, as
are the nurses and the pharmacist.

MISCELLANEOUS AGAIN.
32.
33.

HRCT and not USG is the investigation of choice for renal stones.
Beta blocker, including labetalol, are contraindicated in patients with cocaine
overdose.

34.
35.
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37.

Best initial step for stopping drug abuse is sending the patient to drug rehab, and not
to group therapy. Group therapy like AA is for maintaining abstinence and preventing relapse
once detoxification is done.
BP control is most important to prevent cerebrovascular mortality. Lipid control is
the most important in preventing cardiovascular morbidity.
Screening for DM with FBS and not RBS is recommended 3 yrly in all patients
above 45 yrs of age, and earlier if risk factors like HTN, family history of DM in first degree
relatives, dyslipidemia, overweight, inactivity, PCOD, GDM, vascular disease, or African
American or Hispanic race.
PSA screening for prostate cancer begins at age 50, but for those with family history,
it should begin at age 45.

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A pt with borderline personality says her doctor is the best and saved her life- its
primitive idealization, a part of splitting. So tick the former in mcq!!
Dialectical behavioral therapy is one of the most effective treatment for borderline
personality! TCAs are c/I as these patients have high rate of suicide.
Interpersonal therapy is used for depression. Also CBT.
SSRI are the TOC for depression, even before psychotherapy. OCPs have no relation
with depression, DMPA is suspected to have, but the evidence till date is inconclusive.
Repeated hospital admission with polymicrobial(including anaerobic) bacteremia
should be considered factitious disorder, with patient injecting himself with fecal material.
Iron studies should be done in patients with restless leg syndrome, as IDA might be
the cause.
Urine immunoassays (and not gas chromatography) are employed for drug screening.
An elderly started on fluoxetine comes with severe side effects and want another drug
with better s/e profile- start him on sertraline and not nortryptiline or imipramine, as the latter
have improved safety compared to amitryptiline, but still are not as good as SSRI. TCAs are less
preferred in elderly also coz they are at high risk of suicide.
Pts with AICD implantation-if they have PSVT due to panic attack, they can get
repeatedly shocked by the ICD.
A pt has symptoms of mania with type A schizophrenic symptoms like delusions
and hallucinations- he is having schizoaffective disorder! Like a person who is manic at one
time, and other time thinks that a famous popstar will marry him and sings only for him.
Reactivation with herpes zoster increases with age!
Paroxetine, citalopram, sertraline and new tetracyclic maprotiline all cause weight
gain, and should be substituted instead of fluoxetine if the wt loss due to the latter is troublesome
to the patient.
Hepatorenal syndrome- urine Na<10 and urine osmolality>serum osmolality are
diagnostic. Not FENa.
Pt comes with gross hematuria 3d following URTI, and there is no HTN- its IgA
nephropathy and not PSGN.
Priapism can cause ischemic necrosis and impotence- first treatment is ice packs,
then phenylephrine injection every 5min (or epinephrine). oral terbutaline is also effective but
not TOC.
Pt with shock, pre-renal ARF with hyperkalemia and acidosis, use D5W with low
amt of bicarb as treatement.
DM patients can have emphysematous pyelonephritis due to E coli and Klebsiellawith gas present in perinephric area. Nephrectomy is immediately warranted.
Cimetidine, Probenicid and Trimethoprim cause inhibition of tubular secretion of
creatinine, causing isolated rise of creatinine in the serum, with normal BUN!
A 75M comes with insomnia after the death of his wife- treat it like insomnia with
psychotherapy. Avoid drugs in elderly, as it increases the risk of falls and fractures.
Lithium can cause alopecia, but doesnt cause split hairs. If there are split hair ends
visible, aka trichoclasis, its due to chemical reaction or due to trichotillomania.
Corneal foreign body frequently test positive for coagulase negative Staph.
Patient with DM comes with hyperosmolar coma-the increased osmolality of blood
will draw intracellular water causing dilutional hyponatremia, and after the water is diuresed,
there will be hypernatremia. So for every 100 mg/dl of glucose above normal, add 1.6 mmol/l to

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the Na concentration. So in these patients hydration should be with half NS.

Hypocalcemia presents with increased DTR, convulsions, muscle cramps etc.
Hypomagnesemia causes similar, but is seen after diuresis, NG aspiration, alcoholism and
diarrhea.
In a critical patient on dextrose drip and intubation, PO4 depletion can cause severe
muscular weakness (as no ATP can be formed), and inability to wean from the ventilator.
Zn deficiency causes decreased wound healing and skin rash.
Patellofemoral pain syndrome aka chondromalacia patella is like Osgood
Schlatters disease but in adults from 20-40 yrs, associated with overuse, with theater sign
positive (climbing stairs or getting up after prolonged sitting), crepitus and pain on deep pressure
on patella. Osgood causes pain over tibial tuberosity and not patella. Patellar tendinitis, aka
jumpers knee, has tenderness in infrapatellar region. Anserine bursitis causes pain on the
medial aspect, while prepatellar bursitis causes anterior knee pain with signs of inflammation.
Trick question- a pt who fulfills 4 criteria for SLE, but has dsDNA negative and RA
positive, its still SLE. This is because dsDNA is highly specific, but only 70% sensitive, ie there
can be many false negatives. MCTD needs RNP antibody, with features of systemic sclerosis,
polymyositis and SLE all.
CPK shouldnt be routinely ordered in pts on statins, coz exercise can cause rise in
CPK too. Stopping statin is only needed if it is increased more than 10 fold.
A pt with diffuse systemic sclerosis- most effective measure to prevent renal disease
is monthly BP measurement re. Steroids can infact increase the damage if used in high does,
and ACEI and ARB are only used if the patient presents with renal crisis.
Premature atherosclerosis is the MCC of cardiovascular mortality in patients with
SLE.
In the absence of symptoms, never do ANA, as it has a high false positivity rate. IF it
comes positive, and the patient has no symptoms, no need to follow up with dsDNA too.
Parvoviral arthritis can present with weak RA factor positivity, but it usually lasts for
less than 6 weeks. So before 6 weeks have elapsed, dont label anybody as RA.
Low back pain in <50 has <1% of being anything but musculoskeletal. So only bed
rest and physical therapy. But if he doesnt respond in 6 wks, then do ESR to rule out
malignancy or infection. If it is raised, only then do lumbar XR.
If seronegative spondyloarthropathy is suspected, eg reiters arthritis associated with
UTI, then the first thing to do is XR of pelvis. Though HLAB27 is positive in many, its not
specific and hence is not recommended as the first step. Arthritis due to IBD wont have
conjunctivitis. Rx of Reiters is antibiotics, MTX or sulfasalazine and progressive exercise.
XR pelvis is preferred to HLAB27 even in ankylosing spondylitis suspect, as
evidence of sacroileitis is needed for diagnosis. Life expectancy is not reduced and there is no
overall functional disability re !!!!
Sjogren is associated with B and not T cell lymphoma.
NSAID are the TOC in adult Stills Disease, with evanescent salmon colored
rashes and spiking fever with myalgia and arthralgia. Steroids only in severe disease with
myocarditis etc. Monitor LFT in patients on long term NSAIDS.
Occupational rehab is important for patients with carpal tunnel syndrome who dont
respond to night time splinting of hand, NSAID and steroid injection. Ergonomic keyboard have
been proven not to help.
Tarasoff I is informing the person who is about to be harmed. Tarasoff II is

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protecting the person from harm by detaining the threatening patient.

Thyroid nodule- first do TSH. If normal, ie cold nodule, do FNAC. IF low, do RAIUif the latter shows hot nodule, then RAI ablation or followup if asymptomatic. IF RAIU shows
cold, FNAC again. IF TSH high( rare, due to Hashimoto), do USG to see if this is the only
nodule or if it is the dominant nodule. IF USG is suspicious, FNAC again. IF FNAC shows
malignant, surgery, if inconclusive, do FNAC again; if its benign, then no treatment or thyroxine
to suppress TSH for cosmetic reason.
For thyroid incidentalomas found on USG, FNAC only if >1cm of size, alarm
features like microcalcifications, irregular shape, hypoechoic, or if f/h of thyroid malignancy.
Pts with cirrhosis admitted for variceal bleeding are at increased risk of SBP, and
other infections too- hence should be put on prophylactic ciprofloxacin for a week !
Pt on oral retinoids for acne comes with pancreatitis- simple hydration with dextrose
will increase endogenous insulin secretion, which will help in metabolizing the
hypertryglyceredemia that is causing the problem. If this doesnt work, then dextrose insulin
infusion can be started.
Symptomatic AS should be promptly treated with valve replacement, even in 70 yr
elderly, and shouldnt be left out considering it as sclerosis of the valve.
If a pt on CCB comes with MI, stop it, coz there is no benefit, and infact possibility
of harm with CCB in such patients.
Acute aortic dissection- iv labetalol is the DOC. Dont use nitroprusside without
beta blockade, as it causes reflex tachycardia which can increase the dissection.
An adult comes with syncope, has no other risk factors- the first thing to do is not
Holter but a simple hx and ex and an ECG !
In all patients with torsades, give magsol irrespective of the magnesium level. If
magsol cannot prevent the recurrence, then do transvenous temporary pacing.
Stop metformin in pts undergoing diagnostic cardiac cath, as the contrast agent can
precipitate renal failure.
For acute rate control in AF, use diltiazem or B blockers and not digoxin, as the
former when given iv will act within 5 min, while digoxin even if given iv will take hours to act.
Goal INR for mechanical aortic and mitral valves is 2.5 to 3.5.
Verapamil inhibits tubular secretion of digoxin, causing 100% increase in its levels
and toxicity. Amiodarone and quinidine also cause digoxin toxicity, so does spironolactone.
Orthostatis hypotension- 20 mm fall in SBP, or 10 in DBP
In pts with preexisting heart disease like CAD and AF, amiodarone is the DOC for
keeping the patient in sinus rhythm for long term! Rhythm control is preferred in patients who
are still symptomatic on rate control, eg with palpitation, dizziness, dyspnea. Amiodarone even
if pt has hypothyroidism!! This is because other antiarrythmics can easily cause fatal
arrhythmia in someone with preexisting heart disease, while amiodarone is very safe in this
regard.
Aspirin is sufficient to prevent stroke in patients with lone AF, which is diagnosed
after all other causes of AF have been ruled out. Warfarin has more risks than benefit in such
setting.
Angina at rest and critical AS carry 20 points on preoperative cardiovascular risk
assessment. These are the highest risk factors. Also JVD.
Amiodarone with warfarin- decrease warfarin dose by 25%
MRI is the best modality to diagnose suspected coarctation of aorta, better than CT

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Thiazides are sulfonamides, so can cause photosensitivity rash- thiazide should be

discontinued in that case.
BMI of 30 with HTN and smoking and alcohol- the most effective
nonpharmacological intervention for this patient is weight reduction, more than reduced Na
diet.
Radionuclide imaging is preferred over stress ECHO in patients with angina and
previous revascularization, previous MI which precludes use of ECG, and residual wall motion
abnormality due to previous MI precluding the use of ECHO.
A pt with h/o severe angioedema with DM and HTN, prescribe metoprolol and not
losartan- as there is a low but present danger of angioedema even with ARBs.
Pt on hydralazine- advice to report any flu like symptom, coz that can herald the
development of SLE.
Ator and lovastatin should be changed to pravastatin in patients with
hyperfibrinogenemia, as this is an independent CAD risk factor.
Recent onset angina is unstable angina, and the best thing to do is early coronary angio, and
not stress testing, especially if the pt is diabetic, coz diabetics have a very extensive coronary
blockade.
If INR is high in a pt on warfarin, but not above 5, then only holding the Coumadin for a few
days will do. Higher than that needs oral vit K. FFP and iv vit K is only needed if the pt is
actively bleeding.
Reducing LDL is the most effective way of decreasing the CAD risk, BP control comes
second, then DM control and smoking cessation. But DM is the single most important predictor
of bad cardiovascular outcome, still glycemic control hasnt been proved to be much useful.
Thats why DM is categorized as CAD equivalent.
In a pt with subclinical hypothyroidism, do antithyroid antibodies. If they are positive, then
even subclinical disease needs thyroxine replacement.
A pt who got intraarticular steroid for gout 7d back comes with deranged glyccemic control.
The derangement is due to the stress and not steroid itself, as the steroid disappears from blood
within a few days.
Pt on HRT comes with DVT- dont fall for the trap where answer says discontinue HRT
immediately. It should be tapered off, not discontinued abruptly. So the best thing to do is start
the patient on unfractionated heparin. Warfarin is needed for atleast 3mo in patients with
reversible risk factor, 6mo if no risk factors identified, and lifelong if repeated.
Refractory hypoglycemia due to sulfonylurea is treated with sc octreotide.
A pt on glargine and lispro wants to exercise, but is facing hypoglycemia after exercise in the
morning, and when she tried reducing her evening glargine, then her prelunch and predinner
sugar went up. The mgmt is insulin pump, which gives much flexibility to the patient. Also
advise for snack before exercise.
Insulin shouldnt be stopped in the preop night in DMI even if NPO, as this can cause DKA.
DM pt on metformin comes with acidosis and weakness- with normal glucose and no
hyperamylasemia, then its not DKA but lactic acidosis- so send ABG and lactic acid levels.
Pt with hypothyroidism shouldnt postpone emergency surgery. Oral thyroxine can be
replaced after surgery. T3(liothyronine) is not indicated for hypothyroidism re!!
PAD (PVD) is a CAD equivalent. So if LDL is above 100, start diet and atorvastatin stat.
Also for exercise pain, the best therapy is supervised exercise program. Cilostazol also
decreases the pain but is used only if supervised exercise fails. Pentoxifylline is a third choice. If

this pt has MI, then he should be put on beta blockers, but dont use metoprolol, use combined
alpha-beta blocker as they will not cause vasoconstriction, like labetalol and carvedilol.
114.
Clopid has been shown to be more effective than Aspirin in reducing cardiovascular mortality
in patients with PAD (and probably other risk factors also).
115.
Ant epistaxis- Littles or Kasselbach plexus; post- Woodruffs plexus, formed by
sphenopalatine artery, and common in adults with HTN. The posterior bleeding is usually more
severe.
116.
A pt with allergic rhinitis is going for scuba diving. He shouldnt fly within 24 hrs of diving
to prevent barotraumas, especially because his ETT wont function properly due to the edema
related to the rhinitis. Also use of topical pseudoephedrine has shown to decrease barotraumas
by 75%.
117.
T1 laryngeal tumor is treated with RT mainly, to preserve the vocal cord. Excision with CO2
laser can be done too. Hemilaryngectomy for T2 or those involving anterior commissure. In t3,
induction chemotherapy f/by RT can be tried to preserve the Vc, and if it fails, then total
laryngectomy should be done.
118.
Otitis externa with lots of wax- first step is to clean the wax and debris with cerumen wire
loop or cotton swab! Irrigation only if TM is visible and intact. Only then topical antibiotics.
119.
A pt comes with allergic rhinitis- the best next step is to do nasal cytology re! Eosinophils
point to allergic rhinitis, and if absent, point to vasomotor rhinitis !
120.
A patients seems to be brain dead, but has hypothyroidism, or electrolyte anomaly or
hypothermia- in such patients in whom the criteria is not met, do technetium brain perfusion
scan as the second confirmatory test apart from the apnea test and caloric testing and CT. Other
secondary tests that can be used are EEG, carotid Doppler, cerebral angiography, and evoked
potential in median nerve!
121.
Upright supine position is more effective than left lateral in preventing aspiration in coma.
122.
Tick borne paralysis after hiking in the woods can resemble GBS- dx is by finding tick after
careful skin examination. Eg Rocky Mountain wood tick and American dog tick.
123.
A pt who is hypothermic or in shock or hepatic or renal failure can have severe
hypocalcemia when being transfused blood, as the citrate cannot be metabolized by the liver and
the kidney.
124.
Headache doesnt need cT or MRI unless it is debilitating, or doesnt imrove with appropriate
medication, or starts after exertion like sex, especially in elderly.
125.
Pts on disease modifying drugs for MS like glatiramer or interferon should be using
contraceptives, as these drugs are shown to be teratogenic. MS patients who present initially with
only sensory or optic symptoms have good prognosis than other presentation.
a.
A pt with terminal cancer (and Cheyne Stokes) respiration shouldnt be resuscitated, on grounds
of futility.
b.
Start selegiline first in patients with mild symptoms of Parkinsonism- it delays the progression
of disability. It is a disease modifying drug. If its effectiveness decreases,then add levodopa.
Amantadine and trihexiphenidyl are not the first choice.
BIOSTATISTICS

1. Suicide rates in physicians are found to be higher than in general public. This is
because of the confounding by high socioeconomic status. To find the true effect,
we have to calculate the adjusted rates, aka standardized rates.
2.

One study found high risk of colorectal ca in those who consume saturated fat (RR=4). What

3.

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17.

percentage of colon ca can be attributed to fat consumption? ARP=4-1/4=75%. Attributable risk

percent indicates the excess risk in exposed population that is explained by the risk factor.
Tighter the confidence interval, more precise is the study. Increasing the sample size increases the
precision of the study, but it doesnt affect the accuracy. Accuracy and validity represent the
measure of systematic bias. Accuracy is when test-retest reliability is good. Wider the CI, more
accurate and less precise is the test.
Sampling bias- sample is not representative of the population. Eg predicting population
prevalence by hospital studies (Berkesonian bias), people included in the study are significantly
different from those not in the study( Non-respondent bias). How to prevent it? Randomisation
Respondent bias- when the outcome is obtained by the patients response and not by objective
msmt.
Measurement bias- asking leading questions( you dont like your doctor, do you?), Hawthorne
effect (subjects behavior changes bcoz they are being studied). Prevention- control
group/placebo
Pygmalion effect- experimenters expectations are communicated to subjects. Can be avoided by
double blind studies.
Lead time bias: false estimate of increased survival when the disease is uncovered by a screening
test at an early stage. Prevent by measuring back end survival.
Recall bias- patients fail to accurately recall the events in the past.
Late look bias- severe pts die and are not included in the study, for eg one study
showed that pts with AIDS only have mild symptoms. Prevent by stratifying by severity.
Confounding
Unacceptability bias- medical students may not uncover their smoking status in a
study, coz they know that smoking is harmful.
Effect modification: effect of estrogen on the risk of DVT is modified by smoking.
Loss to follow up will cause selection or sampling bias.
Likelihood ratio is TP/FP rate, or sensitivity/(1-specificity). If a test has sensitivity
of 0.9 and specificity of 0.9, then its likelihood ration is 9, ie a positive result is 9 times more
likely in a patient with disease than in patient without it.
Likelihood ratio for a negative test is given by (1-sensitivity)/specificity. Smaller the
likelihood ratio, better the test performs at ruling out the disease.
A distribution with 10,10,10,20,20,40,50 is positively skewed, as most of the entries
are clustered on the left (low end), and the tail is on the right end, and hence mode>mean.??

ACID BASE DISORDERS:

Acid-Base disorders require understanding of the underlying pathophysiology as well as
familiarity with some formulas. Several Acid-Base scenarios that can be tested on
USMLE Step 3 are
A) Identifying the acid base disorder
B) Identifying the etiology of acid-base imbalance in an Multiple choice question by elimination
process of other choices based on the acid-base characterestic.
C) Diagnosing mixed acid-base disorders by applying simple formulas
D) Causes and treatment of increased anion gap acidosis
E) Causes of Non-Gap Acidosis
F) Renal tubular acidosis and identifying the etiology of the RTA from subtle clues in the

question stem.
G) Osmolar gap and using this concept to identify the etiology in metabolic acidosis and in
toxicology.
Memorize the following formulas:
1) Anion gap = (Na+)-{(Cl-)+(Hco3-)}
Normal gap is 4 to 12.
Anion gap greater than 12 indicates increased anion gap metabolic acidosis. This indicates the
presence of a foreign substance causing acid-base imbalance.
If there is acidosis ( low bicarb <>It is important to know the distinction because the causes of
increased gap metabolic acidosis are different from non-gap acidosis. So, once you know
whether the gap is increased or not, you can further focus only on the relevant causes.
Causes of Increased Gap Acidosis ( MUDPILES)
- Methanol (M)
- Uremia (U)
- Diabetic Ketoacidosis ( D)
- Paraldehyde, Propylene glycol ( P)
- Isoniazid ( I)
- Lactic acid (L)
- Ethylene Glycol (E)
- Salicylic acid ( S)
Causes of Non-Gap acidosis : The gap here is normal because when the hco3- drops, there is a
compensatory increase in the chloride there by, keeping the gap normal. This indicates no
foreign substance but it is because of the loss of bicarbonate either through the GI tract (
Diarrhea) or Renal system ( RTA). These causes are:
- Gastrointestinal loss of Bicarbonate : Diarrhea, small bowel fistulas, urinary diversion
- Renal causes : Renal tubular acidosis, renal insufficiency, hypoladosteronism.
- Recovery phase of DKA
Concept of Urine Anion Gap
Now, let us say you have a metabolic acidosis and the gap is normal --> you know that this is
normal anion gap acidosis. But there are two important causes of normal gap acidosis as
you have already seen earlier - GI vs. Renal . How do you differentiate between the two?
For this, you will need to know URINE ANION GAP
Urine Anion Gap (UAG) = {(urineNa)+(urineK+)}-(urine Cl-)
Normal values for UAG is -10 to +10.
A logical approach here is to look at the urine Na+. If urine Na+ is low ( which you would
expect in dehydration, diarrhea etc), urine anion gap tends to be more negative and points
towards GI losses ( such as diarrhea)
So, a UAG < -10 ( more negative gap) indicates a GI cause for Non Gap Acidosis where as a

UAG > +10 indicates a Renal Tubular Acidosis.

If you have difficulty remembering this, remember neGUTive - negative UAG in bowel
(GUT) causes.
Renal Tubular Acidosis ( RTA)
A normal gap metabolic acidosis with positive urine anion gap ( UAG) could be due to RTA.
There are different types of RTA.
Type 1 ( distal)
Type 2 (proximal)
Type 4 (hyporeninemic hypoaldosteronism)
On the exam, once you identify a metabolic acidosis and then identify an RTA, you will be
tested on the etiology of that RTA. So, it is important to know how to differentiate
between different RTAs and their causes.
To differentiate between various RTAs, first look at the serum potassium. If K+ is high in
an RTA , this is most likely Type 4 ( because low aldosterone causes decreased renal
excretion of acid and potsssium) If the potassium is normal or low, then the RTA
could be Type 1 (Distal) or Type II (Proximal). You will need to look at the urine pH
to differentiate between Distal and Proximal RTA. Remember that Distal RTA can
never acidify the urine so, the Urine pH is never less than 5.5. So, if a MCQ gives a
urine pH of less than 5,5, you are most likely dealing with Proximal RTA.
Type 1 RTA - Distal RTA :
- Causes: autoimmune diseases ( scleroderma), hyperglobinemia states and hereditary
- Present with normal anion gap acidosis, urine pH >5.5, hypokalemia, hypercalciuria,
nephrocalcinosis and stones
- Treatment: alkali i.e. K citrate
Type II RTA - Proximal RTA :
- Failure to reabsorb filtered bicarbonate in the proximal tubule
- Presents with Hypokalemia and normal gap acidosis
- Urine pH > 5.5, but it will be less than 5.5 once serum HCO3 is less than 16
- Causes: Multiple myeloma, Acetozolamide, Ifosfamide Lead, cadmium, copper
Type IV RTA - Hyporeninemic Hypoaldosteronism
- Causes: diabetes mellitus, HIV and tubulo-interstitial disease
- Present with hyperkalemia, normal anion gap acidosis and normal urine pH
Identifying Mixed Acid-Base Disorder in Metabolic acidosis
A) To understand if a patient has both increased anion gap acidosis and non-gap acidosis at the
same time or metabolic acidosis + metabolic alkalosis at the same time, you will need to
know the concept of "Delta Gap" . Delta gap is logically explained in the video clip
below. Logically, if the serum bicarbonate (Hco3-) falls more than the change in the

anion gap, then a patient has both non-gap+increased gap acidosis. If the serum
bicarbonate falls less than the change in the anion gap, then the patient has mixed
disorder - metabolic acidosis + metabolic alkalosis.
For example, if the anion gap is 20 --> you can say the change in the anion gap is 8 ( because
normal anion gap is 12. ) In this scenario let us say if the MCQ gave serum hco3- as 10,
drop in the serum bicarb here is 14 ( remember, for calculation normal serum bicarb is
taken as 24. so, if it is 10 now, the drop in bicarb is obviously, 14). --> this means when
your anion gap has increased by 8 your bicarb has fallen more than 8 i.e; by 14....that
means some other factor apart from the factor responsible for increased gap acidosis is
also contributing to acidosis here! - this suggests co-existing increased anion-gap+normalgap acidosis . A classic example is diarrhea with shock - where diarrhea causes non gap
acidosis but shock can lead to lactic acidosis which increases the gap - so, things can coexist!
B) To understand if your patient has a mixed disorder of metabolic acidosis + respiratory
acidosis or metabolic acidosis + respiratory alkalosis, you will need to be familiar with
Winter's formula.
Winter;s formula :
Expected pCo2 = {1.5(Hco3-) +8} +/-2
If your patient has metabolic acidosis, you expect him to breathe fast and wash out the Co2 so as
to maintain the pH in normal limits ...this is called "Compensation". Compensation
brings the serum pH towards the normal but never makes it completely normal - so, if you
are seeing a normal pH in a metabolic acidosis , you can right away say that you are
dealing with a Mixed disorder rather than a compensation alone.
The expected Pco2 in the above formula is the one that is expected as a comprnsation if your
patient has low bicarbonate or metabolic acidosis. You need to compare this expected
Pco2 with the real value of Pco2 obtained on the arterial blood gases ( measured Pco2).
Pearls for answering questions on Mixed Disorders:
A) If measured Pco2 is lower than the expected Pco2, that means your patient is washing
out more C02 than expected ---meaning, he has respiratory alkalosis co-existent with
metabolic acidosis ( one example of such mixed disorder is Salicylate toxicity) .
B) If measured Pco2 is higher than expected Pco2, that means your patient is retaining
Co2 which means he has a co-existent Respiratory acidosis along with metabolic
acidosis ( eg: Cardiac arrest can cause such mixed acidosis because reduced respiratory
drive causes CO2 retention leading to respiratory acidosis where as shock because of
cardiac arrest causes lactic acidosis which is metabolic acidosis).
eg: If Hc03 - is 16, the expected PCo2 as per Winter;s formula should range between 30 to 34 (
see the above formula). However, let us say your patients Pco2 on the arterial blood gas is

20 --> you can call this metabolic acidosis + respiratory alkalosis. eg : Salicylate Toxicity
If Hc03 - is 16, the expected PCo2 as per Winter;s formula should range between 30 to 34 ( see
the above formula). However, let us say your patients Pco2 on the arterial blood gas is 44 -> you can call this metabolic acidosis + respiratory acidosis. eg : Cardiac arrest
NOTE, normal anion gap is 12, and normal bicarb is 24. Normal ph is 7.35 to 7.45
A. Identifying benign hematuria and its approach
B. Correct interpretation of "Dipstick" Hematuria
C. Evaluation of Asymptomatic Microscopic Hematuria in normal patient population vs. those
at high risk for urological malignancy.
D. Test of choice for symptomatic hematuria ( Urolithiasis, Cystitis etc)
E. Evaluation of Asymptomatic Hematuria
F. If upper tract imaging for Asymptomatic Hematuria is chosen, what is the initial test of
choice? - Many get confused about the initial test for upper tract imaging becauses several
sources state several different things. Students are stuck between the choices CT
urogram vs. Traditional Intravenos Pyelogram. The guidelines have been updated
recently and there is an increasing trend towards CT Urogram even in asymptomatic
hematuria ( please check the explaination below).
Here is a summary on how to approach Hematuria on your exam as well as in your office. All
the recommendations are taken from AUA, American college of radiology guidelines on
appropriate imaging choice.
Hematuria: The following Q and A aaproach will help you understand the principal concepts of
Hematuria.
How do you test for Hematuria?
The initial office test that we use to detect hematuria is "Dipstick". Dipstick is highly sensitive
but not specific. False negatives are very rare but false positives are common. Dipstick
detects "BLOOD" but it does not say whether this "blood" is an RBC or a Pigment.
Remember that pigments such as myoglobin ( as in rhabdomyolysis) or Hemoglobin ( as
in hemoglobinuria, Black water fever) can stain as "Blood" on dipstick. So, please do not
automatically assume that everything that stains as "blood" on a dipstick is an RBC. In
order to know if there is true hematuria, the next step is to do urine microscopy. If the
urine reveals RBCs then there is true hematuria. However, if the dipstick reads "blood"
and if the urine did not reveal RBCs on microscopy then you are dealing with a pigment either myoglobinuria ( rhabdomyolysis) or hemoglobinuria. At this point, if the CPK is
also elevated it suggests that the etiology of blood on the dipstick is Rhabdomyolysis.
So, a dipstick hematuria should always be confirmed with urine microscopy!
If dipstick is negative for blood, it excludes abnormal hematuria ( false-negative results are
unusual with dipstick testing).

Benign causes of "Red" urine but negative dipstick test - In some conditions, you may see a
red urine resembling "Gross hematuria" but dipstick is negative for blood. This should
not be called hematuria. This is just reddish discoloration of urine.
Occurs in :
a) Ingestion of red pigmented foods ( eg: beets, berries, rhubarbs, paprika)
b) Drugs like Rifampin or Phenazopyridine derivatives ( remember these drugs only cause
reddish urine but NOT a positive dipstick).
c) Diseases such as "Porphyria"
Causes of a Positive Dipstick but no true Hematuria: Here Dipstick stains positive for blood
but no RBCs in the urine
a) Myoglobinuria ( Rhabdomyolysis, vigorous exercise)
b) Hemoglobinuria ( Intravascular hemolysis)
Is the Hematuria associated with pain? - Understand the causes of painless hematuria are
different from painful hematuria. Painless hematuria is often from tumors of the urinary
tract, bladder cancer or glomerulonephritis. Painful hematuria is often associated with
urolithiasis ( renal calculi) or inflammation/ infection of the bladder ( Cystitis).
What will be the approach to identify the source of Hematuria? - The work up for hematuria
may involve invasive and expensive approaches. So, it is important to determine the
nature of hematuria so that you can limit investigations to the real and pathological
hematurias.
Gross Hematuria: Reddish or Tea colored urine, dipstick positive for blood and urine
microscopy shows RBCs. Any patient with gross hematuria should always be referred
for urological evaluation unless this is secondary to an infection. If a woman has gross
hematuria but the urine dipstick also reveals leucoesterase or nitrite or if the woman has
symptoms of UTI ( dysuria etc) or if the cultures are growing bacteria, this can be treated
as UTI ( cystitis) with antibiotics with out referring for further evaluation. Even in this
setting of infection, if there are risk factors for urological malignancy the patient should
still be referred for further evaluation ( since hematuria from cancer can also be
intermittent).
Runner's hematuria or March hematuria is another benign condition that presents as gross
hematuria after a severe physical activity. In such cases, patients may be observed for
resolution however, if the hematuria is persistent or if the patient has any risk factors for
having a urological malignancy, must be referred to a urologist
Microscopic Hematuria: Grossly, urine looks normal. Dipstick positive for blood and urine
microscopy reveals RBCs.
Microscopic Hematuria is often intermittent and most causes are usually benign. So, it is
important to define a significant microscopic hematuria that requires further
investigations.
Microhematuria is defined as three or more red blood cells per high-power microscopic

field (RBCs/HPF) in two out of three properly collected and prepared specimens.
Repeat urinalyses to establish whether significant hematuria is present must be done
within 3 to 6 months of the initial test.
Minimal microhematuria ( i.e; one or 2 rbcs per HPF ) in asymptomatic young adults does
not require any evaluation. ( many studies have indicated that small amounts of
blood may be released into the urine of persons with no detectable pathology in the
urinary tracts)
In patients with risk factors for having a urological malignancy, a microhematuria even in one
or more samples must be considered significant and be evaluated.
Some benign causes of Microhematuria :
A) Exercise
B) Sexual activity
C) Menstruation
D) UTI
If UTI is present ( symptoms and dipstick for leucoesterase are clues that point towards
infection) - treat it with antibiotics and repeat urinalysis after the infection has cleared.
E) Benign Prostatic Hypertrophy
F) Prostatitis
Now, carefully look for other charecterestics of urinalysis - Presence of other findings on
the microscopic urinalysis such as RBC casts or Dysmorphic RBCs or proteinuria or
the labs revealing elevated serum creatinine suggests a the hematuria is originating
from the kidney/ glomerulus itself ( eg: Glomerulonephritis, IgA nephropathy). In
such cases, the next step in evaluating hematuria is referral to a nephrologist ( not
urologist) and a renal biopsy.
Further Approach to Microscopic Hematuria
Symptomatic Hematuria: In painful hematuria --> first rule out infection and renal colic. If
infection is absent or if there is a pain similar to renal colic ( classic flank pain) - consider
renal stones as the cause of Hematuria. The best initial step in evaluating the cause of
painful hematuria that is not explained by UTI is Non-Contrast CT scan (Spiral CT) (
test of choice for imaging renal calculi).
In pregnant women, ultrasound can be performed to avoid radiation exposure.
Asymptomatic MicroHematuria : Patients without the classic flank pain of urolithiasis
should be evaluated extensively. Once benign causes such as infection and the kidney
( glomerular) origin are ruled out, further approach should be defined based on the
patient's risk profile.
A) For patients with low risk of urological disease, a less extensive work-up may be
appropriate ( First do upper tract imaging and if this is negative, add urine
cytology+cystoscopy).

B) If the patient is a high risk of having a urological malignancy, extensive work-up is

needed ( see the risk factors below) --> Upper tract imaging + cystoscopy+ urine
cytology all are needed. Urine cytology should be obtained in all patients with
asymptomatic hematuria since it is an easy and non invasive step. Sensitivity of urine
cytology is only 48% but remember that if it is positive it is highly specific for
urological cancer ( 94% specificity)
Risk factors for urological cancer ( bladder ca):
1. Heavy somkers
2. Occupational exposure to aniline dyes
3. History of Gross hematuria
4. History of pelvic irradiation
5. Age > 40 years
6. Analgesic abuse
7. Presence of irritative voiding symptoms
8. Previous use of Cyclophosphamide ( increases the risk of bladder cancer where as ongoing
use often causes hemorrhagic cystitis as a adverse effect)
What imaging studies should be done as initial step in evaluating Asymptomatic
Hematuria?
For both high risk and low risk patients, upper tract imaging must be performed as an initial
step. For upper tract imaging, CT urography ( i.e; non-contrast CT followed by contrast
CT imaging from kidney to bladder) is best recommended initial test now to evaluate
asymptomatic hematuria. CT urography is less affected by overlying bowel gas and is
more sensitive for detecting small tumors and calculi than the IVP. Students often confuse
this with other choices such as ultrasound and Intravenos pyelogram. IVP used to be the
best preferred test for upper tract imaging in hematuria evaluation but now CT urogram is
becoming the preferred method. IVP and ultrasound are good to image the urinary tract
but they do not completely assess the renal parenchyma. If you order an IVP, you may
eventually need to order a CT urogram again to image the parenchyma better - so, in order
to avoid ordering multiple studies, CT urogram is recommended as the best initial test.