PREPARED BY SANTOSH DHUNGANA
UWORLD SYNOPSIS FIRST: step 3 usmleworld.com 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. It’s 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 doesn’t 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 doesn’t 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. Don’t do pacing initially as the brady is usually transient. Don’t 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. 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.
34. ACEI is the DOC in CCF, even more so in elderly with dementia, in whom digoxin and spironolactone etc can cause delirium.
35. 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.
36. 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.
37. 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.
38. CABG TOC for multivessel disease or lt main disease, esp if DM coz in them the chance of restenosis with PTCA is very high.
39. 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.
40. Poor R wave progression- if the R remains same through V1 to V4. Seen in COPD, RVH, LVH, ant infarction, blocks and cardiomyopathy.
drugs, TCA, hypokalemia, seizure and stroke.
42. 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.
43. Aspirin should be stopped 7 d before most procedures, but needn’t be stopped for coronary angio or cath.
44. 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.
45. Pt can resume sexual activity 6 weeks after uncomplicated MI- ie if he recovers without any post MI chest pain, CCF or arythmia.
46. Severe symptomatic AS (area <1cm2) is treated with valve replacement, as balloon valvulotomy is associated with transient efficacy and high procedural morbidity.
47. 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: Beck’s 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.
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 doesn’t 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 paget’s 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 release excess insulin into circulation
8. Diabetic for planned CS section- don’t 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.
9. 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 don’t overlap the insulin. 10. Pt with hyperthyroidism with chief complaints of palpitation- treatment is ppnl and not PTU
11. 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.
12. 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.
13. 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.
14. Mental state change in elderly- always do TFT for diagnosing apathetic hyperthyroidism.
15. A pt on prednisone for RA develops infection and then hypotension- acute adrenal insufficiency. Administer fluid and dexamet, as it is long acting and doesn’t interfere with measurement of serum cortisols. Then do cosyntropin test. Mineralocorticoids aren’t used, because, one- they are not deficient, two- they take a longer time then just simply infusing saline. 16. Amiodarone- monitor patient’s 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.
17. 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.
18. Urinary metanephrines and catecholamines are better test then VMA for pheochromocytoma. Alpha blockade should be started only after the test, as it can falsely 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 doesn’t. 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 doesn’t help as the alpha blockade will blunt the response to vasoconstrictors.
19. Pt with Hashimoto develops rapidly enlarging thyroid and SVCO- probably thyroid lymphoma. Treatment is RT.
20. 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.
21. 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 don’t use it as an antipyretic in the treatment of thryotoxic storm.
22. 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. 23. 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.
24. 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.
25. 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.
26. 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.
27. 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 don’t 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 don’t take iodine. Thallium scintiscan is also nonspecific. 28. Don’t take thyroxin with calcium or iron over the counter supplements.
29. 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.
30. Pituitary incidentaloma with no symptoms shouldn’t be treated, only followed up with regular MRI.
31. 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 doesn’t help, as the intake is decreased also in different thyroiditis, iodine or amiodarone induced
32. 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).
33. HTN with hypokalemia- do aldosterone to renin ratio to
differentiate hypo and hyperreninemic hyperaldosteronism. In Conn’s 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.
34. 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.
35. 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 aren’t usually thyrotoxic as it involves the center of the gland, as well as USG will show multiple abscesses.
36. Hyperthyroidism in pregnancy- PTU is the TOC, as methimazole is teratogenic. If PTU doesn’t work, or cause neutropenia, surgery is indicated, else she can have thyroid storm during the stress of childbirth.
37. 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 study- if 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 don’t 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.
38. CT of neck is less sensitive than USG for nodular thyroid diseases.
39. If pt has papillary cancer on FNAC, then he needs NTT- near total 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.
40. 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.
41. 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.
42. Octreotide can be given in intractable diarrhea in DM gastroparesis patient.
43. DM neuropathy- amitryptiline is the DOC, but since most patients have heart disease also, beware- use gabapentin instead.
44. Erectile dysfunction with normal morning erection- its
psychological impotence. Erectile dysfunction is never a normal part of aging, so don’t tick that.
45. Pt of hypoparathyroidism- Tt is high dose of vit D( calciferol) and calcium; high dose because conversion to calcipotriol is defective. We don’t 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.
46. 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.
47. Those with hyperPTH who don’t need surgery are managed with periodic msmt of ca, Cr, and BMD. Pt can continue their vit D and Ca supplement, as research hasn’t 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 doesn’t 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 doesn’t 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 Addison’s disease develops diabetes I- its autoimmune polyglandular failure type II (Schmidt’s 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 Paget’s 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 doesn’t increase- its called platelet refractoriness, due to
alloimmunisation (formation of anti-platelet 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, don’t 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 those with life threatening VTE like massive PE, or unusual site like mesenteric or cerebral venous thrombosis should also be on lifelong warfarin.
13. 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.
14. 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.
15. 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.
16. 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.
17. 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.
18. Pt with prostate cancer comes with back pain due to mets- TOC is hormonal therapy- LHRH 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. 19. SCC skin- surgery first line, RT if pt refuses surgery, and 5FU is the third line treatment.
20. 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.
21. AIDS with PCNSL- best therapy is HAART itself, tho RT and corticosteroid help, they don’t increase life expectancy. The most important prognostic factor is the increase in CD4 count.
treatment is ERCP and stenting for the pruritus and jaundice. PTC only if ERCP fails. Ursodeoxycholic acid doesn’t help as it doesn’t relieve the obstruction.
23. Pt comes with diarrhea, sclerotic bone lesions, eosinophilia and peptic ulcer- Systemic mastocytosis.
24. 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.
25. 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.
26. Pt with ESRD and ACD, doesn’t 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 transplant.
27. 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.
28. 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.
29. 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.
30. 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.
31. Breast cancer metastasis to brain- stereotactic surgery if single, EBRT if multiple. Chemo don’t penetrate, steroid help, and prophylactic anticonvulsant are not indicated.
32. Sickling crisis- during mens, alcohol, nocturnal hypoxemia- mainstay of treatment is hydration. Morphine or iv ketorolac for pain.
33. 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 wasn’t 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 doesn’t 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 doesn’t 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 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.
8. 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.
9. 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. 10. 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.
11. 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.
12. 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.
13. Febrile transfusion reaction can be prevented by washing the cells, using leukocyte depletion filter, and preferring packed RBC to whole blood.
14. First test in chronic diarrhea is stool examination for leucocytes, parasites, blood, fat, ph, osmotic gap.
15. 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. 16. 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.
17. 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 doesn’t differentiate past and present infection. Endoscopic biopsy is not warranted to document care.
18. Complete resection of a <2cm polyp which proved to be dysplastic, but with cellfree margins, no vascular or lymphatic
involvement- we don’t 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.
19. 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 in HPE. Diffuse spasm: inc peristalsis and inc tone.
20. Kava can cause hepatitis and cirrhosis. Gingko can cause platelet dysfunction. Ginseng can cause SJ syndrome and psychosis. 21. 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.
22. 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. 23. ALS pts need PEG gastrostomy, and not TPN, as it is
irreversible. It is better than NGT as it doesn’t interfere with breathing and speech, and it doesn’t cause sinusitis; tho risk of aspiration is the same with both.
24. Protease inhibitors can be used to prevent ERCP induced pancreatitis.
25. Child Pugh criteria:
i. Albumin- <2.5, 2.5-3.5 and >3.5- score 1, 2 or 3 accordingly ii. Bilirubin- <2, 2-3 and >3
iii. Ascites- None mild and moderate iv. Delayed PT- <15 sec, 15-17 and >17 sec v. Encephalopathy, none, stage 1-2, or stage 3-4
i. 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 patient’s 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 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.
8. 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.
9. 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.
10. 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.
11. 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
12. Wedge shaped infarcts seen in subsegmental PE are seen as Hampton’s hump in XR.
13. 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.
14. 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).
15. Magsol is no more recommended for asthma.
16. 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.
17. Pts with PE can have fever and needn’t be treated, unless very toxic, or with inc WBC with bandemia.
18. 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.
19. 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.
20. 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.
21. Stable COPD need only hx and ex preoperatively, and don’t 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.
22. 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 (doesn’t 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.
23. Lymphangioleiomyomatosis is a rare condition in women, presenting with dyspnea, chest pain and reticulonodular infiltrates on XR, plus effusion and pneumothorax might be there.
24. LT antagonist like zafirlukast are associated with Churg Strauss. They also cause BM suppression and idiosyncratic hepatitis, so monitor LFT. 25. 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.
26. Diagnosis of sarcoidosis- biopsy of parotid or superficial LN should be preferred to hilar LN biopsy.
27. Asthma with PEFR 25% lower than the patient’s 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.
28. Cough induced by forced expiration is very suggestive of asthma, ie bronchial hyperreactivity.
29. Recurrent pneumonia- first do CXR to rule out a mass, if inconclusive, then do HRCT, then only bronchoscopy, as it is an invasive procedure.
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 Alzheimer’s; 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 John’s 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, don’t 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 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.
5. 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 don’t need vaccine, as even if they contract influenza, it is not going to be complicated. C/I if egg allergy.
6. Abrupt cessation is preferred to gradual decrease in smoking (cold turkey), with nicotine patch as the first choice, and then bupropion if needed. 7. 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.
8. 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.
9. 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.
10. FAP: ideal is total colectomy before the age of 20 yrs.
11. 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.
12. 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.
13. 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.
14. 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.
15. 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.
16. 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
1. Truck driver with DM on metformin drinks alcohol- what will you say? ‘Don’t 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.
2. 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 shouldn’t 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.
3. Send to hospice if life expectancy is six months or less, also in patients with end stage COPD, pul fibrosis and cardiomyopathy.
4. Patient is taking unknown herbal medication on which no adequate research has been done- say ‘don’t 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.
5. Eg, ma huang is the Chinese name for ephedra used for wt loss. 6. Be the patient’s 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.
7. 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.
8. 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 needn’t inform the family, but make the patient sign the refusal document.
9. If multiple first degree relatives disagree on the treatment of an unconscious patient, go to hospital ethics board, and then if necessary to court. 10. 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.
11. 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.
12. 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.
13. 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.
14. Tell the truth not only to the patient, but also to the insurance company- else it will be insurance fraud.
15. Jehova’s witness is refusing exchange transfusion to a diseased neonate which might develop kernicterus- since it is not emergency but is urgent, consult the hospital’s 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 patient’s refusal of basic life support. THIS IS NOT THE SAME AS END OF LIFE SUPPORT.
SURGERY
1. A pt involved in MVA couldn’t 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.
responsive, do decompression with ERCP.
4. MVA pt after intubation doesn’t 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 doesn’t 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 don’t 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 shouldn’t 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 shouldn’t 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 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.
14. 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.
15. Pt comes with knife sticking in his head- first thing to do is not CT but coagulation profile and blood match and cross match.
16. 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.
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.
18. Pneumatic compression alone is not sufficient in high risk patients to decrease risk of DVT, because they can still have pelvic vein DVT. 19. <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.
20. Post communicating artery aneurysm- diplopia, ptosis and anisocoria. PICA aneurysm- ataxia and bulbar dysfunction.
21. 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.
22. 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 don’t take the sister’s consent.
23. Elderly with BPH comes with protruding rectal mucosa with bluish discoloration and fraibility- its rectal prolabpse with strangulation and gangrene- immediate surgery (rectosigmoidectomy) is needed. If not strangulated, can try digital reposition under sedation, or application of granulated sucrose to decrease the edema.
24. 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.
25. 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.
26. PSA over 4 needs urology referral for biopsy.
27. Proximal nonmetastatic rectal cancer can be treated with
sphincter sparing surgery, while distal can be locally resected only if mobile, small and nonulcerated. Big tumors can be given neoadjuvant chemoradio to make them resectable.
28. 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.
29. Silicone breast implant haven’t 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 doesn’t affect the mammogram criteria, though the calcifications along its
