REVIEW OF:

Preventive medicine
Statistics
Most important IM questions

Step 3 review
2015

Ahmed Koriesh

Screening

Step 3 review

Preventive Medicine
Vaccines:
MMR:
-

Indication: All people born after 1957

Absolute CI: Pregnancy, immunodeficiency (in HIV if CD4 < 200)
Not contraindicated in: Lactation, pregnancy in household contact, anaphylaxis to eggs
Women should wait 4 weeks after MMR before getting pregnant

Influenza: (killed vaccine)

- Indications: children 6m:18 years, elderly > 65, nursing home residents, chronic
cardiopulmonary disease, pregnancy in 2nd & 3rd trimester, HIV, breast feeding. All people who
can serve as vectors (health care workers, family of high risk patient)
- Contraindication: < 6 months, anaphylaxis to eggs, febrile illness (Temp > 104)
- Egg Allergy: if only skin reaction, give vaccine and observe for 30 minutes
Meningococcal: (2 types conjugate MCV4 & polysaccharide MPSV4)
- Indications: MCV4 is a routine vaccine at age 11-12. MPSV4 recommended for high risk children
2-10 years and adults > 55 years.
- High risk people:
o Freshmen who live in dormitories
o Microbiologists, military, travel to endemic, terminal complement deficiency, asplenia,
HIV patients
- Post-exposure prophylaxis:
o All close contacts (contact with oro-nasopharyngeal secretions, household members)
o Rifampin: Not for pregnant or OCP
o Ciprofloxacin: not for children
o Ceftriaxone: single IM dose (250mg in adults)
Pneumococcal: (2 types: conjugate 7-valent PCV7 & polysaccharide 23-valent PPV)
- Indications: PCV7 is routine for infants < 2 years, PPV-23 for children > 2 years and adults with:
o Asplenia, sickle cell disease, cochlear implants, chronic heart/lung disease, diabetes,
alcoholism, Immunosuppression.
o Routine for adults > 65 years
HAV vaccine:
- Indications: travel to endemic countries, homosexual men, chronic liver disease, food handlers,
routine in children
- Contraindications: alum sensitivity
- Not CI in HIV.
HBV vaccine:
- Indications: sex partner and household contacts of infected patients, homosexual men, IV
abuse, chronic liver disease, dialysis patients, HIV patients, health care workers.
- Contraindications: Bakers yeast allergy

Screening

Step 3 review

Polio:
- Indications: travel to developing country, immunocompromised (IPV not OPV)
- Contraindications:
o OPV: contraindicated in immunosuppressed and household contacts of
immunosuppressed. Pregnancy is relative CI. Allergy to neomycin or streptomycin
o IPV: pregnancy, Allergy to neomycin or streptomycin
Varicella Varivax:
- Indicated for all adults without evidence if immunity (check AB, if ve vaccinate)
- Contraindications: pregnancy, immunocompromised, allergy to neomycin or gelatin
- Post exposure prophylaxis: give varicella vaccine, if vaccine CI give VZIG.
- NEVER give varicella vaccine and IG together (live attenuated vaccine will be inactivated).
Varicella-Zoster Zostovax:
- Live attenuated VZV, virus load is 14 times greater than Varivax.
- Indications: Elderly > 60 years to prevent zoster (50%) and to reduce post-herpetic neuralgia
(66%).
- Contraindications: pregnancy, immunocompromised, allergy to neomycin
HPV:
-

Routine vaccination for women 12-26 years. No benefit after 26. Ideally given before starting
sexual activity.
Capsid Ptn for HBV 6, 11 that cause Cx cancer and 16, 18 that cause genital warts.
Not given in pregnancy (no safety date yet)

HIV patients:
- Live vaccines that are CI: Varicella, OPV, oral typhoid, yellow fever
- Live vaccines that are indicated: MMR
- Non-live vaccines that are indicated: Penumovax, conjugated influenza, HAV in high risk
patients, HBV vaccine.
Pregnancy:
- Contraindicated: Measles, Mumps, Rubella, BCG, Small Pox, Varicella
- Should be avoided: Yellow fever, HPV
Post exposure prophylaxis HBV: Vaccine IG (if not vaccinated)
Post exposure prophylaxis HIV: 3-drug regimen.
Post exposure prophylaxis meningococcus: Rifampin 1st line (600mg bid for 2 days), Ciprofloxacin if
patient on OCP (rifampin increase OCP clearance)

Screening

Step 3 review

Disease screening:
Smoking cessation: Bupropion, nicotine replacement, Varenceline. Varenceline is partial agonist to
nicotinic receptor and avoided in patients with unstable psychiatric symptoms or suicidal ideation.
Dyslipidemia:
- Screen all men > 35
- Screen all women > 45 with increased risk for CAD (DM, FHx of premature CAD, FHx of
dyslipidemia)
- Repeat after 5 years if first test was normal.
DM:
-

Method: Screening with FBS > 126 on two separate times. RBS > 200 with symptoms, but needs
confirmation with FBS.
Indications: all patients with symptoms, all patients with HTN or dyslipidemia.

Osteoporosis:
- Method: DEXA scan
- Indications: all women > 65, women 60-65 with risk factors ( low BMI < 127lb, short, smokers,
drinking alcohol > 2 drinks/day, FHx of osteoporotic fr, steroid use > 3 months)
- Prevention:
o Post-menopausal women: start on Ca & VitD
o Chronic steroid use: Start on Ca & VitD, get baseline Dexa, repeat Dexa in one year.
o
- TTT: Bisphosphonates
AAA:
-

Risk factors: Age > 60, male sex, SMOKING, first degree relative with AAA
Screening: abdominal US for men 65-79 years (especially if smoker). No screening for women.
Follow up with US every 2 years (if < 4cm) or every 6 months (if 4-5.5 cm).
If patient has AAA and HTN: BB is the antiHTN of choice.

Cancer screening:
Test
Mammography
PAP smear
Colonoscopy
Flex sigmoidoscopy
FOBT

Starting age
40
21 or at 1st sexual
intercourse
50
50
50

Frequency
Yearly
Yearly for 3 years then
q 3yrs
10yrs
3-5yrs
Yearly

Ending age
70
65
None
None
None

Cancer colon:
- Routine for people > 50: FOBT yearly and endoscopy (either colonoscopy q10yrs or
sigmoidoscopy q5yrs)

Screening

Step 3 review

Moderate risk: FHx of cancer colon, adenomatous polyps, Cancer colon s/p resection
o FHx (1st degree < 60 or two 1st degree > 60): colonoscopy 10 yrs earlier than youngest
case or at age of 40, repeat q5yrs
o FHx (other relatives): only routine screening
o Polyp single adenomatous < 1cm: repeat colonoscopy within 3 yrs then routine (q10yrs)
o Polyp large or multiple: repeat colonoscopy after 3 years then q5yrs
o Polyp found to be malignant: repeat colonoscopy after 1yr then 3 yrs then q5yrs
High risk: FAP, HNPCC, IBD
o FAP: Colonoscopy starting at puberty, genetic testing (if positive total colectomy or
colonoscopy q 1-2 yrs)
o HNPCC: Colonoscopy starting at 21yrs, genetic testing (if positive colonoscopy q2yrs
till 40 then q1yr)
o UC: colonoscopy q1yr starting 8yrs (if pancolitis) or 15yrs (lt sided) after diagnosis. If
dysplasia colectomy

Cancer breast:
- Routine: Mammogram q2y starting at 50 yrs
- Family member with BRCA: Mammography q1y starting at 20
Genetic testing for breast cancer:
- 2 first degree relatives with breast cancer
- 3 first and 2nd degree relatives
- 1st degree relative with bilateral breast cancer
Cancer prostate:
- Not recommended to screen with PSA.
- Protein bound PSA is more associated with cancer, free PSA is more associated with BPH

Lung cancer
Cancer
prostate
Ovarian
cancer
Breast cancer
Cervical
cancer
Colon cancer

HBV
HCV
HIV

PSA

Recommended low resolution CT LRCT for all adults 55-80 with hx of

smoking 30 PY in the past 15 years.
PSA not recommended for screening
No screening for ovarian cancer

Mammography Recommended biennial mammography for women 50-74 years.

Pap smear
Recommends for women age 21 to 65 years PAP every 3 years or, for
women age 30 to 65 years combination of cytology and HPV testing every
5 years.
FOBT,
Recommended screening for adults 50-75 years using FOBT q1y,
sigmoidoscopy, sigmoidoscopy q5y, or colonoscopy q10y
or colonoscopy
Recommended for pregnant women and high risk persons.
Recommended for adults born between 1945-1965 & high risk persons
Recommended for pregnant women and adults 15-65 years.

Screening

Step 3 review

Syphilis
VZ vaccine
AAA

US

Aspirin
Aspirin for preeclampsia
Lipid
Vision in
children
Vitamin D screening
Vitamin D supplements
Osteoporosis
GBS
Recto-vaginal
Culture

Recommended for pregnant women and at high risk adults

Recommended for adults > 60 years
Recommended for men 65-75 years who ever smoked
May be offered for men 65-75 who never smoked
Recommended for men 45-79 and women 55-79
Recommended for women at risk > 12 weeks of gestation.
Recommended for all men > 35 years
Recommended at least once for children 3-5 years
Not recommended for asymptomatic adults
Recommended for Community-dwelling adults > 65
Recommended for all women > 65 or with risk factors
At 35-37 weeks of gestation

PPD Test:
PPD Positive if:
- > 5mm in immunocompromised (HIV, transolant, other), CXR suggestive of TB, recent contact
with TB patient.
- > 10mm in recent immigrant, residents & employee of high risk settings (healthcare, prisons,
shelters) , IV drug abuser
- > 15mm if no risk factors.
Effect of BCG vaccine on PPD:
- Rarely exceed 15mm induration, significantly decrease after 15 years. IFN gamma assay can
distinguish true positive PPD.
TTT of latent TB: (positive PPD, -ve Xray and sputum)
- INH for 9 months
HCW exposed to active TB patient: PPD now and repeat after 3 months. INH only if PPD conversion.

Statin therapy indications:

General
-

Known atherosclerotic disease

LDL > 190
DM 40-75 years old
Calculated 10-years-atherosclerotic CHD risk > 7.5%

High intensity: if LDL > 190, Age < 75 with significant atherosclerosis (ACS, Stroke, TIA), DM with 10-year
ASCVD > 7.5%.
Moderate intensity: If Age >75, DM with 10-year ASCVED < 7.5%

Breast feeding contraindications:

Screening

Step 3 review

Active TB, HIV, Herpetic breast lesion

Drug or alcohol abuse
Chemotherapy or radiotherapy.

HIV and pregnancy:

-

Prenatal:
o 3-drug HAART, HIV load monthly until undetectable then every 3 months
o If mother already on efavirenz then continue and dont change her regimen, if not
dont start efavirenz in first 8 weeks (neural tube defects) similar to valproate approach
in pregnancy
o Avoid amniocentesis until viral load undetectable
Intapartum:
o Avoid ROM, vacuum or foreceps.
o If mother not on HAART, start Zidovudine, if viral load > 1000 do C-section and start
Zidovudin
Postpartum:
o Mother continue 3-drug HAART
o Infant start Zidovudin for 6 weeks, serial HIV PCR. NO BREAST FEEDING

Ethics

Step 3 review

Ethics:
Parents cant withhold limb or lifesaving treatment from their children
Minors authorized to consent: (certain minors or certain events)
o Emancipated minors (married, pregnant, parents, military, financially independent)
o Certain services: (ER, prenatal care, contraception, abortion, STDs, infectious disease,
HIV testing/ttt, drug/alcohol abuse, sexual assault)
Consent for minors taken from legal guardians (parents). Sister and grandparents cant give consent
Treating family members and friends is ethically problematic. Only in acute care whne no other
physician is available.
ADHD ttt:
- in preschool children behavioral therapy is first line
- In older children, stimulants and atomoxetin are first line. Ask about cardiac hx before starting
on stimulants. Clonidine is a second line agent.
Mood disturbance and home problems can stand against organ transplantation
Pharmaceutical company: We can accept travel reimbursement, Honoria.
Firing patients: physician cant terminate relationship with a patient except after giving a reasonable
notice or providing a referral to another health care provider.
Domestic violence: If wife complain of domestic violence refer to domestic violence program. Child and
elderly abuse are the only reportable.

Neurology

Step 3 review

Alcoholic patient with tremors and ataxia: Management Lorazepam or Thiamine?

- Tremors + Ataxia: think Wernicks, give thiamine
- The area involved in Werncks are mammillary body and thalamus
Three cardinal criteria for diagnosis of brain death:
- Deep coma with no response to painful stimuli
- Absence of brain stem reflexes
- Positive apnea test: No spontaneous breathing with increase of CO2 20mmHg above baseline.
Prerequisites for definite diagnosis of brain death:
- Clinical or neuroimaging evidence of brain catastrophe compatible with brain death
- Exclusion of medical disorders (electrolyte, endocrine)
- Exclusion of drug intoxication or poisoning
- Exclusion of hypothermia (temp > 32)
If patient with presumed brain death doesnt meet the above criteria, we can use confirmatory test:
- Cerebral angiography showing no filling above the circle of Willis
- EEG showing lack or reactivity to somatosensory or audiovisual stimuli
- TCD: Insonation
- Cerebral scintigraphy Tc 99 (HMPAO SPECT): No tracing in the anterior or posterior circulations
Hypocalcemia with blood transfusion:
-

Risk factors include hypothermia, hepatic or renal failure

Avoid by giving Ca gluconate 10 cc with each 500 cc of blood
Total calcium is normal while ionized is low.

NAHCO3 is only indicated if Sr bicarbonate is extremely low (<5meq)

Brain stem syndromes (blood supply and clinical picture)
Dominant parietal lobe lesion: Gerstman syndrome (acalculia, agraphia, finger agnosia and Rt-Lt
disorientation)
Non-dominant parietal lobe lesion: Constructional apraxia (unable to copy simple lines drawing) and
dressing apraxia +- confusion
Dominant temporal lobe: upper quadrantanopia and wernicks aphasia
Non-dominant temporal lobe: upper quadrantanopia
Chronic Valproic acid SE: urinary incontinence and frequency.
Vasovagal syncope: upright tilt table test
Sarcoidosis: patient with facial palsy, hepatomegaly, erythema nodosum nodules on chin of tibia. Order
CXR to screen for sarcoidosis. Common in African American, porto-rican and Scandinavian. If CXR
showed mediastinal widening and bilateral hilar infilterates next step is biopsy.
-

Palpable LN
Parotid gland

Neurology

Step 3 review

Subcutaneous nodule except erythema nodusum.

Lacrimal gland
If there is no easily accessible lesion then Lung biopsy if CXR is positive.

Patient with hashimoto thyroiditis and pyramidal signs, think of B12 deficiency due to pernicious
anemia.
Severe B12 deficiency treatment: patient may develop hypokalemia.
Contraception is required for patient on MS disease modifying therapy
MS good prognosis: sensory onset, CN onset, female, young age of onset.
Bad prognosis: Male, late age of onset, motor symptoms
Drugs that can cause IIH: isotretinone, tetracyclin, minocycline, steroids, danazole, tamoxifen,
thyroxine, lithium and nitrofurantoin.
Parinaud syndrome: loss of vertical gaze, optokinetic nystagmus, pupillary reaction and ataxia. Some
pineal gland tumors secrete HCG.
Carbamazepine side effects: neutropenia, SIADH with hyponatremia, anticholinergic (glaucoma and
urine retention).
Post stroke spasticity: dantrolene is the first line therapy, alike baclofen, it is not sedating
B12 deficiency cause hyperbilirubinemia due to ineffective erythropoiesis: cells die in bone marrow
before maturation.
Miller Fischer test: for NPH, assess gait before and after removal of 30cc of CSF.

Gastro

Step 3 review

Patients with Mallory Weiss usually associated with hiatal hernia

Patients with acute variceal bleeding usually develop infection during their hospitalization (UTI, SBP)
and require prophylactic AB with quinolones.
Acute pancreatitis with fever: start Imipenem once pancreatic infection is suspected
Isotretinone causes hypertriglyceridemia which can cause acute pancreatitis
The most common causes of lower GI bleeding: diverticulosis and angiodysplasia. Angiodysplasia is
associated with Aortic stenosis usually.
Isolated gastric varices occurs due to splenic vein thrombosis in patient with recurrent pancreatitits.
Patients with Mallory Weiss should undergo endoscopy to confirm the diagnosis
Cell washing of PRBCs leukocyte removal prevent febrile reaction to transfusion
Ulcer perforation: next step is X-ray to see air under diaphragm, not CT abd or endoscopy
Drug induced pancreatitis:
- Furosemide and Thiazides
- AED: Valproate
- Anti-metabolic: Azathioprim, Asparginase
- AB: Metronidazole, tetracycline
- AIDS meds: Didanosine, pentamidine
- IBS meds: Sulphaslazine
Ransons criteria for acute pancreatitis severity:
Within 48 hours:
- WBCs > 16000
- RBS > 200
- AST > 250
- LDH > 350
- Age > 55
After 48 hours: observation. remember hypocalcemia in observation not on admission.
- Hypoxemia < 60mmHg
- Hypocalcemia < 8mg/dl
- BUN increase > 5mg/dl
- Hct decrease > 10
- Albumin < 3.2
- Fluid deficit > 4L
Source of bleeding in diverticulosis is erosion of the artery
Acute hep B ttt: supportive care
Acute hep B transformation to chronic: 5% in adults and 90% in infants with perinatal infection.
Herbal medications SE:

Gastro

Step 3 review

KAVA: liver injury

Ginseng: bleeding
Ginko: Steven Jonson syndrome
Aconite: cardiotoxic

Esophageal carcinoma: sq in upper third and adeno in lower third

H pylori: for diagnosis use serology for confirming eradication use urea breath or fecal antigen test 4
weeks after treatment.
Absence of esophageal motility: achalasia if ass with increased LES tone, scleroderma if ass with
decreased LES tone.
Laxative SE:
-

Bisacodyl causes hypokalemia and salt retention

Castor oil causes electrolyte abnormalities
Milk of magnesium is CI in renal failure

Positive Anti HCV Ab: may be infected or cured from infection or false positive ELISA. Next step is HCV
RNA confirmation
Lactose breath hydrogen test for diagnosis of lactose intolerance: patient should be fasting 8 hours
before.
Colonoscopy excised polyp and biopsy showed adenocarcinoma in the head with free stalk:
polypectomy is enough, f/u colonoscopy in 3 years if < 2cm or 3 months if > 2cm
C diff relapse: continue with metronidazole after first relapse, then Vancomycine after 2nd relapse
Barrett esophagous f/u EGD with biopsy in 1-3 years
Patient with Celiac disease with persistent symptoms inspite strict gluten free diet: think of GI
lymphoma. A common complication of celiac disease

Hepatology

Step 3 review

Increased alkaline phosphatase:

- With increased bilirubin: bile duct stone or cholangitis
- Isolated: infiltrative liver disease (lymphoma or TB)
Earliest sign of alcoholic liver disease is disproportionate increase in AST/ALT
Autoimmune hepatitis: antinuclear and anti-smooth muscle Ab.
PBC: anti mitochondrial Ab

Child-Turcot-Pough score:
Points
Bilirubin
Albumin
PT
Ascites
Encephalopathy

1
<2
>3.5
<15
Absent
None

2
2-3
2.8-3.5
15-17
Slight/responsive
Stage 1-2

Class A: score 6
Class B: score 7-9
Class C: score 10
Liver transplantation is considered in all cirrhotic with score >7
When to treat HCV with ribavirin and interferon:
- if ALT is persistently elevated
- liver biopsy shows moderate inflammation
- HCV RNA positive

3
>3
<2.8
>17
Moderate/Severe
3-5

Drugs & Poisoning

Step 3 review

Heat stroke main line of treatment: Evaporating cooling

Anaphylaxis first line ttt is SC or IM Epinephrine not steroids
Antidote of ethylene glycol and methanol is Fomepizole not alcohol
PCP toxicity ttt: low sensory environment with keeping hemodynamic stability
Thiazides and furosemide: cause pancreatitis
Isotretinone: teratogen, hyperglycemia, hypertrigleceridemia, hepatotoxicity. It can cause pancreatitis
due to hypertriglercidemia. It is not teratogenic if used by male partner. Female in child bearing period
must use 2 contraceptive methods 1 month before and 1 month after treatment.
Tretinoin is FDA approved for reduction of wrinkles, hyperpigmentation, and roughness of facial skin.
Tetrabenzne is a dopamine agonist used in HD.
Lithium induced hypothyroidism: dont stop lithium, add L-thyroxin.
Laxatives:
- Cisapride: causes cardiac arrhythmia, limited use in USA
- Phosphate enema: cause electrolyte imbalance.
- Bisacodyl: causes abdominal cramping, diarrhea
- Castor Oil: lubricate bowel to facilitate passage. Impairs absorbtion of fat-soluble vitamins, if
GERD will cause oil aspiration pneumonia.
- Magnesium hydroxide: SAFE in children.
Photosensitivy: Tetracycline, Doxycycline, Benzoyl peroxide, thiazides
Drugs affecting Lithium:
- Diuretics, NSAIDs except ASA, SSRI, ACE, ARB, AED (carbamazepine, phenytoin)
- For BP control: Avoid diuretics, ACE, ARB. You can use CCB or BB
HIV medications:
- Didanosine: pancreatitis
- Abacavir: hypersensitivity
- Indinavir: crystal induced nephropathy
- NRTI: Lactic acidosis
- NNRTI: Stevens-Johnson syndrome
- Nevirapine: liver failure

Drugs & Poisoning

Step 3 review

General

Step 3 review

Drugs that can cause SIADH: Chlorpropamide, SSRI, Carbamazepine and cyclophosphamide
Hyponatremia:
Cause
SIADH

Sr Osmolarity

Polydepsia
Pseudohyponatremia
Volume depletion

Ur Osmolarity
> 100mosmol

Urine NA
> 40 meq

<100 mosmol

< 20 meq

Hemochromatosis: usually affects 2nd and 3rd MCP joints, Positive birefringent CPPD crystals present in
50% of patients. X-ray shows hook-shaped osteophytes and subchondral cysts.
Osteoarthritis: spares MCP joint
Gout: usually affect DIP and spares MCP. Negative birefringent crystals.
Pseudogout CPPD arthropathy: > 65 old, positive birefringent crystals.
MCP
Hemochromatosis
Rheumatoid arthritis
Pseudogout

DIP
Osteoarthritis
Psoriatic arthritis
Reactive arthritis

Suicide:
- High Imminent risk: (Intent and plan), hospitalize involuntary if necessary. Remove all self-harm
risk objects. Constant observation
- High non-imminent risk: treat depression, recruit family for support, secure firearms and
medications.

General

Step 3 review

Obsessions: recurrent thoughts, image or impulse that causes severe distress. Mother who has
recurrent thoughts of killing her children, and this makes her distressed
Compulsions: repetitive compulsive behavior in an attempt to alleviate anxiety by obsessions.
MCC of bleeding in old age: diverticulosis and angiodysplasia (associated with aortic stenosis)
Shoulder pain:
- Rotator cuff impringement: Pain with abduction & external rotation, subacromial tenderness,
normal range of motion, positive neer and Hawkins test.
- Rotator cuff tear: same + weakness with external rotation.
- Frozen shoulder (adhesive capsulitis): decreased passice & active range of motion. May be
idiopathic, secondry to stroke, DM or bursitis.
- Biceps tendinitis: anterior shoulder pain, pain with lifting or overhead reaching.
Acute HBV: treatment is supportive. Antiviral therapy (Lamivudin) only in patients with HCV,
immunosuppressed, severe disease.
DKA:
-

IVF: NS, once glucose <200mg/dl switch to D5W

Insulin: IV infusion, switch to SQ if able to eat, glucose < 200mg/dl, anion gap <12 and HCO3 >15.
K: add IV potassium if K < 5.2meq, hold insulin if K < 3.3
HCO3: consider If PH < 6.9

When to stop statins: if symptomatic or if CK > 10 times normal in asymptomatic.

Surgery in MR: if symptomatic (ShOB, HF) or if EF <60% (considered inadequate in MR patietns)
Euthyroid sick syndrome (ESS or Low T3 syndrome): seen in hospitalized patients with hypothyroidism
manifestations and normal T4, dont treat. Repeat lab after few weeks.
Cataplexy: ttt with SNRI, SSRI, TCA.
Nacrolepsy ttt: Modafinil (1st line), methylphenidate is alternative.
Infantile botulism: common in California, Pennsylvania and Utah. Through ingestion of dust. Dx by
spores or toxins detection in stool. Tx by human-derived immunoglobulin.
ARDS: PaO2/FiO2 is < 300 (example 100/0.2= 500)
Aspirin and Warfarin: use both in patients with aortic or mitral replacement even if coronary is normal.
Mitral valve replacement Aspirin + Warfarin (2.5-3.5)
Aortic valve replacement Aspirin + Warfarin: 2-3 if no risk factor, 2.5-3.5 if risk factor.
(A-fib, hypercoagulable state, EF < 30%, previous
thromboembolism)
Sunburn treatment: NSAIDs and fluid replacement.

General

Step 3 review

Choroidal melanoma: radiotherapy. Enucleation if extrascleral extension or severe pain.

Autoimmune hepatitis: ANA (homogenous staining) and Anti-smooth muscle Ab.
RA: if not responsive to methotrexate, consider anticytokine drugs (infliximab). PPD screening is needed
first.
Molluscum contagiosum: skin to skin transmission. HIV testing may be needed specially if affecting the
face.
Nocturnal enuresis: Start investigate if child > 5 years. Urinalysis is routine. Urologic imaging if daytime
symptoms.
Dumping syndrome (post gastrectomy) ttt: high protein low CHO diet.
Hospice requirements: Prognosis < 6 months and no life-sustaining treatment. (Full code, confusion,
inability to give a verbal consent are not contraindications)
Parents wishes for their child treatment is respected EXCEPT if it results in severe injury or death.
Angina: All patient must be admitted even if pain resolved for serial CKMBT to exclude MI. If no hx of
CAD, stress test will be done after exclusion of MI.
Ulcerative colitis: if acute episode treat with steroids not sulphasalazine.
Reactive arthritis:
- Organisms: Chlamydia, Salmonella, shigella, campylobacter, C. diff.
- CP: Oligoarthritis, dactylitis,enthesitis, uveitis, keratoderma blennorrhagicum, circinate balanitis.
- TTT: AB, NSAIDs. If NSAID failed intrarticular steroids, then oral steroids then DMARDs.
Mental retardation: ask about guardianship first before treatment.
Type I DM: managed with a combination of long acting insulin and mealtime boluses of shortacting.
Hungry bone syndrome: after parathyroidectomy, Ca drop with peak at 2-4 days after surgery.
APCKD: associated with:
- Hepatic, pulmonary, pancreatic cysts.
- Cerebral aneurysms
- Aortic aneurysm
- Colonic diverticula (CT abd before peritoneal dialysis)
Aldosterone-Renin ratio: > 30 equals hyperaldosternoism
Vit D deficiency:
- 25-OH-Vit D: < 20 deficiency, 20-30 insufficiency.
- TTT: Initial 50,000/week for 8 weeks then 1500:2000/day
SCFH Slipped capital femoral head:
- In obese African American children
- Needs immediate fixation with pins

General

Step 3 review

MS disease modifying therapy are low pregnancy risk.

Disorder
PHP
HP
VDD

Calcium
Low
Low
Low

Phosphorus
High
High
Low

PTH
High
Low
High

It is Unethical to accept EXPENSIVE gifts from patients

Analgesic induced nephropathy: NSAIDS can cause
- Nephrotic range proteinuria
- Acute interstitial nephritis
Dyspepsia:
- If GERD: PPI
- If NSAIDS: stop NSAIDS
- If neither:
o if age < 55 if developing country test for H pylori first, If developed country try PPI first
o If age > 55 endoscopy
Rash after Amoxicillin: Consider IMN
Asymptomatic proteinuria in adults:
- MCC is orthostatic proteinuria. Order split (day and night) 24-urine protein. Proteinuria during
daytime only.
PE ttt:
- AC is first line
- Thrombolysis: if PE with hypotension
- Embolectomy: Shocked or failed thrombolysis
Wells criteria for probability of PE:
- 3 points for: DVT
- 1.5 points for: hx of previous DVT or PE, HR > 100, recent surgery < 1 month, Immobilization > 3
days.
- 1 point for: hemoptysis, cancer
- Score <= 4 : PE less likely
- Score > 4: PE likely
Diagnosis of scaphoid fracture:
- MRI or CT
- Repeat X-ray in 7 days
- Bone scan in 3-5 days
Anti D Ig: given at 28 weeks to all Rh-D negative mothers if Anti-D screen is negative and father is Rh-D
positive or unknown. Also peri-partum Anti-D is given to reduce risk.

General

Step 3 review

Effect of Estrogen on L-thyroxin: increase TBG formation which will bind more L-thyroxin. Patient will
need increase in her L thyroxin dose.
Subclinical hypothyroidism: mild elevation in TSH with normal free T4. No treatment if asymptomatic.
Screen for anti-thyroid AB.
Squamous cell carcinoma: Surgery is first line, Cryotherapy, electro surgery, radiotherapy are 2nd line
Extra-articular manifestations of ankylosing spondylitis: uveitis, aortic regurgitation, pulmonary
fibrosis, restrictive lung disease
Drug induced lupus: Hydralazine, procainamide, minocycline, anti-TNF (etanrecept, infliximab). ANA and
anti-histone is positive.
Patient with medullary thyroid cancer and REC proto-oncogene positive, next step?
- Next step screen for MENII.
All patient with medullary thyroid carcinoma: measure Sr calcitonin, CEA, neck US for metastasis, RET
mutation, evaluation for hyperparathyroidism and PCCs.
MEN I: hyperparathyroidism, pancreatic tumor, pituitary tumor (3P)
MEN IIA: Medullary thyroid Ca, Pheochromocytoma, hyperparathyroidism
MEN IIB: MTC, PCC, mucosal and intestinal neuromas, marfanoid features.
Evaluation of thyroid nodule:
1) TSH and thyroid US:
- Suspicious of cancer solid FNA
- Not suspicious:
2) TSH is normal or elevated: FNA
3) TSH is low (likely hot nodule) thyroid scan FNA if hypofunction
PCO: try weight loss first. If it fails to restore fertility Clomiphene citrate
Lichen planus: discrete, intensely pruritic violaceous papules on flexor surface of extremities. Diagnosed
with skin biopsy. Associated with HCV.
Asthma exacerbation: After short acting B agonist in ER:
- If PEF > 70% baseline discharge home on B agonists or steroids
- If PEF 40:69% admit to ward
- If PEF < 40% or PCO2 > 42 admit to ICU
Psoriasis: mild or moderate skin disease treated with UV-B, topical steroids. Arthritis or sever disease
treated with methotrexate. No oral steroids in psoriasis because it ppt pustular psoriasis.
OCD ttt: Cognitive behavioral therapy (exposure and response prevention), Clomipramine.
SLE activity: Anti-dsDNA and Complement levels.
SLE nephropathy: Biopsy is first line, type I,II require no treatment. Type III,IV require steroids.

General

Step 3 review

Necrotizing fasciitis: Caused by GBS

CD4 monitoring: Every 3-4 months if patient not on HAART.
Somatization disorder ttt: regular visits with single provider. Improve coping strategies.
Keloid ttt: intra-lesional steroid injection.
Patient with severe preeclampsia, blurry vision and severe HTN:
- Stabilize with hydralazine and MGSO4 then cesarean section.
SLE lab: ANA highly sensitive, Anti-dsDNA highly specific and 75% sensitive, Anti-smith Ab highly specific
but only 25% sensitive.
RA lab: RF sensitive but not specific, Anti-CCP same sensitivity 75% but high specificity 95%.
MCC of hemoptysis: acute bronchitis
Steroid taper: use of steroids < 3 weeks even if high doses doesnt need taper.
Pain with bending forward: radicular compression, positive leg raising test
Pain with spine extension: spinal stenosis, relieved with bending forward. Associated with neurogenic
claudication.
Apnea test: absence of respiration for 10 minutes with PCO2 > 60 and final Ph < 7.28.
Parents of terminally ill child can withhold life-sustaining ttt if their decision in the best interest of the
child. (Ex: child with fatal dwarfism)
Acute stress disorder extends to 1 month. PTSD considered if symptoms > 1month.
Pheochromocytoma: first order lab (24-h urine fractionated metanephrines) then order MRI abdomen.
If MRI is negative and you are still suspicious order MIBG scan (Metaiodobenzyl-guanidine)
Scrotal elevation: pain decrease in epididymitis but not in torsion
If acute testicular pain: do cremastric reflex, lost in torsion.
TSS: caused by staph aureus exotoxin that acts as superantigen and activates T cells leading to massive
cytokine production. TTT by IVF and AB
ITP: ttt steroids if platelets < 30000
Hemochromatosis ttt: phlebotomy not deferoxamine
Asymptomatic bacteruria: ttt only in pregnant or urologic intervention needed.
Non-dominant parietal lobe lesion: dressing and constructional apraxia (copying drawing).
HCM ttt: BB 1st line, Verapamil is 2nd line
Dementia, hyponatremia and macrocytosis: Think hypothyroidism.
Emergency contraception:

General

Step 3 review

Copper IUD: up to 5 days

Ulipristal pill: up to 5 days (Selective Estrogen Rc modulator best effective oral pill)
Levonorgestrel pill: up to 5 days
OCP: up to 3 days.

Pain medication agreement: the patient sign that he will obtain pain meds from single physician and
single pharmacy and the medication may be discontinued if he violates the contract.
Rupture of chordae tendina: in Ehler dantos
Rupture of papillary muscle: in MI (usually 2-7 days after MI)
Viagra in pilots: Viagra causes blue hazed vision. Pilots have to wait 6 hours after Viagra before flying.
Breast Mass management:
- < 30 years: US then FNA if simple cyst & biopsy if solid or complex cyst.
- > 30 years: US & mammography then core biopsy if suspicious for cancer
Actinic keratosis results from long sun exposure. Has malignancy potential, ttt by excision or destruction
(cry or 4-FU cream)
After tPA, keep BP < 185/105 using IV labetalol
HRT should be avoided in patients with hx of thromboembolic disease.
Nelsons syndrome: after bilateral adrenalectomy in Cushings disease, patients develop pituitary
adenoma with suprasellar extension leading to bitemporal hemianopsia and high plasma ACTH.
Dont give bicarbonate in DKA, diesnt increase survival and may cause hypokalemia
Gall stones:
- Asymptomatic: no ttt
- Symptomatic: elective cholecystectomy
- Biliary colic without gall stones: cholecystokinin-stimulated cholecintigraphy to evaluate GB
functions, if low ejection cholecystectomy
Breast milk jaundice: continue breast feeding, resolve by 3 month. (Mech: high glucoronidase activity in
breast milk that unconjugated bilirubin in intestine and allow its absorption).
Bicuspid aortic valve: increased risk of aneurysm, dissection, IE. F/U echo q1y
Neonatal chlamydial infection: Conjunctivitis at 1 week and pneumonia (staccato cough & hyperinflated
chest) at 4-12 weeks. TTT with erythromycin.
PCP pneumonia: ttt with cotrimoxazole, add steroids if A-a > 35
Marfan: defect in fibrillin, MCC of death is aortic regurge, dissection or aneurysm.
Rosacea: erythema in central part of face. Ttt by topical brimonidine and avoid pdp factors, topical
metronidazole if popular lesions.
Graves disease ttt:

General

Step 3 review

Antithyroid drugs: if mild, pregnant or preparation for surgery.

Radioactive Iodine: moderate/severe
Surgery: suspicion of cancer, pregnant if didnt tolerate thionamide, severe opthalmopathy.

Male Delayed puberty: If no testicular enlargement by age of 14, get x-ray to determine bone age. If
bone age older or equal to chronological age warrants further testing.
ADPKD: IMPORTANT: F/U plan is regular BP checks, not imaging. Screening in family members by Abd
US not genetics. Most common extra renal manifestation is hepatic cyst.
Bacterial conjunctivitis: return school after 24 hours of AB therapy.
Bacterial vaginosis ttt: ORAL metronidazole or clindamycin, if pregnant tell the patient the meds cross
the placenta but no known teratogenic effect.
Bullous skin disease:
- Bullous pemphigoid: TENSE bullae + itching
- Pemphigus vulgaris: Flaccid bullae + ORAL lesions
- Dermatitis herpetiformis: CELIAC disease + ITCHING, buttocks involved
Acute gout ttt:
- First line: NSAIDS
- 2nd line: Colchicine (if CI for NSAIDS)
- 3rd line: steroids (If colchicine CI in liver, renal disease)
Abscess ttt:
- I&D only: if < 5cm, no systemic signs of infection
- I&D + AB: if > 5cm, surrounding cellulitis, systemic signs of infection.
High Anion gap metabolic acidosis:
- Anion gap > 14 (Na (Cl+Hco3))
- MUDPILES: Methanol, Uremia, DKA, Propylene glycol, INH, Iron, Lactic acidosis, Ethylene glycol,
Salicylates.
HIT: start direct thrombin inhibitor, switch to warfarin only when Plt > 150k
Herpangina: caused by coxsackievirus
Ovarian cyst with pregnancy: if persists after 1st trimester and > 5cm surgical removal in 2nd trimester
to avoid complications (eg; twist)
Opsoclonus-Myoclonus: a paraneoplastic syndrome associated with malignancy, Pheochromocytoma
mg is a known cause.
Digoxin toxicity cause decreased appetite. Check digoxin level if suspected.
Women finished LMP ended 6 days ago: dont get HCG, she cant be pregnant.
Upper lib cancer is usually BCC, lower lip is usually Sqcc

General

Step 3 review

Surgery

Step 3 review

Porcelain gallbladder: curvilinear opacity in the GB. TTT is cholecystectomy because it is

precancerous.
Undescended testes: orchopexy as soon as possible.
Fever and Rt shoulder pain after appendectomy: suspect sub phrenic abscess
ODonhue unhappy triad: hitting knee from lateral to medial during sports. Injury of medial
collateral lig, medial lemniscus and anterior cruciate ligament.
Screening for blunt cardiac trauma: EKG, not cardiac enzymes.
PSA is 6 (N 0-4), management is biopsy (if > 4) not repeat after 6 months.
What is the life threatening complication of compartment syndrome? Rhabdomyolysis and
ARF.
The most common complication of TURP is retrograde ejaculation.
Dumping syndrome: treatment by high protein and low CHO diet to increase the passage time.
Thompson test: to diagnose tendon Achilles rupture, normally squeezing tendon Achilles causes
planter flexion of the foot. This response is lost in Achilles rupture.
Hungry bone syndrome: hypocalcemia after parathyroidectomy in patients with
hyperparathyroidism and hypercalcemia.
Rt or bilateral varicocele: order CT abdomen to exclude IVC pathology.
Klienfilter syndrome increase risk of cancer breast in males 50 folds.
Raloxifen should be stopped before surgery to avoid increased risk of DVT. Raloxifen is a
selective bone estrogen receptor agonist.
Inguinal hernia in infants should be surgically corrected as soon as possible. It doesnt resolve
with age and there is high incidence of complications in first years of life
All types of hernia, main treatment is surgery without delay
Loculated cystic pancreatic lesion without hx of pancreatitis considered cancer and surgically
resected (no biopsy).
If you suspect scaphoid fracture and x-ray is normal, order CT scan. If non-displaced thumb
Spica. The most common complication is Non-union.
No dietry change needed after cholecystectomy.

ID

Step 3 review

Gonococcal urethritis: develop 2-4 days postexposure, NGU develop 5-10 days post-exposure.
NGU: Azithromycin or Doxycyline (Azithromycin if hx of non-compliance). If not responsive to
therapy, treat with metronidazole (single dose of 2g) and erythromycin 500mg q6h for 7days.
IRIS: Self-limited, continue HAART and AB for the undergoing infection.
HIV post-exposure prophylaxis: 4 weeks of 2 reverse transcriptase inhibitor (zidovudine &
Lamivudin)
Rabies post-exposure prophylaxis: rabies vaccine only if vaccinated and both vaccine and IG if
not vaccinated before.
Gonorrhea treatment if cephalosporin allergic: Quinolones
Cryptococcal CSF findings: high opening pressure, low glucose, WBCs < 50, increased protein.
India ink preparation is diagnostic.
Adult Vaccination :
The most common vaccines in adults are influenza, pneumococcal and tetanus.
Influenza: people > 50, COPD, CHF, ESRD, pregnant, healthcare workers, residents of long-term
facilities and immunosuppressed.
Pneumococcal: people >65
Tetanus toxoid: only if patient is wounded and last vaccine >5years ago (if dirty) or >10 years (if
clean).
Latent syphilis: patient accidently was found to have syphilis, will need CSF analysis to rule
neurosyphilis in or out which will affect treatment decisions. .
HIV patient with syphilis: if no neurosyphilis, treat with benzathine penicillin for 2 weeks. If has
neurosyphilis treat with crystalline penicillin G IV for 2 weeks.
Necrotizing fasciitis:
Type 1
Type 2
in patients with DM or PVD
healthy individuals after a puncture wound
aerobic and anaerobic organisms
GAS
HIV test: cant be done without a formal consent.
Saliva, tears, sweat dont transmit HIV
Indications of corticosteroids in PJP treatment: A-a gradient > 35 or PaO2 < 75
Latent TB infection: Positive PPD with negative CXR, treat with INH for 9 months then stop.
If TB is suspected, order CXR if positive proceed with sputum analysis and culture, no PPD. (If
CXR is positive, no need for PPD).
PhAT: primary HIV associated thrombocytopenia: treatment with Zidovudin
Acute retroviral syndrome: Primary HIV infection chch by fever, maculopappular rash,
lymphadenopathy, pharyngitis, oral ulcer, leukopenia. ELISA is negative while HIV RNA and P24
Ag are positive.
Catheter associated infection:
o No leukopenia: Vancomycine
o Leukopenia: Vancomycine + Gram negative coverage (cefepime or zosyn)
Trypanosoma Cruzi: Ventricular aneurysm, mural thrombosis with emboli, heart block,
progressive dilation of esophagus and colon.
Cat scratch disease: Bartonella Hensele. Causes LN suppuration, retinitis, encephalopathy, HSM.

Pediatrics

Step 3 review

Sleep terrors usually resolve spontaneously in children. Give benzo if severe and recurrent
Bronchiolitis:
- Child < 2 years with upper respiratory symptoms, low grade fever, wheezing, crackles.
- Cause: RSV
- D: Clinical + RSV in respiratory secretions
- TTT: isolation, supportive measures (fluids, suction, humidified oxygen)
- Prevention: Palvizumab
o In preterm < 29 weeks gestation
o Chronic lung disease of prematurity
o Severe Congenital heart disease
Croup ttt:
Humidified air if mild.
- Steroids (oral, IM or IV), nebulized epinephrine if severe (stridor at rest)
Infants and children with tuberculous meningitis, milliary TB, and tuberculous osteomyelitis should
receive 12 months of ant tuberculous therapy.
The preferred antibiotic therapy for neonatal sepsis consists of a combination of ampicillin and
ceftriaxone or cefotaxime.
Ceftriaxone should not be used if there is hyperbilirubinemia, because it will increase both types of
bilirubin.

Gyna/Obs

Step 3 review

Cervical Insufficiency:
- RF: Hx of cervical dilatation, laceration, conization or excision. Collagen abnormalities.
- Dx: Hx of cervical dilatation with 2nd trimester loss, current cervical dilatation or length < 25mm
in 2nd trimester.
- Tx: Serial US of cervical length and cerclage in 2nd trimester.
Gestational diabetes:
- Diagnosis: 1h after 50-gm glucose (screening) If > 140 100gm-glucose test (diagnosis):
o If Fasting > 95
o If 1 hour > 180
o If 2 hour > 155
o If 3 hour > 140
- Target blood sugar: Fasting <95, 1 hr postprandial <140, 2 hr postprandial < 120.
- Agents: Diet, exercise then insulin and oral agents.
GBS:
-

Routine screening at 35-37 weeks

Prophylactic treatment with penicillin if:
o GBS UTI during pregnance
o Prior birth to GBS infected child
o Uknown GBS status with: <37 weeks, intrapartum fever, ROM > 18hr.

Raloxifen: SERM. Estrogen agonist on bone and antagonist on tissues.

ASC-US & LSIL (atypical squamous cells of undetermined significance, Low grade intraepithelial lesion
in Pap smear):
- Repeat PAP after 1 year
- If negative, ASC-US or LSIL repeat after 1 year
- If ASC-H, AGC or HSIL Colposcopy

STATISTICS

Rates:

Crude mortality rate: death/total population

Cause specific mortality rate: death from particular disease/total population
Case fatality rate: death from particular disease/number of people affected by disease
Standardized mortality rate SMR: observed number of death/expected number of death. Used
in occupational epidemiology. SMR of 2 indicates observed mortality in particular group is twice
higher than expected.
Attack rate: patients with disease/population at risk. Ex attack rate for gastroenteritis in people
who ate contaminated food
Maternal mortality rate: maternal death/live births
Crude birth rate: live births/total population

NNT= 1/incidence
Relative risk and Odds ratio:
- Risk means probability to occur in future. So Relative risk used for prospective cohort study
- In case control outcome is known from the start so we cant calculate risk so we calculate Odds
of exposure.
- Odds ratio compares the odds of exposure to a risk factor in cases and controls.
- Values: from 0 to infinity. Value of 1 indicates no difference
- Rare disease assumption: odds ration approximates relative risk
- Calculation:
o RR: Risk in exposed/ Risk in non-exposed (a/a+b) / (c/c+d)
o OR: Odds of exposure in diseased/Odds of exposure in non-diseased (a/c)/(b/d) = ad/bc
Correlation:
- Correlation coefficient: ranges from -1 to +1
- Correlation of determination (Percent of variability in outcome explained by predictor factor) =
square the coefficient. (How much of the homocysteine variability explained by folic a intake?)
Attributable risk:
- Attributable risk = Difference in incidence between exposed & non-exposed
- Attributable risk percent = percent attributed to risk factor in exposed= attributable risk/incidence in
exposed.
- Population attributable risk percent = percent attributed to risk factor in population = incidence in
exposed incidence in population/ incidence in exposed
Null hypothesis:
- P value represent the probability that null hypothesis is true. P 0.05 = 5% probability that null is true
Confidence interval:
- If includes 1, then there is > 5% chance that the association by chance and P value > 0.05
- Calculation:
o SEM = SD/n
o SEM * Z score (z=1.96 for 95% CI, z=2.58 for 99% CI)
o Mean (SEM * Z)

STATISTICS

Width of CI is inversely related to sample size (n)

If there is 2 studies, the wider CI has smaller sample size.

Central tendency:
- Mean= sum of all values / number of observations
- Median= if observations are odd number (13), then median is the middle number. If observations are
even number (12) then median = adding the middle two values and divide by 2.
- Outlier is an extreme unusual value. It affects mean>median but doesnt affect mode.
Meta-analysis:
- Since it contains larger sample size than each study. The CI will be narrower than any other study.
Meta-analysis will be represented by a smaller vertical line compared with each study.
Diagnostic testing:
- Sensitivity Rule OUT, Specificity Rule IN
- Sensitivity = TP/(TP+FN)
- Specificity = TN (TN + FP)
- PPV = TP/(TP+FP)
- NPV = TN/(TN+FN)
- PPV and NPV If given prevalence, sensitivity and specificity:
o PPV = TP (sensitivity * prevalence)/ TP + FP (1-specificity * 1-prevalence)
o NPV = TN (specificity * 1-prevalence)/ TN + FN (1-sensitivity * prevalence)
- PPV and NPV other method:
o Apply prevalence to the numbers first then apply the short equation without prevalence.
o EX: test with 80% sensitivity, 90% specificity and disease prevalence is 10%.
o PPV: if population is 100, 10 are diseased, 90 are healthy. Test will see 80% of the 10 (TP 8)
and will miss 10% of the healthy (FP 9). PPD = 8/8+9 = 8/17 = 47%
- PPV is affected by specificity and prevalence
- NPV is affected by sensitivity and prevalence
- Likelihood ratio:
o Doesnt depend on disease prevalence
o Means probability of a given test result in patient with the disorder compared to patient
without.
o Positive LR = sensitivity / (1-specificity)
o Negative LR = (1-sensitivity)/ Specificity
People who test positive are . Likely to have the disease than those who tested negative.
Screening test bias:
-

Lead time: the time difference between detection of disease by screening test and diagnosis by prior
methods.
Lead time bias: apparent increase in survival is due to early diagnosis not successful treatment.
o EX: screening test for cancer stomach increased survival few weeks but no difference in rate of
radical gastrectomy.
Length time bias: apparent increase in survival due to screening test preferentially detects less
aggressive forms of the disease.

STATISTICS

Study Design:
- Case control is best for small infectious outbreaks and rare diseases

Variability and Validity:

- Reliability = reproducibility
- Validity = ability of study to measure what was intended.
- Random error= error due to chance, affected by sample size.
- Systemic error = error in study design. If a second investigator was to perform the same study again
he would achieve the same systemic error. Not affected by sample size.
Bias:
-

Selection Bias:
o Berkson: selecting control subjects from hospitalized patients.
o Referral: selecting patients from specialized medical centers.
o Loss of follow up
o Non response bias: if non-responders to survey are sicker than general population
o Prevalence bias (Neyman bias): if incidence is estimated based on prevalence.
If you compare MI in diabetics and non-diabetics by asking the patients. Diabetics will
be under-represented because DM patients more likely die from MI.
o Susceptibility: treatment regimen for patients depends on the severity of their condition.

STATISTICS

ACS patients, healthy patients undergo LHC while sicker patients undergo medical
treatment. LHC will appear superior to medical treatment.
Measurement bias:
o Recall bias
o Observer bias (ascertainment, detection, assessment bias)
Observer effect (Hawthorne effect): people change their behaviors when they are observed
How to limit confounding: Randomization, Matching.
Effect modification: confounding factors that cant be corrected or eliminated. Like family hx of cancer
breast. It is a natural phenomenon and should be mentioned in study discussion. Ex. Study to define
relation between OCP and breast cancer found increased breast cancer incidence in patients with FHx
while no relation in patients with no FHx.

What if patient change from placebo to active group, or patient in active group stop his treatment?
- Intention to treat: patient analyzed along with their original group preserve randomization
(patients were randomized in the beginning of the study)
- As treated: patients analyzed according to their new treatment.
Statistical distribution:
- In normal distribution: 68% of observations lie within 1 SD of the mean. 95% in 2 SD and 99% in 3SD.
Skewed distributions have a tail: positively skewed (tail to the RT), negatively skewed (tail to the
Lt). In Rt skewed; Mode is the peak, median is to the right, mean is further to Rt.
Comparing group:
- Both are Nominal: use Chi square
- Non-nominal:
o Two groups: t Test
o > 2 groups: ANOVA analysis of variance
o Same individual followed overtime: Paired t Test
Survival analysis:
-

Time to event:
o New chemotherapy is analyzed and 2 years survival is 80% and conventional therapy is 80%.
The new drug is effective, how? Although survival is the same but time to event may be
different. Survival time may be 3 months with conventional and 9 months with new drug.
Latent period:
o The period between exposure and development of outcome. Ex: vitamins effect in prevention of
CV disease starts after 3 years of vitamin supplements.
Probability of survival:
o Multiply the probability to survive each month. Ex: probability to survive 3 months =
(probability to survive 1st * probability to survive 2nd * probability to survive 3rd)

Statistical power:
- Type I error: concluding an association when there is none.
- Type II error: concluding no association when there is one.
- Probability of committing type I error is referred as Alpha and expressed as P value.

STATISTICS

Probability of committing type II error is referred as Beta.

1 B is the probability of detecting an association if it exists in reality, called power of the study
Power depends on:
o Increasing sample size increase probability of detecting a difference.
o Magnitude of difference between study groups (subtle difference is more difficult to detect)