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Basic Concepts

In USMLE step 2 CK, we get few different kind of questions like which of the
following is the best initial test? Which of the following is the most accurate test?
Which of the following is the best initial treatment? Which of the following is the
most accurate treatment? Which of the following is the best next step in the
management of this patient? Which of the following is the first step in the
management of this patient?
To give answer to this kind of questions, understand following concepts. Test with
good sensitivity is the best initial test. For example, EKG has good sensitivity to
diagnose and differentiate chest pain so it will be the best initial test for patient with
chest pain. Test with good specificity is the best accurate test. For example, barium
esophagus is the best initial test to diagnose and differentiate dysphagia due to
obstruction or motility disorder but esophageal manometry is the most accurate test
to diagnose dysphagia due to motility disorder. Other important points in choosing
test are cost effectiveness and safety of test. Same way in the treatment, look at the
cost effectiveness and safety of the treatment. For example, atropine and pace
maker, both are good to start heart in first degree heart block but we use pace maker
as a last resort because atropine is more safe and as effective as pace maker and very
easy to use (just give IV). The most difficult question is the next best step in the
management of this patient. It depends on the condition of the patient when patient
arrives at the hospital / clinic or patient leaving the hospital / clinic [Stable,
Unstable or discharging time]. For example, patient with chest pain admitted to
the hospital and treated with Aspirin, Clopidogrel, Morphine and Angioplasty, now
its time to discharge, which of the following is the best next step in the management
of this patient? (a) Stress test, (b) Metoprolol, (c) Captopril, (e) Furosemide. Answer
is Metoprolol. Studies have shown that beta blockers have improved mortality rate
in patient with recent MI so adding Metoprolol to patients regimen will be the best
next step in the management of this patient. Another example, patient with upper GI
bleed comes to ER, BP 90/60, which of the following is the best next step in the
management of this patient? (a) Upper GI endoscopy, (b) IV normal saline, (c) fresh
blood (e) Barium Esophagus. Answer is IV normal saline. First we need to stabilize
the patient then we can order imaging studies. Fresh blood comes with its
disadvantages like infectious diseases so not a good idea! I hope youve got a better
idea by now about how to give an answer to the step 2 CK questions. I have written
best initial test, most accurate test, best initial treatment, most accurate treatment,
next best step and first step in the parenthesis in my notes so it will be easy for you
to recognize and remember everything. These notes are for exam purpose only so I
have written them in a way that they ask question on the real exam. In the real life,
patient can present with many different ways and we deal them accordingly but
always remember standard recommendation and current modification / new in
the management.

Good Luck

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CARDIOLOGY

Myocardial Ischemia / Myocardial Infarction: Substernal squeezing chest pain
[pressure / heavy feeling on chest]
Pericarditis: chest pain relieve by leaning forward
Costochondritis: chest pain reproduce by palpation
Dissecting aortic aneurism: tearing chest pain radiate to back
Pneumonia: pleuritic (increase on inspiration) chest pain
Pulmonary embolism: pleuritic chest pain, dyspnea, tachypnea
Esophageal spam (nut cracker disease): h/o GERD, gastritis, pain occur after
eating, normal EKG

Stable angina: chest pain after exertion
Unstable angina: chest pain at rest [ST Depression] [D E]
Myocardial Infarction: chest pain at rest [ST Elevation]
Prinzmetal angina: chest pain at rest [ST elevation Transmural Ischemia]
[due to coronary artery spam. Pain may relieve by little exercise like patient gets
up and walking and pain relieve because exercise causes increase in Adenosine
which is a potent coronary vasodilator] [Best diagnostic test Angiography
shows No atherosclerosis] [Treatment: Ca
++
channel blockers (CCB), Nitrates]
[Not Aspirin and -blockers]

How will you differentiate unstable / Prinzmetal angina and MI? Angina
means chest pain comes and goes so even though chest pain occur at rest in
unstable / Prinzmetal angina, you can easily diagnose from the presentation in the
question.

Patient with Stable/Unstable angina and MI should receive Aspirin, Nitrates
and -blockers (if no contraindications like Asthma, etc.)
Patient should also receive oxygen (if oxygen saturation is low) and morphine (if
patient is still having chest pain)
Unstable Angina (clot is forming): above 2 steps + Heparin (not thrombolytics)
+ Statins
MI (clot is already formed): above 2 steps + Thrombolytics (If certain criteria
meets) + Statins + Low molecular weight Heparin (If not contraindicated) + ACE
inhibitors (only If CHF due to acute MI) + Lidocaine (only If ventricular
arrhythmias)

Thrombolytics (If it is not contraindicated, if Angioplasty is not readily available)
Within 12 hrs of the onset of MI.
> 1 mm ST segment elevation in two contiguous EKG.
New LBBB (Left Bundle Branch Block).

Best Initial test: EKG; Stress test for Stable angina
Most accurate diagnostic test: Angiography (Ischemia) / Cardiac Troponin &
CK-MB (Infarction) [Both begin to elevate in 4-6 hrs] [Cardiac Troponin remains
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elevated for 1-2 wks] [CK-MB remains elevated for 2-3 days] [best test to check
re-infarction within a week CK-MB because it disappears in 2-3 days]
Most accurate treatment for MI / Unstable angina: Angioplasty
Most important is to know when you will do diagnostic test and when you
will start treatment. Answer what they asked like best initial / most accurate
If patient comes with chest pain for last 1-hr and still having pain, what will
you do first or best initial test? EKG
If patient comes with chest pain for last 1-hr and still having pain, EKG shows
ST depression / ST elevation, what will you do now? Start treatment (all patient
should receive above treatment depends upon what they have like Unstable
angina or MI or stable angina or Prinzmetal angina)
If patient comes with c/o chest pain off & on but no pain at present, what will
you do first? Stress test (EKG may not show anything cause no pain now)
Patient with past medical h/o CAD & other comorbidities (which restrict from
exercise) present with symptoms suggestive of ischemia (i.e. c/o chest discomfort
or feeling heavy in chest for few mins and goes away), next step? Adenosine
myocardial perfusing imaging (to see the progression of ischemia and risk
stratification of CAD) [Adenosine and Dipyridamole scan are C/I in patient with
COPD / Asthma. Use Dobutamine in those patient]
If above scenario but patient is able to exercise, next step? exercise stress test
Different Ischemia scenario: Patient present with typical / atypical intermittent
chest pain (exercise stress test); Patient present with typical / atypical intermittent
chest pain with comorbidities which restrict patient from doing exercise
(Adenosine scan); Patient present with typical / atypical intermittent chest pain
with comorbidities which restrict patient from doing exercise and has Asthma /
COPD (Dobutamine scan); Patient with previous Unstable angina / MI / bypass
present with typical chest pain, EKG show changes (depression) or Stress test
show ST depression (Angiography useful in further Mx Angioplasty / Bypass)
Any male patient present with chest pain (usually 2-3 hrs after dinner to confuse
us on the exam), next step? EKG. If EKG is done & is normal and patients pain
relieved by sub-lingual nitroglycerine, next step? cardiac enzymes (always rule
out cardiac problem first)
Cocaine induced transmural ischemia (ST elevation on EKG), next step? initial
management of ischemia (Oxygen, Aspirin, Nitroglycerin, Morphine) and
Benzodiazepines; If patient continues to have pain after administration of
benzodiazepines, next step? Give Phentolamine [alpha
1
-blocker] [cocaine
causes increase in Norepinephrine which causes HTN by prominent alpha1
action] If still c/o pain, next step? Angiography
Chest pain didnt relieve by nitroglycerine & EKG is non-specific, next step?
admit the patient and serial monitoring of cardiac enzymes (always try to rule out
cardiac cause first)

* Complication of MI : Ventricular Arrhythmia (MCC of Death)
Rupture (Ant Wall, Papillary muscles, Interventricular Septum) 3-7 days
Autoimmune Pericarditis (Dresslers Syndrome) 6-8 weeks PostMI Tx:
NSAIDs
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- Sexual activity can be resumed after 2-4 weeks post-MI
- Management of bradycardia following acute MI IV Atropine. If bradycardia
persist for more than 24-hrs Transcutaneous pacemaker
- Alternate tachycardia and bradycardia in a patient who had MI Sick sinus
syndrome Tx: Pacemaker
- Acute right ventricular infarction IV normal saline bolus (first step); then if
it fails to improve hypotension, give ionotropic agents like dobutamine

at 70% of target rate (after 5-7 days)
Stress Test PostMI
at 80% of target rate (after 2-3 weeks)

EKG changes in Acute MI: Peak tall T-wave ST elevation T-wave inversion
Q-wave
Inferior wall MI [RC]: II, III, aVF
Anterior wall MI [LAD]: V
2
V
4

Anteroseptal [LAD]: V
1
V
3

Lateral wall MI [LAD / Circumflex]: I, aVL, V
4
V
6

Posterior wall MI [Posterior Descending]: V
1
V
2


LIPID MANAGEMENT

(<100 mg /dl) < goal > (< 70 mg / dl)

Coronary artery disease Coronary artery disease
or + ++ +
Diabetes, Hypertension, Tobacco Diabetes, HTN, Tobacco

Risk Factors

One More than One


LDL > 160 mg/dl LDL > 190mg/dl LDL > 130 mg/dl LDL > 160 mg/dl
Diet Statins Diet Statins

Two main factors that reduce risk of CAD reduce LDL & HTN (in DM patient)

* Unstable Angina (Acute Coronary Syndrome): Stress Test Contra indicated
(C/I) [Other C/I of stress test acute myocardial infarction within 48 hours,
symptomatic severe aortic stenosis, uncontrolled arrhythmia, aortic dissection,
pulmonary embolism, and pericarditis]
Statins are best initial drugs for management of high LDL.
Generalized aches & pain with extremely high CPK in patient taking Statins,
next step? stop Statins

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Congestive Heart Failure


Right Sided Left Sided
JVD Pulmonary Edema
Hepatomegaly Paroxysmal nocturnal dyspnea (PND)
Ascites Orthopnea
Pedal edema S
3
gallop & murmurs

Positive Hepato jugular reflex is seen in right side heart failure is helpful in
differentiate cause of lower extremity edema from Heart problem / Liver problem

Diagnosis :
- History & Physical Examination
- CXR , Echocardiography
- MUGA scan / radionuclide ventriculography for measurement of ejection
fraction (most accurate test)
Treatment :
- Acute CHF (c/o short of breath, etc) 1
st
step give Oxygen Next step
Diuretics (reduce pre-load) [Nitrates, Morphine are helpful too] If still no
improvement give Dobutamine (ionotropic agent) [Digoxin takes time;
Dopamine increase after-load by vasoconstriction]
- After stabilization ACE inhibitor (reduce after-load) / Angiotensin II receptor
antagonist (those who dont tolerate ACE inhibitors), -blockers (Studies have
shown decrease in mortality by beta blockers in patient with CHF)
- Chronic CHF patients should be on Diuretics, ACE inhibitors, -blockers,
Digoxin
- Spironolactone have been shown to reduce mortality when added with all of the
above chronic CHF drugs

- Asymptomatic patient with low ejection fraction (means heart is failing), next
step? find out etiology (IHD most common cause so order a stress test)

- Management of acute pulmonary edema due to any cause Oxygen, Morphine,
Loop Diuretics. If it is due to hypertensive crisis Give Nitroglycerin or
Nitroprusside. If it is due to acute heart failure Dobutamine. Next step after
stabilization of patient with acute pulmonary edema of unknown etiology
echocardiography (to rule out MS or AI)

Pt on multiple drugs for multiple problems including digoxin, furosemide, next
step? serum electrolyte measurement (furosemide cause hypokalemia which
may cause digoxin toxicity)

Mitral valve Prolapse: Mid-late Systolic Click
- Presentation Asymptomatic, Palpitation (most common presentation), Chest
pain, Syncope, Sudden death
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- Marfan Syndrome / Asymptomatic
- Most common cause of mitral regurgitation in U.S.
* Treatment No specific treatment in most cases
- Endocarditis Prophylaxis Only If murmur present
- - blockers if chest pain occurs, palpitation and autonomic symptoms
- Antiarrhythmic if arrhythmia occurs

Infective Endocarditis: Splinter hemorrhages , Roths spot in eye , Janeway
lesions, Valve regurgitation
- Pathophysiology of Roths spot & Oslers node immune vasculitis; Janways
lesion septic emboli
- Strep. Viridians most common overall cause (previously damage valve )
- Staph. Aureus IV drug abuse ( Normal / Previously damage valve ) Tricuspid
Valve
- Staph. Epidermidis Prosthetic devices
- Strep. bovis ulcerative colitis / colorectal cancer patient

- Conditions that do not require infective Endocarditis Prophylaxis
pt. with cardiac pacemaker and defibrillation
Mitral valve prolapsed without regurgitation (without murmur)
Surgically repaired ASD, VSD, PDA
h/o Rheumatic fever without valvular dysfunction
h/o Kawasaki disease without valvular dysfunction
h/o isolated bypass surgery
h/o isolated ostium secondum ASD

Prophylaxis of Infective Endocarditis in patient allergic to Penicillin:
Dental, oral, respiratory, esophageal procedure Clindamycin, Azithromycin
GI & genitourinary High risk Vancomycin + Gentamycin
Low risk Vancomycin
First step start empiric antibiotics after drawing blood for culture
Next step Transesophageal echocardiography to see vegetation
Empiric antibiotic for IE in IV drug abuser Vancomycin + Gentamycin
In general Nafcillin + Gentamycin

- Loeffler Endocarditis restricive cardiomyopathy prominent Eosinophil
infiltrates leading to the fibrotic thickening of portions of the heart









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Valvular Heart Disease :

Stenosis Problem in opening of valve therefore murmur occurs during opening
of the valve
Regurgitation Problem in closing of valve therefore murmur occurs during
closing of the valve

Mitral Stenosis Aortic
Regurgitation

Mitral
Regurgitation
Aortic Stenosis
Diastolic murmur Diastolic
decrescendo
Holosystolic
radiate to the Axilla
Systolic ejection
radiate to carotid
Opening snap

Austin Flint
murmur

CXR double
density Right heart
Border.

Echocardiograph
y
Echocardiograph
y
Echocardiograph
y
Echocardiograph
y

Treatment Treatment Treatment Treatment
Diuretics (best
initial)
Endocarditis
Prophylaxis
Digitalis Endocarditis
Prophylaxis
Balloon
valvuloplasty (if
diuretics dont help)
Diuretic, ACE
inhibitors
Diuretics , ACE
inhibitors
Surgery if valve
area < 0.8 cm
2

( Normal 2.5-3 cm
2
)
Valve replacement
(If both of above
fail to relieve
symptoms)
Valve replacement
( Presence of Austin
Flint murmur
indicates the need
for replacement of
the valve )
Anticoagulant Balloon
valvuloplasty
Digitalis(if AF)
Anticoagulant (if
AF)
Valve replacement Indication for
surgery chest pain
/ Syncope during
exercise in elders;
Stable angina due to
stenosis next step?
Echocardiography
[not stress test]


Austin Flint murmur: regurgitant stream from incompetent Aortic valve hits
anterior mitral valve leaflet producing a diastolic murmur.

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Right sided murmur increase in intensity with Inspiration
Cardiomyopathies


Dilated Hypertrophic Restrictive

Echocardiography Echocardiography Echocardiography
CHF following
URTI
Autosomal Dominant
chromosome 14

Catheterization: square
root sign on tracing
ventricular pressure
Treatment thickening of Interventricular
septum
Mimic Constrictive
Pericarditis
- Diuretics Mechanism of mitral
regurgitation systolic anterior
motion of mitral leaflet
No good treatment
- Vasodilators ejection fraction 80-90 % (
Normal 60% 5% )
Consider Heart transplant
- Digoxin Sudden Death in athletes EKG low voltage
If Arrhythmia Treatment
- blockers
Procainamide /
Quinidine
Ca
+ 2
channel blockers
Anticoagulants Disopyramide

speckled pattern on
echocardiography
cardiac amyloidosis


Valsalva / Standing: Preload Obstruction
Squatting / Hand grip: Preload Obstruction
Increase in Pre-load decrease murmur in Mitral valve prolapse and
Hypertrophic cardiomyopathy.














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Pericardial Diseases


Acute Pericarditis Cardiac Temponade Constrictive Pericarditis

Chest pain Pulsus paradoxus Kussmauls Sign

Relieved by leaning
forward
SBP more than 10 mmHg
on normal inspiration
jugular venous distension
with inspiration
Pericardial friction rub
(Diagnostic)
Neck vein distension
with clear lung
Pericardial knock
EKG diffuse ST
segment elevation (In MI
ST elevation is in different
leads according to
involvement of heart and it
is convex)
Shock [Becks triad
Hypotension, JVP, muffled
heart sound], next step?
Pericardiocentesis. If no
blood on pericardiocentesis,
next? Thoracotomy
(blood is clotted in
pericardial sac)
EKG low voltage
Treatment involves
treating its etiology
Echocardiography

small Heart
Catheterization: square
root sign



Treatment

D/D: Restrictive
cardiomyopathy
- Pericardiocentesis CT scan - best choice to
demonstrate thickened
Pericardium
- Subxiphoid Surgical
drainage.
Treatment

- Diuretics
- Pericardiectomy

Pericardial Effusion :

Serosanguineous TB / neoplasm
CXR water bottle configuration of cardiac silhouette
Echocardiography (Best test)
Treatment : Fluid Aspiration, Treat etiology





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Arrhythmias



Heart Block

1
st
Degree 2
nd
Degree 3
rd
Degree

PR interval > 0.2 sec.
Type 1 Type -2
All atrial beasts are
blocked.
usually asymptomatic
( Wenckebach ) dropped
beat occur
suddenly
No PR
lengthening
Ventricles beat by a focus
distal to the site of block.
(Automaticity of heart)
Tx: usually none. If
Symptomatic
Atropine.

Progressive Tx:
Prolongation of Pace -
PR until a P wave maker
is completely (no resp-
Blocked & onse to
Dropped Atropine)
Beat

Tx : Pacemaker
Tx: usually none. If
Symptomatic give
Atropine.


Premature atrial beats and PVC (premature ventricular contraction) observe
(never required any treatment)



Sinus Bradycardia Sinus Tachycardia PSVT

Rate < 60 / min Rate > 100 / min Rate 130-220 / min
QRS complex Normal QRS complex - Normal Regular rhythm
Treatment
None if asymptomatic
Treatment
Right carotid sinus
massage
Treatment
IV Adenosine.

Atropine (1
st
choice)
Pacemaker
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Atrial Arrhythmias

Multifocal Atrial
Tachycardia
Atrial Flutter Atrial Fibrillation ( AF )
Irregular rhythm Regular rhythm Irregular rhythm

morphology of P wave
varies from beat to beat
2 : 1 block 300-500 impulse / min
Cardioversion if
hemodynamically unstable
Tx : cardioversion if
hemodynamically
unstable
Tx : cardioversion if
hemodynamically
unstable or AF is due
to angina / MI
If hemodynamically
stable then give Digitalis /
Calcium Channel Blockers
(CCB)
If hemodynamically
stable then give
Digitalis / -blockers (IV
Metoprolol) / CCB (IV
Diltiazam) to lower the HR
[below 100] and then
elective cardioversion
Patient with following
sign / symptoms should
consider as
hemodynamically
unstable:
- Hypotension
- Chest pain
- Confusion

If AF for 48 hrs then
give Warfarin 3 weeks
before elective
cardioversion and
continue 4 wks after normal
sinus rhythm or do
echocardiography to see if
there is any clot or not and
then do cardioversion
Digoxin preferred if
poor LV function
CCB & -blockers are C/I
in patient with poor LV
function

- DOC for Paroxysmal Atrial fibrillation Amiodarone
- First step in management (Mx) of stable patient with Multifocal Atrial
Tachycardia rule out etiology [hypoxia, hypokalamia, hypomagnesemia]

Wolff Parkinson White Syndrome ( WPW ):
- Short PR interval followed by a wide QRS complex with a Slurred initial
deflection, or delta wave, that represent early ventricular activation (Pre
excitation Syndrome)
- Tx: Cardioversion if hemodynamically unstable
- Procainamide is DOC for WPW
- Digoxin & Ca
+ ++ + 2
channel blockers are contraindicated
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Torsade de Pointes:
- Prolong QT interval, wide QRS complex
- Drugs : Quinidine
Procainamide
which Disopyramide
block K
+
channel Anti- Psychotics
[Phenothiazine & Thioridazine]
- Tx: Magnesium

- First step in management of patient with Torsade de pointes immediate
defibrillation. DOC for Tx & prevention IV Mg (give Mg regardless of patients
Mg level)

Ventricular Arrhythmias

Ventricular Tachycardia Ventricular Fibrillation

Rate > 120 beats / min Significant electrical activity on EKG
with no signs of an organized pattern
IHD (most commonly seen)
QRS complexes are wide and often
bizarre

VT (Pulse)

Pulseless VT / VF

Cardioversion
Stable unstable

IV lidocaine 1 mg/kg cardioversion
or
Amiodarone / Procainamide
(Amiodarone is preferred when poor LV
function)


Asystole : 1mg Epinephrine every 3-5 mins

1 mg Atropine every 3-5 mins

2-5 mg Epinephrine every 3-5 mins

Patent ostium primum (patent foramen ovale) failure of septum primum to
fuse with endocardial cushions
Atrial Septal Defect (ASD) incomplete adhesion b/w septum primum &
septum secondum Wide fixed split S2
VSD defect in membranous interventricular septum
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PDA machinery murmur associated with congenital rubella PGE
2
keep it
open it shunts pulmonary artery blood to aorta in fetus

Coarctation of Aorta:
Turners syndrome
Rib notching on CXR, MRI of chest (best test)
Tx: surgery
Endocarditis prophylaxis required

Tetralogy of Fallot (TOF):
Pulmonary stenosis, VSD, RVH and Over riding of aorta
Boot shaped hert on CXR
Murmur disappears & cyanosis improves when child squats
Single or soft S2
Tx: Surgery
Endocarditis prophylaxis required

Transposition of great vessels:
- Cyanosis in first 24-hrs of life, Infants of diabetic mothers
- Give PGE1 to keep open PDA until surgical correction done

Acute Rheumatic fever:
- Aschoff bodies (pathognomic) [central area of necrosis surrounded by reactive
Histiocytes (Anitschkow cells)]
- Pericarditis, Polyarthritis, Chorea, Erythema marginatum and subcutaneous
Nodules (Jones criteria)
- Usually occur 1-3 weeks after a preceding Strep. Pyogens pharyngitis
- ASO titers
- Treatment of acute infection and monthly Penicillin prophylaxis then after.
- Tx of Sydenhams Chorea (seen several months after acute attack of Rheumatic
fever; carditis and arthritis manifest within 21 days) Oral penicillin for 10 days
immediately

Yong child with Mitral stenosis due to Acute Rheumatic fever without any
symptoms, next step? Penicillin prophylaxis; If AF develop then consider
anticoagulation

Location of Murmur Conditions
Upper Rt sternal border AS, IHSS
Upper Lt sternal border PS, PDA
Lower Lt sternal border VSD
Apex MVP

Cardiac Myxoma left atria mesenchymal tumor embolic episode in young
person (next step? Send thrombus for pathologic examination, order echo),
syncopal episode young adult
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Rhabdomyoma children associated with tuberous sclerosis hemartoma

Best step in management of patient with Acute Aortic Dissection emergent
surgery. First step give IV beta blockers [Type A Ascending aorta (emergent
surgery) Type B Descending aorta (IV beta blockers)]
Diagnostic test for Aortic dissection Transesophageal echocardiography or CT
scan

Abdominal Aortic Aneurysm pulsatile abdominal mass, next step? USG
(first step) / CT scan (before repair) < 4 cm (observe), > 6 cm (elective repair)
- Tender AAA / Excruciating back pain, fainting episodes, unequal femoral pulses
in patient with known case of AAA Emergency surgery [Retroperitoneal
bleed causes fainting attacks]
- Complication of AAA repair Ischemic colitis [30% of cases IMA is the only
artery which supply sigmoid colon and by repairing AAA obstruct IMA which
present as severe abdominal pain, foul smelling diarrhea 2-3 days after repair,
next step? Sigmoidoscopy followed by exploration]

Peripheral Arterial Disease (PVD): Intermittent claudication / Rest pain, first
step? Ankle-Brachial pressure index measurement Arteriogram (most
accurate test) stop smoking, stop beta-blockers start Aspirin, Cilostazol
(Antiplatelet vasodilator) stent / Bypass (most effective treatment)

Lerich Syndrome: Aortoillio atherosclerosis atherosclerosis of hypogastric
artery c/o impotence and claudication

Deep vein thrombosis: Duplex USG (Best initial test) Venography (most
accurate test) If Duplex USG positive, next step? LMW Heparin (sc) for 5-7
days followed by Warfarin for 3-6 months (INR 2-3) [only in patient with
metallic heart valve keep INR at 3-4]

Sign & Symptoms of DVT, next step? Compression UGS to confirm
diagnosis before anticoagulation treatment (to avoid potentially serious side
effects of anticoagulation therapy in unnecessary pt.)

Fludrocortisone is the first line medicine for orthostatic hypotension but should
be tried after non-pharmacologic trial fail like discontinue dugs causing
orthostatic hypotension [Nitrates, CCB, TCA, Opiates analgesics]

Best initial test / next step in management of patient with acute syncope EKG





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15
Preventive Medicine: Mx of exposed health care worker to TB place PPD now
and repeat it in 3-wks
Nicotine replacement is preferred over buproprion for the management of nicotine
withdrawal during early stage of smoking cessation give behavioral counseling
and nicotine patch [First counseling then treatment; If you have never counseled
patient regarding smoking cessation, do not pick prescribe nicotine patch or any
other treatment for smoking cessation (most probably wrong answer)]
CXR is not done routinely for screening purpose for lung cancer
There are no screening test indicated routinely for many cancers like bladder CA,
Ovarian CA, pancreatic CA, lung CA, Hepatocellular CA, etc so do not pick
answer telling you order this screening test to rule out this CA
Prophylaxis of meningococcal meningitis Rifampin
Prophylaxis of meningococcal meningitis in women taking OCP ciprofloxacin
HRT can cause significant elevation in triglyceride. If hypertriglyceridemia
doesnt solve after discontinuation of HRT and dietary modification , start
treatment
Smoking cessation has shown benefit in patient with osteoporosis
Cigarette smokers have been shown to have more wrinkles than do nonsmokers
Dehydration aggravate skin damage and therefore patient going on vacation in a
area with lot of sun exposure should be educated to drink more water and wear
protective clothes
Prevention of malignant melanoma Protective clothing
Most important risk factor in stroke HTN
A clear association has been found b/w excessive alcohol intake & development
of hypertension
Several studies has suggested strong correlation b/w alcohol intake and colon CA
Colonoscopy should be started at age of 50 yrs in a general population with
average risk and at age of 40 yrs or 10 yrs earlier than detection of colon CA in
family member, whichever come first
Patient with ulcerative colitis and pancolitis should begin surveillance
colonoscopy after 8 yrs of having the disease
Do nothing after complete resection of <2cm pedunculated adenomatous polyp;
surveillance colonoscopy after 3 yrs; If negative at 3 yrs follow up,
surveillance colonoscopy period can be extended to 5 yrs.
Mammography screening started b/w 40-49 yrs of age every 2 yrs; After 50
yrs of age annually [The American Medical Association, American College of
Radiology, American Cancer Society, American College of Obstetricians and
Gynecologists, and the USPSTF all support mammography screening beginning
at age 40; In patient with h/o breast CA in first degree relative, begin at 10 yrs
earlier than detection of breast CA in family member]
Pap smear within 3 yrs after onset of sexual activity or age of 21 yrs,
whichever occur first [some says age of 18 yrs] [If 3 annual pap smears are
negative, then do pap smear every 2 yrs until age of 70 yrs] [Annual pap smear
screening is recommended for all women regardless of their sexual orientation
(hetero/homosexual women)]
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Prostate CA screening African-American and individual with family h/o
prostate CA should begin annual screening (PSA level and digital rectal exam) at
age of 40 yrs; at age of 50 yrs for everyone else
Screening of DM is indicated in everyone aged 45 yrs or older. [FBS]
Gestational Diabetes Screen b/w 24-28 wks 1-hr 50g oral GTT (screening
test) If level >140 mg/dl, do definitive test (3-hrs 100g oral GTT done after
overnight fasting) FBS (<126 gm/dl), After 100g oral GTT at 1-hr (<180
gm/dl), at 2-hrs (<155 mg/dl), at 3-hrs (<140 mg/dl)
Triple marker screen b/w 15-20 wks MS-AFP, hCG, Estriol - (MS-AFP
& Estriol), hCG Trisomy 21 (Down syndrome), next step? Amniocentesis;
(All three) Trisomy 18, next step? Amniocentesis for karyotyping
Rh-isoimmunization Blood typing at first prenatal visit If Rh-negative
mother, Indirect Coombs test at 28 wks of gestation [<1:8 no fetal risk]; give
RhoGAM to all Rh-negative mothers at 28-wks of gestation
RhoGAM is given to Rh-negative mothers at 28-wks of gestation, after delivery
of Rh-positive infant, within 72-hrs of amniocentesis, D&C, chorionic villous
sampling
Chlamydia Trachomatis Screening All sexually active women age 24-yrs
and younger and in other women who are at increased risk of STDs
CDC recommended vaccination id Adult Td (every 10 yrs after age of 18 /
last booster at age of 50), acellular Pertusis (booster b/w age of 19-64), Influenza
(All adults >50 yrs of age IM route; Healthy 5-49 yrs of age, non-pregnant
women Intranasal), Pneumococcal (All adults >65 yrs of age)
Vaccination in HIV positive patient Influenza (IM), MMR, S. pneumoniae,
Hepatitis
First trimester screening tests CBC, Rubella IgG antibody, Hep B, Blood
type, Rh & Antibody screen, cervical culture, urine culture, PPD, VDRL/RPR,
Pap smear and HIV ELISA [require specific consent]
Screening tests for All newborn Hypothyroidism, Galactosemia,
Phenylketonuria
Voiding after intercourse has been shown to decrease the risk of UTI in sexually
active females
Breast cancer prevention trial suggest that Tamoxifen reduce the risk of breast
cancer in patients who have an increased risk of developing breast cancer
[Ideal body weight for female 5 feet height = 100 lbs then add 5 lbs for each
inch increase in height; Ideal body weight for male 5 feet height = 106 lbs then
add 6 lbs for each inch increase in height]

Drugs Decrease long term mortality in different condition
ACE inhibitors CHF, Prevent diabetic nephropathy, reduce insulin resistance
Beta blockers Acute MI, Perioperative period
Aspirin Acute MI
Home Oxygen COPD, Right sided heart failure due to pulmonary hypertension
Spironolactone With ACE inhibitors in CHF

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HPV subtypes associated with cervical CA 16, 18, 31, 33, 35
Atypical squamous cells (ASC) on pap smear ASC-US or ASC-H (cant
exclude HSIL)

Classifications: Pre-cancerous stages

CIN = cervical intraepithelial neoplasia
CIS = carcinoma in situ
LSIL = low grade squamous intraepithelial lesions
HSIL = high grade squamous intraepithelial lesions

That means: Mild dysplasia = CIN-I = LSIL
Moderate dysplasia = CIN-II = HSIL
Severe dysplasia / CIS = CIN-III = HSIL
Dysplasia CIN Bethesda
Mild I LSIL
Moderate II HSIL
Severe III
CIS
How will it present to us?
Abnormal routine Pap smear
(Atypical Sqmaous Cells)
c/o Post-coital bleeding
Next step?
Next step?
HPV DNA testing &
Colposcopy
Cervical Biopsy
If abnormal findings
(mosaicism, punctuation,
white lesions, abnormal
blood vessels), Next step?
If biopsy confirms
invasive CA, Next
step?
Ectocervical biopsy of above
colposcopic findings
Endocervical curettage (ECC)
(All non-pregnant women)
Metastatic work-up
Managements
If Pap smear finding is worse than
histology or If abnormal ECC, Next
step?
Cone Biopsy
Cervical Cancer
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Management of Pre-cancerous lesions:

ASC-US, CIN-I: repeat Pap smear in 4-6 months (If patient is unreliable for
follow-up, do Colposcopy instead of waiting for patient to come back for Pap
smear)
CIN-I, CIN-II, CIN-III: Cryotherapy, laser, LEEP, cold-knife conization
Biopsy confirmed recurrent CIN-II,III: Hysterectomy

Management of Invasive Cervical CA: Depend upon stage
Stage 0 - full-thickness involvement of the epithelium without invasion into the
stroma (carcinoma in situ)
Stage I - limited to the cervix
o IA - diagnosed only by microscopy; no visible lesions
IA1 - stromal invasion less than 3 mm in depth and 7 mm or less in
horizontal spread
IA2 - stromal invasion between 3 and 5 mm with horizontal spread
of 7 mm or less
o IB - visible lesion or a microscopic lesion with more than 5 mm of depth
or horizontal spread of more than 7 mm
IB1 - visible lesion 4 cm or less in greatest dimension
IB2 - visible lesion more than 4 cm
Stage II - invades beyond cervix
o IIA - without parametrial invasion, but involve upper 2/3 of vagina
o IIB - with parametrial invasion
Stage III - extends to pelvic wall or lower third of the vagina
o IIIA - involves lower third of vagina
o IIIB - extends to pelvic wall and/or causes hydronephrosis or non-
functioning kidney
Stage IVA - invades mucosa of bladder or rectum and/or extends beyond true
pelvis
Stage IVB - distant metastasis

Stage-Ia1: simple hysterectomy
Stage-Ia2: hysterectomy + lymphnodes removal
Stage Ib1 and IIa less than 4 cm: radical hysterectomy with removal of the
lymph nodes or radiation therapy.
Stage Ib2 and IIa more than 4 cm: radiation therapy and cisplatin-based
chemotherapy, hysterectomy or cisplatin chemotherapy followed by hysterectomy
Stage-IIb, III, IV: Radiation and Chemotherapy (cis-platinum)

Pregnancy & Cervical CA: Diagnosis & management is same as in non-
pregnant women except ECC is not done in pregnant women


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Endometrial CA:
Prolong Estrogen (E) exposure without Progesterone (P)
Post-menopausal bleeding (most common presentation)
Next step? Endometrial sampling
If negative histology Hormone replacement therapy
If positive histology Surgery, Radiotherapy, Chemotherapy

Leiomyomas:
most common benign uterine tumor
Intramural within the wall of the uterus
Submucous located beneath the Endometrium; causes Menorrhagia (heavy
bleeding) and Metrorrhagia (irregular bleeding in between menses)
Subserosal located beneath uterine serosa
Asymmetric, Non-tender, enlarged uterus in the absence of the pregnancy
Tx: GnRH analog (3-6 months), myomectomy, embolization, Hysterectomy

Adenomyosis:
endometrial glands and stoma located within the myometrium of the uterine wall
(uterus)
Pain immediately before and during menses
Symmetric, tender, enlarged uterus in the absence of the pregnancy
Tx: levonorgestrel intrauterine system

Endometriosis:
endometrial glands and stoma located outside the uterus
Chocolate cyst of the ovary, utero-sacral ligament nodularity, pain during
intercourse (dyspareunia), infertility
Dx: Laparoscopy
Tx: OCPs (oral contraceptive pills)

Vulvar neoplasm:
c/o intense vulvar pruritus
Melanoma black lesions biopsy & excision
Pagets disease red lesions biopsy & excision
Squamous cell CA HPV association whitish lesions biopsy & excision
Hypertrophic dystrophy of the Vulva corticosteroid ointment
Atrophy of Vagina Estrogen cream

Pagets disease (of breast, cervix) Adenocarcinoma
Pagets disease of bone isolated elevation of Alkaline phosphate in elderly
Patient with normal Ca+2, Po4 & amino transferase level - Worrisome changes
in Pagets disease of bone sarcomatous (1-3%) Tx: asymptomatic Pagets
disease of bone nothing; symptomatic bisphosphonates

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Simple Cyst on US: <7 cm, next step? observe for 6-8 wks, resolved
spontaneously, start OCPs to prevent further functional cysts fro forming; >7 cm
or already on OCP (for atleast 2-months), next step? Laparoscopy
Complex mass on US: Cystectomy (to preserve ovarian function);
Oophorectomy if conservative failed
Any cyst in pregnancy which is greater than 5 cm should be removed during
second trimester of pregnancy

Most common benign ovarian tumor serous cystadenoma
Most common malignant ovarian tumor serous cystadenocarcinoma
Granulosa-theca cell tumors secrete estrogen
Sertoli-Leyding cell tumors secrete testosterone
Krukenbergs tumor contains signet ring cells from Metastatic stomach cancer
Dysgerminoma resembles Seminoma of the testis
Meigs Syndrome Ovarian fibroma, Ascites & right sided pleural effusion
Abdominal pain + Adnexal mass, diagnosis? Torsion of the ovary, next step?
surgical intervention (exploratory laparotomy)

Immature teratoma primitive epithelial cells & developing skeletal muscles,
potentially malignant [teratoma derivatives of all 3 germ layers [ectoderm,
mesoderm and endoderm hair, tooth, thyroid gland, etc]

Adnexal Mass
Pre-Pubertal Reproductive Age Post-Menopausal
Germ cell tumors Simple cyst
Complex mass
[Teratoma (Dermoid
cyst)]
Ectopic Pregnancy
Ovarian Cancer
Next step?
Obtain tumor markers
LDH
Dysgerminoma
-HCG
Choriocarcinoma
AFP Endodermal
sinus tumors (Yolk-
sac tumors)
-HCG
US (ultrasonography)
Next step?
Next step?
Find GI tract and
Urinary tracts
lesions
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Dermoid cyst: A dermoid cyst is a mature cystic teratoma containing hair and
other structures characteristic of normal skin and other tissues derived from the
ectoderm. The term is most often applied to teratoma on the skull sutures and in
the ovaries of females.
Struma ovarii: mature teratoma that contains mostly thyroid tissue.

Gestational Trophoblastic Neoplasia (GTN):
HTN in the first trimester, fundus larger than dates, snowstorm appearance on
US, grape-like vesicles, high beta-hCG, hyperthyroidism
Complete Mole: empty egg, 46XX (parental), No fetus, progression to
malignancy (20%)
Incomplete Mole: 69(XXX), fetal parts present, progression to malignancy
(10%)
Lung most common site of metastasis, Tx: Suction D&C
After D&C for molar pregnancy, patient should be put on OCP so they dont get
pregnant and beta-hCG level monitor effectively
Follow-up with beta-hCG [upto 1-yr if benign; upto 5-yrs if malignant]

Uterine Incontinence:

& receptors prevent micturation
cholinergic receptors enhance micturation
Urethra receptors (estrogen)
Bladder receptors (progesterone) & cholinergic receptors

Genuine stress incontinence:
Cystocele, positive Q-tip test [Q-tip rotate >30
0
when intra-abdominal pressure
increase, eg. Cough]
Mx: Kegel exercise, estrogen replacement, urethropaxy

Irritative incontinence:
Infection, stone, tumor, foreign body
Mx: treat the cause

Hypertonic incontinence:
Idiopathic detrusor contraction
Urgency (most common symptoms)
Mx: Anticholinergic medication

Hypotonic incontinence:
Denervated bladder (DM, Multiple Sclerosis)
c/o pelvic fullness, pudendal nerve sensation
Mx: Intermittent self catheterization, cholinergic medications
Fistula, Bypass incontinence:
h/o radical pelvic surgery or h/o pelvic radiation therapy, c/o continuous leaking
Mx: Surgical repair
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Ectopic Pregnancy:
Amenorrhea, vaginal bleeding and unilateral pelvic-abdominal pain
Positive beta-hCG, no intrauterine pregnancy (IUP) on US
IUP detected with vaginal sonogram at 1500 mIU beta-hCG titer
IUP detected by abdominal sonogram at 6500 mIU beta-hCG titer
Beta-hCG level in normal IUP doubles every 58-hrs
Age is an important risk factor for an ectopic pregnancy besides PID (35-44 age
group, 3 fold increase in risk for ectopic pregnancy)
Mx: Confirm diagnosis (first step) (beta-hCG titer >1500 mIU, no IUP)
Ruptured ectopic: immediate surgical intervention (salpingectomy)
Unruptured ectopic: pregnancy mass <3.5 cm, beta-hCG level <6000 mIU, absent
fetal heart motion, no folic acid supplementation Methotraxate
If above criteria not met Laparoscopy (salpingostomy)
Rh-negative mother should receive RhoGAM, follow-up with beta-hCG titer
Beta-hCG routinely drawn on day 4 and day 7 of treatment of ectopic pregnancy
with Methotraxate. If it drops 15% from day 4 to day 7, treatment of ectopic
pregnancy is thought to be successful and patient returns for beta-hCG blood draw
until it is negative

Bacterial Vaginosis: thin, grayish-white discharge, fishy odor, vaginal pH above
5, epithelial cells with smudged borders (clue cells) due to bacteria adherent to
cell membranes Tx: Metronidazole (contraindicated in pregnancy, use
Clindamycin during pregnancy)

Trichomonas Vaginitis: frothy, green discharge, itchy, burning pain with
intercourse, vaginal pH above 5, sexually transmitted disease (STD),
trichomonads on microscopic examination Tx: Metronidazole (treat both
partners) - Tx of trichomoniasis in lactating women 2 g of Metronidazole single
dose and ask her to discontinue breast feeding for 12-24 hrs

Yeast Vaginitis: curdy, white discharge, pH <4.5, not a STD, Pseudohyphae on
microscopic examination Tx: single dose Fluconazole

Menstrual Cycle Hormones:

FSH: stimulate granulosa cells to secrete E & Inhibin (inhibits FSH release)
Estrogen: Negative feedbacks to FSH
Low E Negative feedbacks to LH
High E Positive feedbacks to LH
LH: stimulate production of androgens from theca cells, LH surge stimulates
synthesis of prostaglandins to enhance follicular rupture & ovulation
Progesterone: secreted by corpus luteum, prepare Endometrium for blastocyst
implantation


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Puberty changes:
Thelarchy (breast development) 9-10 yrs (E from the ovary)
Adrenarchy (pubic & Axillary hair) 10-11 yrs (Adrenal hormones)
Maximal growth rate 11-12 yrs
Menarchy (onset of menses) 12-13 yrs

Precocious Puberty: development of puberty before age 8 in girls and before age
9 in boys
GnRH stimulation test helpful to differentiate central Vs peripheral cause of
precocious puberty - LH after GnRH injection indicates central cause
Central: hypothalamic-pituitary-ovarian axis disturbance
Peripheral: ovarian tumor, adrenal tumor, exogenous estrogen, McCune-Albright
Management of patient with precocious puberty GnRH agonist to inhibit
secretion of estrogen to prevent premature fusion of the epiphyseal plates

Abnormal Vaginal Bleeding
Premenarchal Reproductive Age Post-Menopausal
Vaginal foreign
body
Sexual abuse
Precocious puberty
Sarcoma
botryoides (grape
like protrusion
through vagina)
Pregnancy
Anatomic causes
DUB (Dysfunctional
Uterine Bleeding)
Atrophic
changes
Endometrial
carcinoma
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Dysfunctional Uterine Bleeding: Anovulation (So no progesterone effect
which left estrogen unopposed), no secretory phase, no mid-cycle rise in
temperature Biopsy: Proliferative Endometrium with stromal breakdown. No
secretory endometrium Tx: OCPs
First step in management of heavy unremitting endometrial hemorrhage through
menarche and perimenopause period high dose unconjugated estrogen (to
suppress bleeding); Once stabilize D&C should be performed & pt should be put
on OCP
If perimenopausal women c/o an episode of heavy dysfunctional bleeding or
irregular menses, then do endometrial surveillance in the form of vaginal
ultrasound (to ensure endometrial thickness <4mm) or endometrial biopsy
Precocious Puberty
Gonadotropin Dependent Gonadotropin Independent
CNS Pathology
Sarcoidosis
Meningitis
Other causes
Tx: treat
pathology
Idiopathic
80% of cases
Tx:
Leuprolide
McCuneAlbright
Syndrome
Autonomous
stimulation of
aromatase enzyme
which estrogen
production from
ovary
Caf-au-lait skin
spots
Multiple cystic
bone lesions
(Polyostic fibrous
dysplasia)
Tx: Aromatase
enzyme inhibitors
McCune Albright
syndrome has
association with
Cushings
syndrome, not
Cushings disease
(which is due to
Pituitary tumor)
Granulosa cell tumor
Secrete estrogen
Tx: Surgical
removal of tumor
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Kallman Syndrome: anosmia + absent GnRH Tx: OCPs

Secondary Amenorrhea: absence of menses for 3 months if previously regular
menses or for 6 months if previously irregular menses
Hypogonadotropic (Hypothalamic or Pituitary dysfunction)
Hypergonadotropic (ovarian follicular failure)
Eugonadotropic (pregnancy, Anovulation, out-flow obstruction)
First step in management beta-hCG titer to rule out pregnancy
Next step? TSH level (hypothyroidism) Prolactin level (Hyperprolactinemia)
Next step? Progesterone challenge test (PCT)
If PCT positive diagnosis of Anovulation [Estrogen production is adequate]
If PCT negative inadequate Estrogen / Out-flow obstruction
Estrogen Progesterone challenge test (EPCT)
If EPCT positive inadequate Estrogen [Y-chromosome mosaicism, savage
syndrome (ovarian resistant syndrome)]
If EPCT negative out-flow obstruction
Primary Amenorrhea
Breast Present (secondary sexual
characteristics present)
Uterus Absent
Breast Absent
Uterus Present
Next step? Karyotyping
and Testosterone level
Next step? Karyotyping
and FSH level
Mullerian
Agenesis
(Rokitansky
Kuster
Hauser
Syndrome)
Androgen
Insensitivity
(Testicular
feminization)
Turners
syndrome
Hypothalamic
Pituitary
failure
Normal
female (XX)
Normal
Testosterone
Tx: Surgical
elongation of
vagina
Genetically male
(XY)
Secondary
female sexual
characteristics
Tx: Remove
testis and give
estrogen
supplement
45 (XO)
FSH
Streak ovary,
cystic hygroma
(web neck)
Tx: OCP (oral
contraceptive
pills)
FSH
Absent
secondary
sexual
characteristic
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Cause of amenorrhea in patient who lost more weight estrogen deficiency (due
to low LH and GnRH). They are also at risk of developing Osteoporosis

Premenstrual Syndrome (PMS): wide range of physical & emotional symptoms
occur, typically two weeks before menstruation and disappear with menses for
atleast 3 consecutive cycles
Tx: SSRIs (fluoxetine); If it fails, give Alprazolam; Diuretics, Vit-B6



First step in management of infertility in patient with PCOD weight loss; If it
fails, try Clomiphen citrate or Metformin
Metformin has shown to induce ovulation in patient with PCOD. It should be
discontinued during pregnancy once pregnancy is documented


Hirsutism Virilization
(Hirsutism + Musculinizing signs
like clitorimegaly, baldness, etc.)
Congenital Adrenal
Hyperplasia
Gradual onset
17-OH progesterone
Tx: Corticosteroid
replacement
PCO (Polycystic Ovarian
Syndrome) (Stein-
Leventhal Syndrome)
LH:FSH, Obese,
Testosterone
Cystic appearance of
ovary (neckless) on US
Tx: OCP, Metformin
Idiopathic
Positive family history
Normal level of all
hormones
Tx: Spironolactone
Adrenal Tumor
Rapid onset
DHEAS level
Tx: Surgical removal
Ovarian Tumor
Rapid onset
Testosterone level
Tx: Surgical removal
c/o hair growth in female
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Infertility:
First step in management semen analysis
Screening test for ovulation BBT (basal body temp) & mid-cycle progesterone
level
Luteal phase Defect Abnormal basal body temperature curve & low mid-luteal
progesterone level. Confirmation of diagnosis? Endometrial biopsy. Initial
Treatment? Progesterone supplement; if it fails, then? Clomiphene citrate /
hMG (human menopausal gonadotropin)
Best measure for pt with premature ovarian failure who still want to conceive
egg donation
Once diagnosis of premature ovarian failure is made (< 35 yrs of age, low
estrogen, high FSH) next step? Chromosome analysis to rule out presence of Y
chromosome

Hormone replacement therapy in Menopause:
Women with uterus Estrogen + Progesterone
Women without uterus Estrogen
Indication: vasomotor symptoms only (optimally do not exceeded 4 yrs)
Estrogen alternatives: Tamoxifen, Raloxifen
Raloxifen can be given in patient with positive family history for Breast CA to
prevent osteoporosis
First-line drug to prevent osteoporosis Bisphosphonates

Conclusion from WHI trial for HRT (Hormone Replacement Therapy)
No cardiovascular benefit
Increased risk for stroke with long term use
Increased risk for Breast CA [but not with unopposed estrogen]

Contraception: Estrogen causes Thromboembolism, not progestin
Contraception of choice in patient with bleeding disorders Depot
Medroxyprogesterone acetate. (it is ideal for h/o PID, heavy menstrual bleeding,
heavy smoking, fibroids, sickle cell disease) [Menorrhagia is the most common
complication in women using Norplant (six capsules of levonorgestrel)]
Emergency contraception levonorgestrel within 12-hrs (good efficacy within
48-hrs; appears to work up to 120-hrs after intercourse)
OCP decrease chances of ovarian CA
Pregnancy decrease chances of ovarian and breast CA
OCP decrease the risk of Gonococcal PID [Basis it increases thickness of
mucous & prevent gonococci to enter in fallopian tube]
Advise regarding contraception in adolescents use barrier methods in addition to
OCP (barrier method is useful to prevent STDs)

Identical twins (monozygotic twins embryo split during blastomere &
blastocyst stage) monochorionic, monoamniotic & monochorionic, diamniotic

Good Luck