1. Upper gastrointestinal endoscopy is the diagnostic study of choice when a patient presents with acute alkali ingestion.

2. Quantitative CT of the spine is the most sensitive diagnostic test for osteopenia but it is not a gold standard because of its poor reproducibility. The test of choice in most settings is dual-energy X-ray absorptiometry of spine
3. Despite of other risks, HRT is still the best form of therapy for osteoporosis in postmenopausal women
4. Pap smear: If 3 consecutive pap smears are normal, screening may be performed less frequently (every three years) in a low-risk patient. Screening is usually started at 18 and stopped at 60-75 years.
5. If a woman has undergone a hysterectomy for cancer or cervical dysplasia she needs yearly Pap smear screening of the vaginal epithelium and inspection of the vulvar and perianal epithelium.
6. Learn the Hepatitis-B prevention. Know when to give vaccine and when to give HBIG. If someone is exposed to HBV and has a documented response to HBV vaccination, he does not need anything else but reassurance
7. Human studies have demonstrated a significant association between type A personality and exaggerated cardiovascular response.
8. Pneumococcal vaccine contains capsular polysaccharides and it produces T cell independent B cell response
9. Racemic epinephrine decreases the need for intubation in patients with croup and should always be tried before any invasive procedure
10. Adolescent onset of hirsutism and virilism, with normal menstruations and elevated 17-hydroxyprogesterone, are diagnostic of congenital adrenal hyperplasia
11. Spontaneous hemarthrosis raises the suspicion for hemophilia for which factor VIII assay is diagnostic
12. Decreased tympanic membrane mobility is specifi c for the diagnosis of acute otitis media.
13. Tetralogy of Fallot, the most common cyanotic congenital disease in children of less than 4 years of age, presents with cyanotic spells and pansystolic murmur on examination.
14. Neonatal sepsis is suspected when a baby develops jaundice after the 3rd day and within the first week, especially if he is feeding poorly and lethargic; work-up with blood cultures and lumbar puncture is the next step.
15. Rubella is charact erized by low-grade fever, lymphadenopathy (sub-occipital and posterior auricular) and rash
16. The prodrome of measles may show Koplik sign, a pathognomonic finding, which appears as bluish white lesions on the erythematous buccal mucosa opposite to the first and second upper molars, and sometimes on the inner conjunctivae and vaginal mucosa.
17. An epiglottis rolling in from side to side is the diagnostic finding of laryngomalacia, and all such babies should be fed in the upright position.
18. Bedwetting is a normal phenomenon until the age of 5.
19. Severe dehydration in a neonate in the presence of hyponatremia, hyperkalemia, hypoglycemia and metabolic acidosis suggests the diagnosis of congenital adrenal hyperplasia.
20. First step in the management of an infant with suspected congenital diaphragmatic hernia is the placement of orogastric tube.
21. Kawasakis disease is a disease of blood vessel walls leading to aneurysm formation. It is usually self-limited though it can be fat al because of aneurysm formation, thrombosis or rupture of the coronary arteries, leading to myocardial infarction.
22. Moderate to severe degree of slipped capital femoral epiphysis requires surgery
23. Ileo-ileal intussusceptions, which may be caused by Henoch- Schonlein purpura, require surgical reduction.
24. Friedreich Ataxia is an autosomal recessive condition and genetic counseling is recommended for prenatal diagnosis for parents with one affected child.
25. Displaced anterior fat pad is a radiographic sign of supracondylar fracture, which may be complicated by Volkmanns ischemic contracture
26. Fragile X syndrome is characterized by low to normal IQ with learning disabilities, generalized language disability, short attention span, autism, large head, prominent jaw, large low set ears and macroorchidism.
27. Meningitis may be complicated by regression of developmental milestones
28. Cerebral anoxia is the most common cause of cerebral palsy
29. Fetal alcohol syndrome is characterized by irritability, mild to moderate mental retardation, hypoplastic maxilla, long philtrum, thin upper lip border, and microcephaly
30. Deficiency of sphingomyelinase causes Niemann-Pick's disease, which is characterized by cherry red macula, protruding abdomen, hepatosplenomegaly, lymphadenopathy, and regression of developmental milestones.
31. Bed rest with hip joint in the position of comfort is the treatment of choice for transient synovitis of the hip
32. Arthrocentesis and empiric treatment with IV nafcillin are the most appropriate measures for the management of suspected septic arthritis in a child
33. Aspirin therapy with monitoring of liver enzymes are the mainstay of the treatment of systemic juvenile rheumatoid arthritis
34. Presence of dermatitis herpeti formis and chronic non-bloody diarrhea in a child of 12-15 months, suggests the diagnosis of celiac disease
35. Positive anti-Smith antibodies and/or anti-double stranded DNA antibodies is speci fic and confirmatory for the diagnosis of systemic lupus erythematosus
36. Duodenal atresia presents with bilious vomiting, and its typical radiographic finding is the double bubble sign
37. Sudden onset of respiratory distress may be caused by foreign body aspiration, and rigid bronchoscopy is the procedure of choice, both for diagnostic and therapeutic purposes
38. Recurrent self- limiting episodes of vomiting and nausea in children, in the absence of any apparent cause, suggest the diagnosis of cyclical vomiting.
39. The 24-hour esophageal pH monitoring is the gold standard for the diagnosis of gastroesophageal reflux disease
40. Mast cell stabilizers are the drugs of choice for asthmatic patients who also have evidence of other allergic disorders
41. Increased gastric residues in a preterm neonate are highly suspicious for necrotizing enterocolitis.
42. Unilateral flank mass in a child more than 3 years is most likely due to Wilms tumor, which arises from the metanephros.
43. Nodular swellings in the irises of patients with neurofibromatosis are hamartomas.
44. The investigation of choice, for the diagnosis as well as the follow-up, in cases of Sturge-Weber syndrome is CT scan of the head. The cerebral lesions in Sturge-Weber syndrome are histologically similar to the facial lesions.
45. Turner's syndrome with 46 XY karyotype is associated with a higher incidence of gonadoblastoma, and hence, prophylactic bilateral gonadectomy is indicated.
46. Revise the management of hyponatremia from SIADH.
Mild (asymptomatic with sodium 120-130 meq/L) = Fluid restriction
Moderate (asymptomatic with sodium 110-120 meq/L) = Loop diuretic + normal saline
Severe (symptomatic) = hypertonic saline
47. NSAIDs can cause SIADH, which results in euvolemic, hypotonic, hyponatremia
48. Radioactive Iodine is the treatment of choice for Graves disease
49. Propylthiouracil can cause agranulocytosis, which should be suspected in patients presenting with sore throat and fever while on the drug
50. Hashimotos may rarely cause hyperthyroidism but the radioactive Iodine uptake is low thus distinguishing it from Graves disease
51. Indication for parathyroidectomy in asymptomatic patients with hyperparathyroidism are S. calcium 1 mg/dL above upper limit with urine calcium excretion over 50mg/24hr, urine calcium excretion over 400mg/24hr, cortical bone density more than 2SD below normal, under age 50-60, pregnancy, follow up difficulty.
52. Primary adrenocortical defi ciency is associated with hyperpigmentation of the skin due to increased levels of ACTH that helps to differentiate from secondary adrenal insuffici ency, which is due to pituitary failure.
53.
When Addison s disease is suspected clinically, the short cosyntropin (ACTH) stimulation test is performed to make a diagnosis
54. Failure to suppress 24-hour urine cortisol level following high dose dexamethasone suppression test suggests ectopic ACTH production rather than Cushings syndrome.
55. Know how to differentiate between primary and secondary hyperaldosteronism. Plasma rennin activity is low in primary hyperaldosteronism and is high in secondary hyperaldosteronism
56. Suspect DKA in stuperous patients with rapid breathing and history of weight loss, polydypsia and polyuria.
57. The single best screening test for virilizing neoplasm is to obtain serum testosterone and DHEA
58. Know the importance of fluid replacement in the treatment of acute hypercalcemia. Loop diuretics are indicated only after adequate rehydration.
59. Dehydration in Diabetes insipidus is managed with isotonic saline until the volume defi cit is restored
60. Know that detection of microalbuminuria is the best screening test for diabetic nephropathy
61. Management of DKA includes restoration of intravascul ar volume with normal saline and correction of ketosis with regular insulin
62. In non-ketotic hyperglycemic hyperosmolar coma: ketones are not found in the serum; blood glucose levels are very high (greater than 600 mg/dl); there is no acidosis; anion gap is not elevated and serum bicarbonate level is either normal or mildly decreased; neurological manifestations including coma are often present; serum osmolality is greater than 310 mOsm/kg
63. Fluid replacement is the most important step in the management of non-ketotic hyperglycemic coma
64. Waning of insulin dose results in hyperglycemia at 3 AM and 7 AM whereas in Dawn phenomena the hyperglycemia occurs only at 7 AM.
65. Insulinomas secrete excessive amounts of insulin, C peptide, and pro insulin
66. Arterial pH or anion gap is the most reliable indicator of metabolic recovery in patients with diabetic ketoacidosis
67. Know the management of diabetic nephropathy. Protein restriction to 0.8 g/kg of body weight has a beneficial effect on the course of diabetic nephropathy.
68.
Thyroiditis is associated with hyperthyroidism and low radioactive Iodine uptake
69. In the management of type 2 diabetes mellitus, if one oral hypoglycemic agent becomes ineffective then often another agent from a different group is added to achieve better glycemic control.
70. Treatment of choice for streptococcal pharyngitis is single injection of IM Benzathine penicillin G.
71. TMJ syndrome often presents with unilateral and chronic pain in the muscles of mastication. Pain is described as a dull ache worsened by chewing. Recognise the radiation to the ear, jaw, and posterior cervical region.
72. Know the clinical features and management of peritonsillar abscess or quinsy, which is a suppurative complication of acute tonsillitis
Contralateral deviation of the uvula
Throat pain markedly more severe on the affected side and occasionally referred to the ipsilateral ear.
Exudates on the tonsil AND Erythema of the tonsil

73. Fibreoptic laryngoscopy establishes the diagnosis of epiglottitis but it must be performed in the operating room with preparations already made to perform endotracheal intubation
74. While breaking bad news, physicians have to begin with an appropriate initial sentence, which would help the patient feel at ease
75. D-xylose absorption is abnormal both in bacterial overgrowth and Whipples disease. However, with bacterial overgrowth, the test becomes normal after antibiotic treatment.
76. When a motility disorder of esophagus is suggested by contrast studies, the next step is usually esophagoscopy to exclude mechanical causes of dysphagia like stricture or esophageal cancer
77
Esophagoscopy is indicated when a patient with gastroesophageal reflux disease (GERD) fails to respond to empiric treatment or when patient has features of complicated disease.
78. Hepatitis B virus immune globulin plus lamivudine treatment is the most effective treatment to prevent recurrent HBV infection after liver transplantation.
79. When diarrhea caused by clostridium difficile is severe, administration of metronidazole is also needed along with discontinuation of the offending antibiotic
80. Increased intragastric pressure during vomiting could cause tears in the mucosa of the cardia and sometimes of the distal esophagus- called Mallory-Weiss tears.
81. CT scan is the best test for the diagnosis of diverticulitis in acute setting
82. Fulminant colitis is a serious complication of ulcerative colitis and plain radiography shows distended colon. Proctosigmoidoscopy with biopsy establishes the diagnosis of ulcerative colitis and it can be performed in acute settings.
83. Always suspect Crohns disease as a cause for chronic diarrhea in a young patient
84. Migratory thrombophlebitis and atypical venous thromboses are suggestive for chronic DIC, most probably due to some visceral malignancy.
85. Abdominal CT scan is the next diagnostic test when abdominal ultrasound does not explain cholestatic jaundice
86. Gastro-intestinal (GI) blood loss without GI complaints in an elderly patient is most probably caused by colon cancer and needs a colonloscopy
87. Recurrent peptic ulcers with hypercal cemia are best explained by MEN type 1
88. Barium swallow is the initial test of choice for all patients with dysphagia
89. Manometry establishes the diagnosis of diffus e esophageal spasm
90. Recognize Zenkers diverticulum. Barium esophagogram is the investigation of choice for confirmation
91. Know how to manage severe
symptomatic bradycardia. IV atropine is usually the first step.
92. Recognize the hemodynamic features of mediastinal hemorrhage and know how to differentiate it from pericardial tamponade
93. Recognize mesenteric arterial stenosis in a patient that presents with abdominal angina
94. Recognize the clinical presentation of mesenteric thrombosis. Severe abdominal pain out of proportion to the physical findings along with bloody diarrhea should make you think about this.
95. Think of PE in a postoperative patient with JVD and new onset RBBB.
96
. Recognize the classic presentation of a tension pneumothorax. Remember the hypotension shortness of breath jugular venous distension and decreas ed breath sounds
97. Recognize the clinical presentation of pulmonary edema. Iatrogenic fluid overload is one of the common causes of pulmonary edema in perioperative patients
98. MI is one of the differential diagnoses of acute abdominal pain and should be ruled out in patients with risk factors.
99.
Learn the clinical presentation of mesenteric artery thrombosis.Always consider abdominal angina in a patient with risk factors for atherosclerotic vascular disease. Postprandial pain typically shortly aft er 20-30 mins Pain Last 60- 90 mins. Wt loss because fear of food might cause pain. Abdo pain and blood in stool. Sudden onset. Tx. Laparotomy and prophylaxis antibiotics.

100. Antihypertensive management should be the first step in patients with aortic dissection with hypertension
101. Thiazide diuretics are the initial antihypertensive of choice in patients with osteoporosis.
102. Learn how to differentiate ischemic angina from aortic stenosis angina. Echocardiogram should be the next step in suspected AS.
103. Know the natural history and complications of Marfan's syndrome in pregnancy. Every woman with Marfans syndrome who is contemplating pregnancy must be screened by echocardiography to determine the size of her aortic root.
104. Know how to recognize and treat right ventricular infarction. IV NS to increase the outflow from right ventricle should be considered in these patients
105. Sudden onset of shortness of breath (SOB), bibasilar rales, and an 'apical' murmur radiating to the axilla are quite characteristic of new onset mitral regurgitation. Papillary muscle dysfunction, or rupture, is the most common cause of MR in this setting
106. Choose the appropriate initial antihypertensive therapy in a patient with asthma. HCTZ is the initial drug of choice in patients with chronic persistent asthma
107. IV adenosine is the drug of choice for paroxysmal SVT. Know how to recognize the rhythm on ECG
108. Any patient who presents with sudden onset of chest pain, SOB, and has evidence of hypoxia and the new onset right bundle branch block should be considered as having a PE until proven otherwise. Therefore, the next best step from the choices offered is to get a V/Q scan
109. IV nafcillin is the treatment of choice for cellulitis with systemic signs.
110. Lithium precipitates and exacerbates psoriasis which is characteri zed by sharply defined erythematous areas with whitish, silvery and scaly plaques
111. Look for electrolyte abnormalities and correct them in patients with arrhythmias
112. Know how to differentiate between primary hyperparathyroidism and familial hypocalciuric hypercalcemia in a patient with increas ed serum calcium, decreas ed serum phosphorus, and increased PTH levels. Calcium excretion is decreased in familial hypocalciuric hypercalcemia and is normal or elevated in primary hyperparathyroidism
113. In a patient with hypochloremic metabolic alkalosis due to gastric outlet obstruction, potassium is usually low and needs to be supplemented
114. Parathyroidectomy is the only effective treatment for primary hyperparathyroidism
115. Plummer-Vinson syndrome is characterized by atrophic glossitis, stomatitis, and upper esophageal webs associated with iron-deficiency anemia. Usually these webs dont regress with conservative treatment and require dilatation
116. Paracentesis provides useful diagnostic information in patients with ascites
117. Slow tapping of ascitic fluid balanced with infusion of albumin per liter tapped, is the final conservative measure for the treatment of acsites secondary to cirrhosis that has to be attempted before surgery.
118. Hypotension, hyponatremia, azotemia, and oliguria with normal urinalysis in a patient with severe liver disease are suggestive of hepato-renal syndrome. Measures are taken to withhold all possible precipitating factors and initial management includes careful volume load.
119. Patients with carcinoid syndrome are at risk of developing niacin deficiency owing to increased formation of serotonin from tryptophan.
120. Varicoceles that fails to empty when the patient is recumbent raises the suspicion for renal cell carcinoma for which abdominal CT scan is the investigation of choice.
-------------------------------121. Suspect medullary cystic disease in adults with recurrent UTI or renal stones and contrast filled cysts demonstrated by IVP
122. Know the different causes of nephrotic syndrome and their likelihood in a given patient. Focal segmental glomerulosclerosis (FSGS) is the most common cause of nephrotic syndrome in African American adults. It also occurs in patients with HIV and IV drug abuse.
123. Indications for dialysis includes uremic symptoms such as pericarditis, encephalopathy, coagulopathy, and fluid overload unresponsive to diuresis, hyperkalemia not amenable to standard therapy, and pH less than 7.20
124. Know the factors that have been shown to delay the progression of chronic renal disease. Protein restriction and use of ACE inhibitors are two such factors.
125. Acute pyelonephritis presents with fever, chills, flank pain, pyuria, and bacteriuria. CVA tenderness may be present. Sometimes WBC casts may be seen.
126. Hydration is the cornerstone of therapy for renal stone disease. A detailed metabolic evaluation is not needed when a patient presents with their first renal stone.
127. Colicky flank pain with radiation to groin indicates renal colic. Small bowel disease such as surgical resection or chronic diarrhea, leading to the malabsorption of fatty acids and bile salts can predispose calcium oxalate stones
128. Know the differential diagnosis of microscopic hematuria, and know to differentiate myoglobinuria from hematuria. Alcoholism can cause rhabdomyolysis; the resulting myoglobinuria causes a positive dipstick analysis for blood and a negative microscopic examination for RBCs.
129. IgA nephropathy is the most common cause of glomerulonephritis in adults. Suspect IgA nephropathy in patients with gross hematuria associated with upper respiratory infection, GI symptoms, or flu- like illness
130. Any patient with recurrent sinusitis, cavitary lung lesions, pulmonary hemorrhages and glomerulonephritis will most likely have Wegeners glomerulonephritis
131. The common presentation of cryoglobulinemia includes palpable purpura, glomerulonephritis, non-speci fic systemic symptoms, arthralgias, hepatosplenomegaly, peripheral neuropathy, and hypocomplementemia. Most of these patients have evidence of Hepatitis C.
132. Suspect Alports syndrome in patients with recurrent episodes of hematuria, sensorineural deafness and family history of renal failure.
133. Oral trimethoprim-sulfamethoxazole is the preferred empiric treatment for acute uncomplicated cystitis.
134. When isolated proteinuria occurs, the evaluation of the patient should begin by testing the urine on at least two other occasions
135. Chlamydial urethritis is suggested by the presence of mucopurulent urethral discharge, sexual history with multiple partners, and absence of bacteriuria on urinalysis
136. Patients with prostatodynia are afebrile and have irritative voiding symptoms. Expressed prostatic secretions show normal number of leukocytes and culture of these secretions is negative for bacteria.
137. Ultrasound or other imaging techniques should be done in patients with pyelonephritis whose symptoms do not respond 48 -72 hours after appropriate antibiotics
138. Acute epididymitis in younger patients is usually caused by sexually transmitted organisms such as C. trachomatis or N. gonorrhea. In older men it is usually non-sexually transmitted and is caused by gram-negative rods.
139. Know how to recognize and treat nonbacterial prostatitis. Rule out bladder cancer in all elderly patients with irritative voiding symptoms and have negative urine culture.
140. Acute post streptococcal glomerulonephritis occurs 10-20 days after streptococcal throat or skin infection. It presents with hematuria, hypertension, red cell casts, and mild proteinuria.
141. Renal vein thrombosis is an important complication of nephrotic syndrome, which is the most commonly caused by membranous glomerulonephritis in adults.
142. 70% of cases with interstitial nephritis are caused by drugs such as cephalosporins, penicillins, sulfonamides, sulfonamide containing diuretics, NSAIDs, Rifampin, phenytoin, and allopurinol. Discontinuing the offending drug is the treatment of drug-induced interstitial nephritis.
143. Patients with nephrotic syndrome are at increased risk for developing hypercholesterol emia, hypertriglyceridemia, and hypercoagulable state.
144. Acalculous cholecystitis occurs in critically ill patients and imaging studies show diagnostic findings of thickening of the gall bladder wall and presence of pericholecystic fluid.
145. Primary Polydypsia (psychogenic polydypsia) is charact erized by primary increas e in water intake. Patients taking phenothiazines have this problem due to dry mouth caused by anticholinergic action of phenothiazines
146. Accidental ingestion of battery into esophagus warrants its immediate removal.
147. Warfarin induced skin necrosis is a complication seen in patients with protein C or S deficiency especially when it is started in high doses without heparin coverage
148. Gentamicin causes vestibular toxicity
149. Spherocytosis is due to RBC membrane defect mostly from spectrin defici ency
150. Aortic dissection is an acute emergency and its medical management includes prompt blood pressure lowering with IV nitroprusside and short-acting beta-blocker.
151. Vitamin A and its derivatives taken in large doses can lead to pseudotumor cerebri as a complication. The presentaion includes headache, nausea, vomiting, papilledema, and elevated CSF opening pressures, which is characteristic of pseudotumor cerebri.
152. Patients who are on high doses of vitamin D and calcium should have a close eye on serum calcium levels. Signs of toxicity include nause, vomiting, constipation, polyuria, and mental status changes.
153. Wernickes encephalopathy is a syndrome characterized by ataxia, ophthalmoplegia, nystagmus and altered mental status. Wernickes encephalopathy is seen in chronic alcoholics with thiamine defici ency
154. Hypercarotenemia is commonly seen in patients with anorexia, diabetes & hypothyroidism.
155. Excessive use of vitamin C in patients with renal insuffi ency can cause oxalate stones
156. Pellagra, a niacin deficiency syndrome is characterized by a triad of 3 Ds of Diarrhea, Dermatitis, and Dementia and if untreated eventually leading to Death (4th D).
157. Patients who eat heated food all the time, such as toast and tea are more likley to develop folic acid deficiency.
158. Vitamin K deficiency is usually manifested by prolonged PT, normal platelet count and normal bleeding time. PTT is variable.
159. Vitamin B 12 defi ciency: Subacute combined degeneration of the dorsal and lateral spinal columns is the classic neurologic manifestation. Symmetrical neuropathy, ataxia with loss of vibration and position sense is the clinical clues.
160. Penile fracture is a medical emergency and needs prompt surgical repair, but it should always be preceded by retrograde urethrogram to rule out urethral injury which is very common with penile fracture
161. Removal of impacted esophageal foreign body is mandatory
162. Pressure sores are common over the sacrum, heels and hips. Frequent turning of the patient is the only best method to prevent these
163. Heat stroke is a life threatening catastrophic medical emergency due to failure of thermoregulatory center leading to severe hyperthermia with body temperature generally greater than 105 F. Patients will have CNS symptoms
164. Heat exhaustion, also known as heat prostration is a syndrome characterized by volume depletion under the conditions of heat stress. It can be distinguished from heat stroke by T< 40 C and lack of severe CNS symptoms.
165. Rapid cooling of the patent is the cornerstone of management of heat stroke and should be done in adjunction of stabilizing treatment. Evaporation cooling is the preferred modality.
166. Think of Conversion disorder in a female patient with sudden onset neurological symptoms preceded by an obvious stressor. The treatment of choice would be Psychotherapy
167. Zinc defici ency is associated with alopecia, mental changes, diarrhea, and dysgeusia, smell abnormalities, maculopapular rash around the mouth and eyes, and impaired wound healing.
168. Severe, excruciating pain should be treated with IV opioids even if the patient has a history of drug abuse
169. Lithium toxicity presents with tremulousness, headache, confusion, GI distress, fatigue and, in extreme cases, with seizures, coma, hyperreflexia and opisthotonus
170. Hypothyroidism should always be considered in patients with an unexplained elevation of serum CK concentration and myopathy.
171. For frostbite injuries, the best treatment is rapid re-warming with warm water. Whenever frostbite or cold injuries are diagnosed, no attempt should be made to dbride any tissue initially. Rapid re-warming with dry heat (like a fan) is not effective for frostbite.
172. Beta blockers decrease the risk of perioperative myocardial infarction, and thus do decrease mortality in perioperative patients with vascular disease undergoing noncardiac surgery. Beta 1 selective agents are the drugs of choice for this purpose.
173. Wiskott Aldrich syndrome is one of the immunodeficiency syndromes, characterized by recurrent pyogenic infections, atopic eczema and thrombocytopenia. IgM levels will be decreased, but IgA, & IgG will be within normal limits
174. In a HIV patient, bilateral interstitial pneumonia is most likley due to Pneumocystis carinii infection.
175. Flumazenil, a benzodiazepine antagonist, is antidote for acute benzodiazepine intoxication.
176. Glucagon is used to treat beta-blocker toxicity
177. Mucormycosis requires aggressive surgical debridement plus early systemic chemotherapy with amphotericin B.
178. Association of diabetes mellitus and Mucor-mycosis is frequently tested in the examination.
179. Empiric antibiotic therapy with either ceftazidime or cefepime should be started in febrile neutropenic patients
180. Invasive aspergillosis occurs in immunocompromised patients like those with neutropenia, those who are taking cytotoxic drugs like cyclosporine or those who are taking very high doses of glucocorticoids. Invasive pulmonary disease presents with fever, cough, dyspnea or hemoptysis. Chest x-ray may show cavitary lesion. CT scan shows pulmonary nodules with halo sign or lesions with air crescent.
181. Treatment of disseminated Histoplasmosis in HIV patients is IV amphotericin B followed by lifelong treatment with itraconazole
182. Lymphocutaneous Sporotrichosis is the most common form and presents with painless papule at the site of inoculation which later on ulcerates.
183. Always remember Blastomycosis is big-based budding yeast. Blastomycosis is endemic in south central and north central USA.
184. Know the epidemiology of the fungal infections. Patient from Arizona should make you think of Coccidioidomycosis
185. Whenever there is suspicion of HSV encephalitis, IV acyclovir should be started without delay
186. Always suspect Infectious mononucleosis in a young patient presenting with sore throat and nonspeci fic spectrum of symptoms. Recognise the role of steroids in treating complications.
187. In both infants and children, Staphylococcus aureus is the most common organism responsible for osteomyelitis.
188. S. Epidermidis is a frequent cause of osteomyelitis associated with prosthetic devices.
189. Gram-negative rods like Klebsiella or Pseudomonas cause osteomyelitis when patients have a history of urinary tract infection (UTI) or urinary instrumentation
190. Three phase technetium scan is the test of choice for acute osteomyelitis and it is very sensitive.
191. Learn the clinical presentation, pattern of organ involvement and the complications in a case of mumps. Orchitis is one of the most frequent complications of mumps in adults.
192. Always consider the risk of splenic rupture in case of infectious mononucleosis and advise the patient to avoid contact sports to prevent this hazard.
193. Amoxicillin-clavulanate is the antibiotic of choice for prophylaxis against infections caused by human bite
194. Cat-scratch disease that usually occurs after scratch or bite by a cat and is caused by Bartonella.
195. Strep viridans is a frequent case of infective endocarditis in patients with damaged heart valves
196. Failure to respond to herpes simplex with acyclovir indicates resistance. The patient most likely requires foscarnet.
197. Babesiosis should be suspected in any patient from an endemic area who presents with a tick bite. Remember 'splenectomized patient'
198. The herpes simplex virus (HSV) esophagitis ulcers are usually multiple, well circumscribed and have a "volcano" (small and deep) like appearance, whereas the ulcers seen in CMV infection tend to be large, shallow and superficial.
199. Skin lesions of Kaposi sarcoma usually occur on the trunk, face and the extremities. Usually these lesions are papules that later on become plaques or nodules. The color changes from light brown to pink to dark violet.
200. So far there has been no case reports of congenital rubella syndrome in women inadvertently vaccinat ed during early pregnancy.
201. Pyridoxine (Vitamin B6) is an antidote for isoniazid
202. Duration of QRS complex is the best measure for assessment of severity of tricyclic antidepressant toxicity.
203. All chemical injuries to eyes should be immediately washed with plain water or saline.
204. Impaired concentration and conjunctival injection are important features of marijuana use.
205. Calcium is useful in reversing cardiac effect of calcium channel blocker.
206. Tyramine contained in aged cheese reacts with monoamine oxidase inhibitors to produce hypertensive crisis
207. Dextromethorphan interacts with monoamine oxidase inhibitors and can produce severe hyperthermia.
208. Decision of use of N acetyl cysteine as an antidote for acetaminophen overdose is generally based on 4 hour post-ingestion acetaminophen levels
209. Bromocriptine is used in the treatment of neuroleptic malignant syndrome, which is characteri zed by marked hyperthermia, muscular rigidity, tremors, altered mental status, and diaphoresis.
210. First step in the management of pesticide poisoning is to remove the source of poison.
211. Phenothiazines cause hypothermia by causing vasodilatation and by inhibition of shivering
212. Sodium bicarbonate prevents the development of arrhythmia in patients with tricyclic antidepressant toxicity by alleviating cardio- depressant action on sodium channels
213. Recognize the affect of alcohol intake on acetaminophen induced hepatic injury
214. In case of suspected osteomyelitis, blood cultures and x-rays should be taken and the patient should be started on intravenous antibiotics. If the x-rays are negative three-phase technetium bone scan should be considered. Needle biopsy can be done to identify the organism if the blood cultures are negative.
215. Cervicofacial actinomycosis classically presents as slowly progressive, non-tender, indurated mass, which evolves into multiple abscesses, fistulae, and draining sinus tracts with sulfur granules, which appear yellow. Treatment is high dose penicillin for 6-12 weeks.
216. Cauda equina is an acute compression syndrome presenting with acute motor and sensory loss, loss of rectal tone and urinary retention. It has to be treated urgently
217. Neurofibromatosis is a neurocutaneous syndrome, which has a tendency to form tumors of the central nervous system (CNS), peripheral nervous system, skin and viscera
218. CT scan showing hyperdense (White) area suggests hemorrhage. The infarcts on CT are seen as hypodense (Black) parenchymal areas.
219. Asymptomatic patients with carotid artery stenoses of 60 to 99 percent are considered to have a proven indication for CEA. Complete occlusion (100 percent stenosis) of the carotid artery is a contraindication to surgery
220. When a patient presents with painless visual loss lasting a few seconds, a duplex ultrasound of the carotids should be the first test of choice.
221. Petit mal seizures may present with a sudden cessation of mental activity, which occur repeatedly. There are not associated with complex automatisms or tonic clonic activity. Diagnosis can be best confirmed by EEG studies
222. Primidone is an anticonvulsant agent, which can be used to treat benign essential tremor. However, it can also precipitate acute intermittent porphyria. Diagnosis of porphyria is made by assessing urine for porphobilinogen.
223. Itch, redness and fissuring in swimmers is typical of athletes foot. The condition is best treated with antifungal creams such as tolnaftate.
224. In a child who has been to the ER several times and has bruises of unknown origin on his/her body, child abuse should always be suspected and reported to the appropriate authorities.
225. Gonorrhea is a common organism, which causes sexually transmitted disease. It is also a common cause of pharyngitis, generally acquired from oral sex.
226. Postherpetic neuralgia can cause significant pain along the nerve dermatomal distribution. The best treatment is with the anti viral agent, acyclovir
227. Urethral cultures have higher yield than synovial or blood culture in cases of suspected gonococcal purulent arthritis.
228. Always suspect endocarditis whenever a patient is febrile and has other constitutional features in the presence of a new heart murmur.
229. Patients with trichinosis, presents with gastrointestinal (GI) complaints followed by muscle pain, swelling, and weakness. Presence of subungual splinter hemorrhages, conjunctival and retinal hemorrhages, periorbital edema and chemosis should make you think about trichinosis.
230. Always suspect rubella when a febrile patient with rash has occipital or posterior cervical lymphadenopathy and arthritis.
231. Vibrio parahaemolyticus is usually transmitted by ingestion of seafood. Patients having symptoms of food poisoning after intake of seafood should be suspected for this.
232. Group A beta-hemolytic streptococcus is the most frequent cause of erysipelas and cellulitis.
233. Proteus is the most likely cause of urinary tract infection in patients with alkaline urine.
234. Facial nerve palsy and classical Erythema migrans (EM) indicate Lyme disease, which is a tick borne disease.
235. Pseudomonas aeruginosa is the most frequent cause for malignant otitis externa.
236. Mefloquine is the drug of choice for chemoprophylaxis of chloroquine resistant malaria
237. Amoxicillin is used for treatment of pregnant/lactating patients with early-localized Lyme disease
238. Doxycycline is used to treat primary syphilis in penicillin allergic patients
239. Pneumococcal vaccine is recommended in all HIV infected patients whose CD4 count is > 200 cells/micro-L.
240. IV amphotericin plus flucytosine is the antibiotic regimen of choice for central nervous system cryptococcal infection in AIDS patients.
241. Bacillary angiomatosis, a great mimicker of Kaposi sarcoma, is caused by gram-negative rod Bartonella and is success fully cured with antibiotic treatment. They are highly vascular, initially are smooth and in the form of small papules that gradually become enlarged and pedunculated or nodular.
242. Azithromycin or clarithromycin is the drug of choice for MAC prophylaxis in HIV patients with CD4 cell count below 50/microL.
243. Whenever a health care worker is exposed to HIV, baseline HIV testing should be performed immediately and postexposure prophylaxis with combination of two or three antiretroviral drugs should be started without any delay.
244. Any patient from southwestern region with history of tick bite developing systemic symptoms along with leukopenia and thrombocytopenia should make you think about Ehrlichiosis.
245. HIV patients are at a high risk for tuberculosis and require prophylactic treatment to prevent an active disease. PPD is done to verify this. Skin induration of greater than 5 mm with PPD testing in HIV patients requires prophylaxis with isoniazid for 9 months
246. Listeria monocytogenes is a frequent cause of meningitis in patients older than 55 and therefore in such patients ampicillin should be added to the empiric antibiotic regimen.
247. Presence of erythema chronicum migrans in a patient with tick bite history warrants immediate treatment without waiting for serology of Lyme's disease.
248. Lyme disease prophylaxis is given in pregnant patients who have history of tick bite and have anxiety about acquiring disease.
249. Methanol intoxication is associated with visual loss.
250. Patients with hemochromatosis are vulnerable to listeria monocytogenes infections and some other bacterial infections. Know the various bugs that are likely to jeopardize such patients.
251. Pinpoint pupils and respiratory depression are the hallmark features of acute opioid toxicity for which naloxone is the drug of choice
252. Heterophil antibody test is sensitive and speci fic for diagnosis of IM. EBV specific antibody test is used in patients with high suspicion for IM and have negative heterophil antibody test.
253. Albendazole or mebendazole is the first line of treatment for E. vermicularis infection. Pyrantel palmate is an alternative.
254. Consider CMV pneumonitis as a late complication in post BMT recipients with dyspnea and cough.
255. Serotonin agonists (triptans) are the drugs of choice to abort acute attacks of migraine when simple analgesics or NSAIDs fail.
256. Pregnancy testing should be considered in patients with high risk of being pregnant prior to starting treatment with sumatriptan
257. The choice of prophylactic agent for migraine depends upon any associated medical condition. In patients with coexistent depression, antidepressants should be used for prophylaxis of migraine.
258. Rupture of saccular aneurysm is the most frequent cause of non-traumatic subarachnoid hemorrhage (SAH). Know the CT appearance of SAH.
259. Campylobacter jejuni is the most frequent precipitant of Guillain-Barr Syndrome (GBS).
260. Atrophy of the caudate nucleus is a characteristic feature of Huntingtons chorea. Recognize the classic clinical presentation of Huntingtons chorea.
261. Acetazolamide is the first line medical treatment for idiopathic benign intracranial hypertension.
262. Acute exacerbations of MS are treated with corticosteroids. Beta-interferon or Glatiramer acetate is used to decrease the frequency of exacerbations in patients with relapsing-remitting or secondary progressive form of MS.
263. Oligoclonal bands are present in 85-90% of cases of multiple sclerosis. CSF pressure, protein and cell count is grossly normal in patients with MS.
264. Initial presentation of multiple sclerosis with optic neuritis or sensory symptoms carries a good prognosis.
265. Cutaneous larva migrans is a common cause of dermatological disease in travelers from tropical regions, and is characterized by pruritic elevated serpiginous lesion on the skin.
266. Always consider malaria in patients from endemic areas with high-grade periodic fever and chills. Anemia and splenomegaly are the clinical clues.
267. Condyloma Lata and bilaterally symmetrical maculopapular rash involving the entire trunk and extremities are characteristic of second stage of syphilis. Remember the rash is present on palms and soles. Serological tests are positive in secondary syphilis.
268. It is recommended that all patients with atherothrombotic TIA should receive an antiplatelet agent if there is no contraindication to its use and antiplatelet agent of initial choice for this purpose is aspirin.
269. Anticoagulation is considered when TIA is due to emboli arising from the heart.
270. Anticholinergics are useful treatment for Parkinsonism patients who are younger than 70 with disturbing tremor and minimal bradykinesia. Parkinsonism tremor is a resting tremor.
271. Oral anticholinesterase is usually the initial treatment of choice for myasthenia gravis and all patients should have evaluation for thymectomy
272. First step in all patients suspected of having stroke is CT scan without contrast. If they have evidence of ischemic stroke, then carotid Doppler and TEE are performed to evaluate the possible source of embolism.
273. Presence of cord cavity is the most characteristic feature of syringomyelia that typically presents with areflexic weakness in the upper extremities and dissociated anesthesia in a "cape" distribution. Other features like caudal displacement of fourth ventricle or cerebellar tonsils or focal cord enlargement may or may not be present.
274. CT/MRI picture of heterogenous and serpiginous contrast enhancement is typical of high-grade astrocytoma. Recognize the classic butterfly appearance.
275. Patient with cerebellar hemorrhage presents with ataxia, vomiting, occipital headache, gaze palsy, and facial weakness. There is no hemiparesis. It is crucial to make early and correct diagnosis, as urgent surgical decompression may be life saving in such cases.
276. Treatment of myasthenia crisis consists of endotracheal intubation and withdrawal of anticholinesteras es for many days.
277. The most common site of hypertensive hemorrhage is putamen (35%). Internal capsule that lies adjacent to putamen is almost always involved leading to hemiparesis.
278. All those patients who are on warfarin treatment and develop serious bleeding need rapid revers al of anticoagulation and fresh-frozen plasma is the most appropriate first choice for this purpose.
279. Untreated LGV may progress to a severe and chronic disease causing ulceration, proctocolitis, rectal stricture, rectovaginal fistulas and elephantiasis.
280. Riluzole is a glutamate inhibitor and is currently approved for its use in amyotrophic lateral sclerosis.
281. Intravenous cefotetan, ampicillin/sulbactam, or the combination of clindamycin and a fluoroquinolone is the appropriate empirical treatment for limb-threatening infections in diabetics, whereas mild, or non-limb-threatening, infections can be treated with oral antibiotics like cephalosporin, clindamycin, amoxicillin/clavulanate and fluoroquinolones.
282. The majority of human infections with E. granulosus are asymptomatic. Hydatid cysts can be found in almost any part of the body but liver (MC) is involved in two-thirds of patients and the lungs are involved in 25 percent of patients. It is most commonly seen in areas where sheep are raised.
283. Neurocysticercosis is the most common parasitic infection of the brain and highest prevalence seen in rural areas where pigs are raised and there are poor sanitary conditions
284. Streptococcus bovis endocarditis is associated with colorectal cancer and colonoscopy is advisable in such patients.
285. Condylomata acuminata are skin colored or pink, verrucous and papilliform skin lesions present around the anus and podophyllin is one of the available treatment options.
286. EatonLambert syndrome is associated with small cell carcinoma of the lung and results from autoantibodies directed against the voltage-gated calcium channels in the presynaptic motor nerve terminal.
287. Immunocomplex disease is primarily responsible for glomerulonephritis, Roth spots and Oslers nodes. Janeway lesions result from septic embolism.
288. MRI is the test of choice to support the clinical diagnosis of multiple sclerosis
289. Multiple observational studies have demonstrated that patients with hypertension have about four times the risk of stroke when compared to non-hypertensive subjects
290. Understand the concept of lead-time bias in screening tests. The concept of lead-time bias includes prolongation of apparent survival in patients to whom this test was applied, without changing prognosis for the disease.
291. Confounding is referred to the bias that can result when the exposure-disease relationship is mixed up with the effect of extraneous factors called confounders.
292. Know the concept of positive predictive value; positive predictive value depends on the prevalence of the disease of interest in the population to which the test is applied. PPV increases with an increas e in prevelance of disease in the study population. For NPV, the inverse is true.
293. Thymectomy may induce remission in patients with myasthenia gravis and should be considered in all patients who are between puberty and 60 and whose disease is not confined only to the extraocular muscles.
294. Incidence is the measure of new cases, the rapidity with which they are diagnosed. Prevalence is the measure of the total number of cases at a particular point of time.
295. 68% - within 1 standard deviation from the mean
95% - within 2 standard deviations from the mean
296. 99.7% - within 3 standard deviation from the mean
297. Observer bias occurs when the decision as to whether outcome is present is adversely affected by the knowledge of the exposure status.
298. Any HIV-positive patient with bloody diarrhea and normal stool examination should have a colonoscopy and biopsy done to look for CMV colitis. CMV colitis is characterized by bloody diarrhea with abdominal pain, multiple ulcers and mucosal erosions on colonoscopy; biopsy shows characteristic cytomegalic cells with inclusion bodies.
299. Dihydropyridine Ca-channel antagonists can cause peripheral edema and should always be considered in the differential diagnosis of this condition, along with other causes, such as heart failure, renal disease and venous insuffi ciency.
300. Elderly patients with depression often present with memory loss (Pseudodementia.), which can mimic other causes of dementia, including Alzheimers dementia, while the CT will be normal in these patients, the DST may be of value.
301. In cross-sectional study, exposure and outcome are measured simultaneously at a particular point of time (you can remember it as a snapshot study). In other study designs, a certain time period separates exposure and outcome.
302. Situational syncope should be considered in the differential diagnosis of syncopal episodes. The typical scenario would include a middle age or older male, who loses his consciousness immediately after urination, or a man who loses his consciousness during coughing fits.
303. Recognize normal pressure hydrocephalus by the triad of gait disturbance, dementia and urinary incontinence. Other features are normal CSF pressures on lumbar puncture and enlarged ventricles on MRI
304. VDRL testing, PPD skin testing, Hepatitis A and B serology and antibody titer for Toxoplasma are indicated as a part of initial work-up in all newly diagnosed HIV-positive patients.
305. Primary polydypsia is a disorder in which the patient drinks fluids in excess of 5 L per day and both plasma and urine are diluted.
306. SIADH results in hyponatremia, low serum osmolality and inappropriately high urine osmolality.
307. Diabetes insipidus presents with polyuria and polydypsia and urine osmolality is less than serum osmolality.
308. Several well-organized and well-controlled clinical trials demonstrated that ACE inhibitors could slow the progression of diabetic nephropathy and reduce albuminuria
309. Somogyi effect refers to early morning hyperglycemia caused by counter regulatory hormones following nocturnal hypoglycemia
310. Acute respiratory alkalosis (increase in extracellular pH) causes a fall in ionized plasma calcium by increasing the affinity of albumin to calcium
311. There are various mechanisms by which malignancy produces hypercalcemia. These are: the production of cytokines, parathyroid hormone related peptide, calcitriol and ectopic PTH
312. Remember when albumin is low, serum calcium concentration falls in the ratio of 0.8-1 mg of calcium to 1 g of albumin.
313. Always suspect surreptitious vomiting as a cause of hypokalemic alkalosis in a normotensive patient and distinguish it from other entities like d

524. Beta blockers are the initial drugs of choice for the treatment of isolated left ventricular diastolic dysfunction as they improve diastolic filling by lowering the heart rate and increasing the diastolic filling time
525. Recognize the clinical features of cardiogenic shock. Elevated PCWP is the most important finding to concentrate.
526. ST segment depression, T wave inversion and first degree AV block can occur at therapeutic levels of digoxin and they do not repres ent digitalis toxicity and therefore there is no need for discontinuation of the drug.
527. Whenever a patient of chronic aortic regurgitation develops symptoms of LV dysfunction, he should undergo aortic valve replacement after his congestive symptoms are relieved by intense medical treatment with digoxin, diuretics, and vasodilators
528. Infective endocarditis prophylaxis and repeated regular follow-ups are recommended for all patients of aortic stenosis even if they are asymptomatic
529. The majority of patients who have a mild degree of mitral stenosis can tolerate pregnancy without any complications.
530. Procainamide or disopyramide are the drugs of choice for atrial fibrillation in the context of WPW syndrome. Remember digoxin and calcium channel blockers should not be used.
531. Any patient, who has undergone genitourinary instrumentation, has a history of IV drug abuse, or a history of prosthetic valves should be suspected for infective endocarditis if they have fever, chills, weakness, and/or a new onset murmur.
532. Any patient who comes from South America and have findings suggestive of cardiomyopathy should make you think about Chagas disease.
533. The classic findings of pericarditis on EKG are:
a. Diffuse ST segment elevation with upward concavity at J point.
b. No new Q waves
c.'PR segment elevation in aVR with PR depression in other leads
534. Once sick sinus node syndrome has been diagnosed, the best treatment is placement of a permanent pacemaker.
535. Wenckebach or Mobitz type I heart block is charact erized by a narrow QRS, progressive increas e in PR interval until a ventricular beat is dropped, and then the sequence is repeated. It is a benign arrhythmia and is transient. Unless the patient is symptomatic, it requires no treatment.
536. First-degree heart block is a completely benign arrhythmia and requires no treatment
537. Torsades de pointes is an arrhythmia of gradually changing QRS morphology and most often caused by Quinidine
538. Ventricular tachycardia in the presence of a stable blood pressure does not warrant cardioversion. The best treatment is loading with lidocaine or amiodarone
539. Coarctation can present with rib notching on the chest-x ray. A 3 sign is typically seen with coarctation of longer duration, implying proximal aortic dilation, constriction and descending aorta dilatation
540. Mobitz type 2 block is a dangerous arrhythmia which can progress to complete heart block and requires a permanent pacemaker
541. Atrial flutter with unstable hemodynamics is best treated with cardioversion. Acute atrial flutter with stable hemodynamics can be treated with cardioversion or can be managed with rate control. Chronic stable atrial flutter is best treated with rate control, which is best achieved with either calcium channel blockers or beta-blockers.
542. Premature atrial beats are benign and neither requires any follow up nor treatment.
543. When atrial fibrillation is associated with hemodynamic compromise, cardioversion is the treatment of choice.
544. The treatment of ventricular fibrillation is STAT defibrillation with 200-360 joules. If defibrillation fails, lidocaine or amiodarone (drug of choice) can be loaded and the patient shocked again. Epinephrine can sensitize the heart and lower the threshold for conversion.
545. Anytime if the patient is hemodynamically unstable, treatment of choice is electrical cardioversion. If the patient is hemodynamically stable, then you have to think whether it is an acute process? or a chronic process?. If it is an acute process then you can choose to convert the patient to sinus rhythm by either cardioversion or you can keep the patient under rate control. If it is a chronic process then it is best managed with rate control along with anticoagulation. Rate control is best achieved with diltiazem or metoprolol.
546. Complete heart block is a dangerous condition, which can cause sudden cardiac death. It requires immediate placement of permanent pacemaker.
547. Amiodarone is a class III antiarrhythmic agent and is well known to cause lung fibrosis. Also, remember thyroid dysfunction (both hypo and hyper), hepatotoxicity, cornel deposits and bluish-slate gray discoloration of the skin.
548. Bluish discoloration and cool fingers in the ICU are a common finding aft er use of norepinephrine for hypotension
549. Amoxicillin is the drug of choice for prophylaxis of infective endocarditis in dental and respiratory procedures. In patients who are allergic to penicillin, alternatives include cefazolin, clarithromycin or clindamycin.
550. For genitourinary and GI procedures, other than esophageal procedures, the regimen of choice is ampicillin plus gentamicin in high-risk patients. If the patient is allergic to penicillin, a combination of vancomycin plus gentamycin is used in high-risk patients
551. GI endoscopy is a low-risk procedure for infective endocarditis. For GI endoscopy, prophylaxis is optional in high-risk patients and not recommended in moderate- risk patients.
552. Patients with artificial pacemakers and defibrillators do not require prophylaxis for infective endocarditis.
553. Aspirin, beta-blockers, ACE inhibitors and spiranolactone improve survival in patients with heart failure, while digoxin and loop diuretics does not provide any survival benefit
554. A patient who develops a cold leg after an MI should be suspected of throwing an embolus. An angiogram is diagnostic and an embolectomy is required.
555. Isolated premature ventricular arrhythmias generally do not require any medical treatment; observation is usually the treatment of choice.
556. It is better to keep systolic pressure < 130 mmHg to slow end-organ damage in patients with diabetes and chronic renal failure
557. Syncopal episode without following disorientation (post-episode confusion is more characteristic for a seizure), hearing impairment, normal physical exam, and family history of sudden cardiac death should make you think of congenital long QT syndrome. Beta-blockers are the drugs of choice
558. It is important to recognize that oral contraceptives can be a potential cause of hypertension, and simply discontinuing its use can correct the problem
559. In all cases of ST elevation MI, reperfusion therapy with thrombolytics or PTCA(PCI) with or without stenting must be performed as soon as possible. PTCA(PCI) is preferred over thrombolytics.
560. Presence of hypotension, pulsus paradoxus, and pulseless electrical activity in a patient with a recent acute MI should make you think of free ventricular wall rupture.
561. Suspect aortic dissection as a cause of tearing chest pain in the setting of HTN and BP difference in the 2 arms.
562. Recognize the high risk of arterial thromboembolism associated with anterior wall MIs
563. The most common cause of aortic dissection is systemic HTN
564. CK-MB fraction has a high specifi city for an acute MI (slightly lower than cardiac troponins). It begins to rise within 4-6 hours after MI and returns to baseline within 48-72 hours. Its high speci ficity and rapid return to the baseline makes it the biomarker of choice for the diagnosis of a recurrent MI.
565. Thrombolytic therapy is not indicated for unstable angina or non-ST elevation (non Q wave) MI. The treatment of unstable angina primarily includes aspirin, beta-blockers, heparin and nitroglycerin
566. Electrical alternans is an important EKG finding for the diagnosis of pericardial tamponade. Other findings include sinus tachycardia and low voltage QRS complexes.
567. Viral infection is the most common cause of myocarditis that results in idiopathic dilated cardiomyopathy. The most frequently implicated virus is Coxsackies B virus.
568. Exercise testing is indicated in the risk strati fication of patients with coronary artery disease. Understand the indications of other non-invasive tests for the diagnosis of coronary artery disease
569. Know how to treat acute pulmonary edema in the setting of acute MI. Loop diuretics should be given to treat pulmonary edema.
570. Tobacco and alcohol are reversible risk factors for the development of atrial premature beats.
571. A detailed medical history and physical examination is the most effective way to screen a low risk population for the presence of underlying cardiac disease
572. Hypertrophic cardiomyopathy is the most common cause of sudden cardiac death in young athletes
573. HCM follows autosomal dominant inheritance
574. Know how to manage symptomatic HCM. Beta-blockers are usually the first line of medication.
575. Total abstinence from alcohol is the mainstay of alcoholic cardiomyopathy management and it may revers e this condition if it is employed earlier in the course of the disease
576. Know the physiology of HCM and be able to correctly identify the factors that increas e or decrease the intensity of the murmur in HCM. Valsalva maneuver and standing-Increase; Handgrip, Phenylephrine and Leg elevation; Decrease the murmur.
577. Screening should be done in all first- degree relatives of the patients of hypertrophic cardiomyopathy and the most effective way of screening these people is echocardiography
578. Mitral valve prolapse is the most common cause of mitral regurgitation in USA
579. Restrictive cardiomyopathy is charact erized by severe diastolic dysfunction due to a stiff ventricular wall.
580. Beta blockers are used to treat chest pain, palpitations, and autonomic symptoms of MVP.
581. Know how to diagnose mitral valve prolapse based on clinical findings. Remember the systolic click
582. . The presence of a tapping apex beat, a loud first heart sound, and a mid-diastolic rumble at the apex suggest the diagnosis of mitral stenosis in this patient.
583. Atrial fibrillation in MS is due to left atrial dilatation.
584. It is important to look for and treat hemochromatosis early in patients who present with restrictive cardiomyopathy, because this intervention significantly improves prognosis in these patients.
585. Know how to manage a case of CHF exacerbation due to atrial fibrillation with a rapid ventricular response. Digoxin is the drug of first choice in this situation
586. S. Aureus is the most frequent cause of IE in IV drug abusers
587. Transesophageal echocardiography or computed tomographies are the diagnostic studies of choice for suspected aortic dissection.
588. The typical radiographic abnormalities and PaO2/FiO2 ratio of 91.6 (which is less than 200) in the setting of absent clinical evidence of elevated left atrial pressures (or PCWP 50, do yearly digital rectal plus PSA (Prostate Specifi c Antigen)
749. In Waldenstrms Macroglobulinemia, IgM is produced in excess amounts which causes hyperviscosity of the blood. IgM spike on electrophoresis and hyperviscosity are two important diagnostic clues for this disorder.
750. Eradication of H. pylori by antibiotics is the most accepted and recommended next best step in the management of gastric mucosa- associated lymphoid tissue lymphoma without any metastasis.
751. Adenocarcinoma of lung has the least association with smoking. It is usually located peripherally and consists of columnar cells growing along the septa. It presents as a solitary nodule and may be detected incidentally.
752. Squamous cell carcinoma of mucosa of head and neck may present with palpable cervical lymph node. The best test for such patients is panendoscopy to detect the primary tumor.
753. There is no evidence that ultrasound of abdomen can help in decreasing mortality from ovarian cancer.
754. For a breast mass that disappears completely with FNA and fluid aspirated is clear, next step is to observe for 4 weeks.
755. Tamoxifen reduces the risk of breast cancer in patients who are at an increased risk of developing breast cancer.
756. Pagets disease presents as a persistent dermatitis of the nipple. There is a red, oozing, crusted lesion, which is often unresponsive to topical steroid and antibiotics. Biopsy shows malignant cells that invade the epidermis and have abundant pale staining cytoplasm surrounding a hyper-chromatic nucleus, with prominent nucleoli.
757. Tamoxifen increas es the risk of two types of cancer that can develop in the uterus: endometrial cancer, which arises in the lining of the uterus, and uterine sarcoma, which arises in the muscular wall of the uterus.
758. Recognize migratory thrombophlebitis and consider appropriate investigation to find out the possible occult malignancy.
759. Ondansetron is the drug of choice for chemotherapy- induced emesis.
760. Melanoma should be on the top of the list if a metastatic mass bleeds inside brain.
761. In low risk patients (i.e. < 40 years and non smokers) a solitary pulmonary nodule is not a sign of immediate alarm. The best approach is to ask for an old x-ray.
762. The best way to handle bone tumor is to recognize it and leave it for experts.
763. Amphotericin should be started in febrile neutropenic patients if they are persistently febrile despite of 5-7 days of ceft azidime/cefepime plus vancomycin.
764. Febrile neutropenia is a medical emergency; patient should be admitted in hospital and started on broad-spectrum antibiotics preferably 3rd generation cephalosporins after obtaining blood cultures.
765. Radiologically, Ewing's sarcoma is associated with a lamellated or "onion skin" periosteal reaction. The lesion is usually lytic and central. Endosteal scalloping is often present.
766. Any contrast enhancing, heterogeneous, irregular mass on kidney is a malignancy until proven otherwise. Through workup by an urologist is recommended
767. Hypercal cemia and hilar mass in a smoker of more than 45 years is most likely from a squamous cell carcinoma of the lungs.
768. Hypercal cemia and intractable ulceration can be due to MEN syndromes.
769. Syndrome of inappropriate antidiuretic hormone secretion is often seen with small cell carcinoma of the lung.
770. CT chest should be done to look for thymoma in all newly diagnosed myasthenia gravis patients.
771. IV normal saline is the first step in managing acute hypercalcemic crisis.
772. An increas e in serum levels of both insulin and C-peptide and hypoglycemia is diagnostic of insulinoma.
773. Acanthosis nigricans might be a manifestation of occult gastrointestinal malignancy.
774. Water restriction is the first step in managing hyponatremia in patients with syndrome of inappropriate antidiuretic hormone secretion.
775. Hypocalcemia is an important component of Tumor Lysis Syndrome. It is believed to be due to the release of intracellular products by cell lysis. There are a number of metabolic abnormalities associated that include hyperphosphatemia, hypocalcemia, hyperkalemia, and hyperuricemia.
776. Any adolescent boy who presents with epistaxis and has localized mass with bony erosion on the back of the nose has an angiofibroma until proven otherwise.
777. Patients with Peutz-Jeghers syndrome have a high risk of developing ovarian tumors.
778. Hyperglycemia, necrolytic migratory erythema and diarrhea should make you think about glucagonoma.
779. Know how to diagnose osteosarcoma. Codmans triangle and sunburst appearance are the two classic radiologic features of this entity.
780. Spironolactone is the diuretic of choice for managements of ascites.
781. The drug of first choice for cancer-associated anorexia is Megestrol acetate.
782. Recognize acute monocytic (FAB M5) leukemia based on the smear and positive alpha-naphthyl esterase
783. Chronic lymphocytic leukemia is almost always seen in elderly patients; presence of marked leukocytosis with predominant lymphocytosis and smudge cells are the diagnostic features.
784. Multiple myeloma is a plasma cell disorder and often presents with lytic lesions, hypercalcemia, and renal failure.
785. Know about the typical presentation of infectios mononucleosis and always keep in mind that heterophil antibody test is usually positive after 3 weeks of infection.
786. Recognize the importance of tartrate resistant acid phosphatase stain in the diagnostic of hairy cell leukemia.
787. Acute lymphoblastic leukemia is predominantly a disease of children and recognize the importance of periodic acid schiff positive staining in diagnosis.
788. Know the blood indices in various types of anemias. Megaloblastic anemias are characterized by elevated MCV, 90% of the times elevated MCH, and normal MCHC.
789. Patients with high MCV should be tested for vitamin B12 and folic acid levels. Know how to differentiate between various causes of megaloblastic anemia.
790. In a patient with increased reticulocyte count, increas ed bilirubin, negative Coombs test and spherocytes on peripheral blood films, the diagnosis of Hereditary Spherocytosis (HS) is top on the list
791. PA is the most common megaloblastic anemia and is the prototype of the group. In PA, Vitamin B12 defici ency is caused by reduced Intrinsic factor (IF) secondary to gastric atrophy. In majority of the cases antibodies to parietal cells have been reported.
792. Microcytic anemia and basophilic stippling in a child should make you think about lead poisoning.
793. In Paroxysmal Nocturnal Hemoglobinuria , a red cell membrane defect causes increas ed binding of complement to the red cell leading to increased intravascular hemolysis.
794. Know the iron studies in various types of microcytic anemias. Low serum iron, ferritin, and increased TIBC indicates iron deficiency anemia.
795. Polycythemia can present with hypertension. Know various presentations of polycythemia vera and try to identify it from other causes of hypervolemia.
796. Presence of antibodies to ds-DNA is specific for the diagnosis of systemic lupus erythematosus
797. New onset diabetes, arthropathy, and hepatomegaly should alert you about the possibility of hemochromatosis.
798. In P. Vera urinary erythropoetin assay reveals the absence of measurable erythropoetin in the urine.
799. In CLL, presence of thrombocytopenia is a poor prognostic factor.
800. Try to identify chronic lymhpocytic leukemia from clinical picture and hematological findings. Lymph node biopsy not bone marrow biopsy confirms the diagnosis.
801. Know that leukocyte alkaline phosphatase score is high in leukemoid reactions and usually low in chronic myeloid leukemia.
802. The hallmark of Bernard Soulier syndrome is the Giant platelets. There is mild thrombocytopenia but the major defect is of membrane glycoprotein Ib. This defective platelet membrane lacks the receptor site for vWF so the platelets cant adhere to vascular subendothelium.
803. Glazmanns Thrombasthenia is a qualitative platelet defect with normal platelet count but prolonged bleeding time and abnormal aggregation test with ADP.
804. Elderly patient with anemia, renal failure, and hypercalcemic should make you think of multiple myeloma
805. Imatinib has changed the prognosis in patients with chronic myelogenous leukemia.
806. Know the diagnostic features of Hairy Cell Leukemia and that Cladribine is the drug of choice for it.
807. Know the presentation of thrombotic thrombocytopenic purpura and its differentiating features from disseminated intravascular coagulation, idiopathic thrombocytopenic purpura and hemolytic uremic syndrome.
808. Folic acid supplementation is encouraged in patients with high risk for developing aplastic crisis.
809. Bone marrow iron stain is the most definite way to diagnose iron deficiency anemia.
810. Recognize the pathology of B12 deficiency anemia. B12 stores are available for 3-4 years.
811. Supplementation with folic acid may correct anemia but will not correct neurological complications in patients with vitamin B12 defici ency.
812. Consider macro vascular hemolysis as a cause of microcytic anemia in patients with artificial heart valves or severely calcified aortic valves.
813. Always consider G6PD deficiency in patients who develop acute hemolysis following ingestion of primaquine or sulfa drugs. Also, G6PD levels are often normal during the hemolytic episode.
814. Acute cord compression in cancer patient is a medical emergency and needs prompt administration of intravenous steroids as the first step.
815. Radiation therapy is useful in managing bone pain in patients with prostate cancer who have undergone orchiectomy.
816. Vitamin K deficiency can occur following chronic diarrhea or broad-spectrum antibiotic use, manifesting with bleeding disorders in the form of easy bruisability, mucosal bleeding, etc. PT is prolonged. If the PT is not corrected with administration of vitamin K, it should make you think that this is not the result of vitamin K deficiency and liver disease should be suspected.
817. Recognize HUS in a child who has recently recovered from a diarrheal illness and presents with acute renal failure, microangiopathic hemolytic anemia, fever, thrombocytopenia and characteristic peripheral smear finding of schistocytes.
818. Chronic liver disease or cirrhosis from almost any cause is a risk factor for hepatocellular cancer. Hepatocellular cancer is responsible for 30% of deaths in patients with hemochromatosis.
819. Chronic liver disease or cirrhosis from almost any cause is a risk factor for hepatocellular cancer. Hepatocellular cancer is responsible for 30% of deaths in patients with hemochromatosis.
820. Reyes syndrome or acute fatty liver with encephalopathy can lead to fulminant hepatic failure in children.
821. Pancreatic pseudocyst is a complication of both acute and chronic pancreatitis and is diagnosed by ultrasound.
822. Anti mitochondrial antibodies are present in 90% of patients with primary biliary cirrhosis.
823. Liver disease should be evaluated on the basis of tests to assess both the function and the structural integrity of the liver.
824. Hyperestronism in cirrhosis leads to gynecomastia, testicular atrophy, decreas e bodily hair, spider nevi and palmar erythema.
825. Suspect spontaneous bacterial peritonitis (SBP) in cirrhotic patients with fever and ascites.
826. High serum AFP (>500 ng/ml) in an adult with liver disease and without an obvious G.I. malignancy is strongly suggestive of hepatocellular carcinoma.
827. Abdominal ultrasound is the best initial investigation for gallbladder pathology.
828. The triad of sudden onset right upper abdominal pain, fever, and leucocytosis is highly suggestive of acute cholecystitis.
829. Newborns of mothers with active hepatitis B should be passively immunized at birth with hepatitis B immunoglobulin followed by active immunization with recombinant HBV vaccine.
830. Risk factors for non alcoholic hepatic steatosis are obesity, diabetes mellitus, hyperlipidemia, total parental nutrition and bypass surgery for obesity.
831. Hemochromatosis is an autosomal recessive disorder characterized by increased skin pigmentation, diabetes, cirrhosis and arthralgia.
832. Checking for anti HBcAg and HBsAg is the best screening of the acute hepatitis B.
833. HCV RNA is the single most sensitive serological marker to screen for HCV infection.
834. Hepatitis E has a very high rate of progression to fulminant hepatitis in pregnant women.
835. Acute liver failure or fulminant hepatitis is most commonly due to acetaminophen toxicity.
836. Persons who received blood transfusions before 1992 should be screened for Hepatitis C and those with blood transfusions before 1986 should also be screened for hepatitis B.
837. Isoniazid causes idiosyncratic liver injury with histology similar to viral hepatitis.
838. Primary sclerosing cholangitis is caused by inflammatory destruction of both the intrahepatic and extrahepatic biliary channels. It is often associated with ulcerative colitis.
839. Alpha-1 Antitrypsin defici ency can cause panlobular emphysema and cirrhosis.
840. Non-selective B blockers are used in primary and secondary prevention of variceal bleeding in cirrhotic patients who have portal hypertension with varices.
841. The first step in the treatment of acute variceal bleeding is to get vascular access with two large bore intravenous needles.
842. C-J 1 is characteri zed by:
1. Unconjugated hyperbilirubinemia of 8-30mg/dl.
2. Normal liver enzymes and histology.
3. High rates of kernicterus
4. No response to Phenobarbital
C-J 2 is characteri zed by:
1. Unconjugated hyperbilirubinemia of 1000mg/dl can cause acute pancreatitis.
878. Endoscopic retrograde cholangiopancreatography is the investigation of choice for patients with recurrent pancreatitis with no obvious cause.
879. Paracent esis can be used for both diagnostic and therapeutic purposes in patients with ascites.
880. Hydatid cysts in the liver are due to infection with Echinococcus granulosus.
881. Transjugular intrahepatic portosystemic shunt procedure is used in cirrhotic patient for refractory ascites, refractory hydrothorax, and surgical management of acute recurrent variceal bleeding.
882. Entamoeba histolytica is a protozoan, which can cause amebic liver abscess. Remember the Mexico trip.
883. Factors independently associated with high rates of liver fibrosis in chronic hepatitis C patients are:
1. Male gender.
2. Acquiring infection after age of 40.
3. Alcohol intake: alcohol intake in any amount can hasten the progression of fibrosis in patients with chronic hepatitis C.
884. ERCP with sphincterotomy is the treatment of choice for sphincter of oddi dysfunction
885. The treatment of acute cholangitis is to give supportive care, broad-spectrum antibiotics, and biliary drainage with an endoscopic retrograde cholangiopancreatography.
886. Checking for urinary excretion of bilirubin is an easy and effective way of determining whether the cause of jaundice is conjugated or unconjugated bilirubin. So the presence of bilirubin in urine is indicative of conjugated hyperbilirubinemia.
887. Conjugated hyperbilirubinemia is mainly becaus e of intrahepatic or extrahepatic obstruction or congenital impaired hepatic excretion of bilirubin.
888. Acute pancreatitis is one of the conditions causing acute abdomen, which is managed conservatively.
889. About 10% of patients on isoniazid develop a mild elevation of aminotrans ferases within first few weeks of the treatment. However, this elevation of aminotrans ferases returns to normal despite continued use of isoniazid in most of the patients.
890. Orthotopic liver transplantation remains the only effective mode of treatment of fulminant hepatic failure and should be considered in any patient presenting with fulminant hepatic failure, regardless of the etiology.
891. Liver biopsy is the most reliable way to distinguish chronic active from chronic persistent hepatitis.
892. Benign intrahepatic cholestasis can develop after a major surgery in which hypotension, extensive blood loss into tissues and massive blood replacement are notable.
893. Hepatic venogram or a liver biopsy is the diagnostic test of choice for the evaluation of congestive hepatomegaly secondary to hepatic vein occlusion (Budd Chiari syndrome).
894. Porcelain gall bladder is an entity usually diagnosed on an abdominal x- ray. The condition predisposes individuals to gall bladder carcinoma and requires resection.
895. In a patient with primary amenorrhoea and no breasts, estrogen is low and FSH measurement should be ordered: if it is decreased, GnRH stimulation test is the next step; if it is increas ed, karyotype is the next step.
896. In any woman of childbearing age with amenorrhea, first rule out pregnancy.
897. DUB is the most common cause of abnormal uterine bleeding, but owing to its benign nature, it is a diagnosis of exclusion. About 70% of cases are caused by anovulatory cycles. After menarche and before menopause it is considered physiologic. IV estrogen is the drug of choice for uncontroled bleeding.
898. When to perform endometrial biopsy to rule out endometrial carcinoma in patients with DUB? If the patient is older than 35 years, obese, diabetic or with chronic hypertension.
899. OCPs have been shown to decreas e the risk of ovarian and endometrial carcinoma. As for breast cancer, the risk does not seem to change with their use. Beside hypertension, OCPs expose to other complications such as thromboembolism, cerebrovascul ar disease, MI, gallblader disease and benign hepatic tumors.
900. Postcoital or emergency contraception has become necessary because it is estimated that around 60% of pregnancies in the US are unplanned. It can be given upto 72 hours.
901. Presence of dysmenorrhea, heavy menses, and enlarge uterus is almost diagnostic of either adenomyosis or fibroid uterus.
902. Primary dysmenorrhea usually appears 6 to 12-months after menarche. NSAIDs are highly effective for treatment; oral contraceptive pills inhibit ovulation and are also effective.
903. Patients with polycystic ovarian disease (PCOD) usually have elevated DHEA levels. Although ACTH levels are normal in these women, ACTH stimulation test produces an exaggerated response of DHEA becaus e of increas ed sensitivity of the adrenal gland to ACTH.
904. Treatment for overflow incontinence includes cholinergic agents and intermittent self- catheterization.
905. External hordeolum or stye is a common staphylococcal abscess of eyelid, which is treated with warm compresses and if the resolution doesnt begin in next 48hrs, with incision and drainage.
906. Age related macular degeneration is usually seen in patients above 50yrs of age, presents with progressive and bilateral loss of central vision with preservation of navigational vision.
907. Congenital cataract is the most common cause of white reflex in pediatric population.
908. Allergic conjunctivitis is an acute hypersensitivity reaction caused by environmental exposure to allergens and characteri zed by intense itching, hyperemia, tearing, conjunctival edema and eyelid edema.
909. Cataract is a vision-impairing disease, due to progressive thickening of lens and characteri zed by blurred vision and glare.
910. Angle Closure Glaucoma occurs predominantly in people aged 55-70 yrs and presents with acute onset of severe eye pain and blurred vision associated with nausea and vomiting.
911. Open Angle Glaucoma is more common in African Americans, is generally asymptomatic in intial stages and characterized by gradual loss of peripheral vision over a period of years resulting into tunnel vision.
912. Postoperative endophthalmitis is the most common form of endophthalmitis, usually occurs within six weeks of surgery.
913. Vesicular rash in the terminal distribution with dendriform corneal ulcers is suggestive of Herpes zoster opthalmicus.
914. CMV retinitis occurs when CD4 count is less than 50/ul; may be asymptomatic and is diagnosed by the characteristic fundoscopic findings of yellow white patches of retinal opacification and hemorrhages.
915. Optic neuritis presents with changes in color perception and decreased visual acuity. Afferent pupillary defect and central scotoma should make you think of optic neuritis. Remember the association between optic neuritis and multiple sclerosis.
916. Trachoma presents as follicles in the conjunctiva and signs of nasopharyngeal infection.
917. Dacryocystitis presents with inflammatory changes in the medial canthal region of the eye.
918. Hordeolum is a painful, tender swelling localized to the eyelid.
919. Corneal vesicles and dendritic ulcers characterize Herpes simplex keratitis.
920. Amaurosis fugax is transient loss of vision due to embolic phenomena
921. Recognize the clinical presentation of retinal detachment; it usually presents with sudden onset of photopsia and float ers.
922. Vitreous hemorrhage occurs in patients with diabetic retinopathy and the fundus is hard to visualize.
923. When an individual with acute glaucoma is diagnosed, all agents, which can dilate the pupil, like atropine, should be avoided.
924. Spontaneous subconjunctival hemorrhage is a benign finding and does not require any treatment.
925. In any patient less than 3 years old and presenting with impairment in social interactions and communication, delayed language development, and stereotypical behaviors, always thinks of autism.
926. Thus, in any patient with symptoms of short attention span, impulsivity, and hyperactivity, for more than 6 months in more than one setting, ADHD should be considered as the most probable diagnosis.
927. Infant botulism is transmitted by ingestion of food contaminated with C. botulinum. The germ grows in the gut and produces a toxin, which is responsible for the clinical signs.
928. Ventricular septal defects are common in patients with Edwards syndrome, which is characterized by micrognathia, microcephaly, rocker bottom feet, overlapping fingers, and absent palmar creases.
929. Hirschsprungs disease occurs with increas ed frequency in patients with Downs syndrome.
930. Cystic fibrosis may presents with meconium ileus, which is characterized by bilious vomiting, failure to pass meconium at birth, and ground glass appearance on abdominal X-rays.
931. Midgut volvulus usually presents in a child less than one month with bilious vomiting, abdominal distension and bloodstained stools.
932. In a neonate who presents with bloody diarrhea, the presence of eosinophils in the stools and positive family history of atopy suggest the diagnosis of milk protein intolerance.
933. Painless melena in a 2 to 3-year-old child is most likely due to Meckel's diverticulum.
934. Fiberoptic laryngoscopy in the operating room is the most appropriate next step when diagnosis of acute epiglottitis is suspected.
935. Pyloric stenosis presents with non-bilious vomiting in a 4 to 8-week-old child, and abdominal ultrasound confirms the diagnosis.
936. Gauchers disease is diagnosed based on the radiological appearance of Erlenmeyer flask deformity of the distal femur, and characteristic Gaucher cells with their wrinkled paper appearance in bone marrow examination.
937. Children with a parental history of elevated total cholesterol levels (>240 mg/dL), or risk factors for coronary artery disease should get a screening test for total cholesterol level.
938. Peroxisomal disorders such as Zellweger's syndrome should be considered in neonatal seizures, especially if the neonate presents with typical facial dysmorphism.
939. Patients with classic phenylketonuria present with fair skin, blue eyes, musty body odor and eczema, and labs show elevated plasma phenylalanine levels.
940. Cri-du-chat syndrome is due to 5p deletion and it presents with features of hypotonia, short stature, and a characteristic cat-like cry.
941. Edwards' syndrome commonly presents with microcephaly, prominent occiput, micrognathia, closed fists with index finger overlapping the 3rd digit and the 5th digit overlapping the 4th, and rocker bottom feet.
942. Downs syndrome, or trisomy 21, presents with flat face, upward and slanted palpebral fissures, epicanthal folds, simian crease, short and broad hands, hypoplasia of the middle phalanx of the 5th fingers, and high arched palate.
943. Vitamin D deficiency rickets is more common in dark skinned infants who are less exposed to sunlight and are 1-2 years of age. It presents with craniotabes, rachitic rosary, and thickening of the lower end of long bones, all due to defective mineralization.
944. Birth injuries such as clavicular fracture are common complications in mothers with GDM and large babies.
945. Mongolian spots are flat blue or gray lesions, characteristically well demarcat ed, seen more commonly in the sacral or presacral areas, and disappear by the first few years of life.
946. Conduct disorder is characterized by disruptive behavioral patterns that violate basic social norms present for more than one year, in patients less than 18 years old.
947. Suspect Vitamin A deficiency in any child 2 to 3 years of age presenting with dry eyes and skin, photophobia, and impaired dark adaptation.
948. Iron supplementation in the form of iron-fortified milk formula or medicinal iron, should be started at 6 weeks in all premature and low birth weight babies.
949. Maternal HIV infection is an absolute contraindication to breast-feeding.
950. Heroin withdrawal usually presents within the first 48 hours of life, with tremors and hyperirritability as the most prominent symptoms.
951. Surgery is advised in umbilical hernia if the hernia persists to the age of 3-4 years, exceeds 2 cm in diameter, causes symptoms, becomes strangulated, or if it enlarges progressively after the age of 1 to 2 years.
952. Physiological jaundice usually presents after 24 hours of birth. Any jaundice in the first 24 hours of birth, or a direct hyperbilirubinemia, needs detailed evaluation for the cause of jaundice.
953. Neonatal necrotizing enterocolitis should be suspected in any preterm or low birth weight infant with fever, vomiting, abdominal distension, and roentgenographic finding of pneumatosis intestinalis.
954. Hyaline membrane disease should be suspected in preterm infants with respiratory distress and hypoxia not responding to oxygen therapy, and is treated early with mechanical ventilation and surfactant
955. Cephalohematoma is a subperiosteal hemorrhage, presents few hours after birth as scalp swelling limited to one cranial bone.
956. Absence seizure is a generalized seizure of childhood and is charact erized by sudden and brief lapses of consciousness without loss of postural control. It usually presents with multiple 'daydreaming' episodes and decline in school performance.
957. Intussusception, the most common cause of intestinal obstruction in the first two years of life, presents with intestinal obstruction and red currant jelly stools containing blood and mucus.
958. Calcified lesion above the sella requires an evaluation for craniopharyngioma.
959. Sturge-Weber syndrome is a neurocutaneous syndrome and is characterized by congenital unilateral cavernous hemangioma along the trigeminal nerve distribution; radiography shows characteristic intra-cranial calci fications that resemble a tramline.
960. Supportive care is the mainstay of treatment in cases of infant botulism.
961. The treatment of Kawasaki's disease consists of aspirin and IV immunoglobulins.
962. Always suspect pyloric stenosis in a neonate who presents with non-bilious, projectile and persistent vomiting, and order abdominal ultrasound to establish the diagnosis.
963. Osgood-Schlatter disease is generally a disease of children age around 10-17 years, which presents with knee pain at the tibial tuberosity, that is, at the site of insertion of the quadriceps tendon.
964. Recognize fetal alcohol syndrome and know that it is the most common cause of mental retardation in children. Remember the midfacial abnormalities.
965. Guthrie test is a qualitative (coloration) test which can detect the presence of metabolic products of phenylalanine in the urine.
966. The healthy appearance of the neonate, the evanescent nature of the rash, and the distinctive red halo surrounding the lesions support the diagnosis of erythema toxicum. The presence of eosinophils in the skin lesions is diagnostic.
967. Galactosemia should be considered for the newborn or young infant who has failure to thrive, bilateral cataract, jaundice and hypoglycemia. Early diagnosis and treatment by elimination of galactose from the diet are mandatory.
968. Aplastic anemia should be suspected in any patient with pancytopenia following drug intake, exposure to toxins or viral infections.
969. American Academy of Pediatrics advises against the use of cow's milk in the first year of life. Infants should receive breast milk or iron fortifi ed formulas for the first year of life, and iron-fortified cereal should be added at the age of 4-6 months.
970. Any patient with recurrent or unusual lymphadenitis, hepatic abscesses, osteomyelitis at multiple sites, or unusual infections with catalase-positive organisms (e.g., S. aureus) requires clinical evaluation for chronic granulomatous disease.
971. Severe combined immune deficiency is a life-threatening syndrome presenting with recurrent bacterial, viral and fungal infections, and diagnosed by absence of lymph nodes and tonsils, lymphopenia, and absence of a thymic shadow on chest X-rays.
972. Hyper-IgM syndrome (HIM) is characteri zed by high levels of IgM with defici ency of IgG, IgA and poor speci fic antibody response to immunizations.
973. Brutons agammaglobulinemia classically presents in a male infant of 6-9 months of age with recurrent pneumonia and otitis media. Level of all classes of immunoglobulins and circulating B-lymphocytes are decreas ed.
974. Salicylates are contraindicated in young children with viral infections. Recognize the clinical presentation of Reyes syndrome.
975. Hypoglycemia, lactic acidosis, hyperuricemia, and hyperlipidemia, in the presence of liver and kidney enlargement, are hallmarks of Type I glycogen storage disease (deficiency of Glucose- 6-phosphatase).
976. Kawasaki's disease is characteri zed by fever, conjunctival vascular injection, cracked lips, polymorphous erythematous rash, diffuse erythema of palms and soles and unilateral lymphadenitis.
977. In patients suspected of epiglottitis, visualization of the epiglottis should not be attempted. Securing the airways as soon as possible is the first and foremost step in management of these patients.
978. Croup is caused by Parainfluenza virus and commonly presents in children younger than 3 years with hoarseness, a barking cough, and varying degrees of respiratory distress.
979. Myotonic dystrophy, a slowly progressive, dominantly inherited disorder, usually manifests itself in the third or fourth decade but occasionally appears early in childhood. The genetic defect has been localized to the long arm of chromosome 19 in the type 1 disorder. Myotonia leads to complaints of muscle stiffness and is evidenced by the marked delay that occurs before affect ed muscles can relax aft er a contraction. This can often be demonstrated clinically by delayed relaxation of the hand after sustained grip or by percussion of the belly of a muscle.
980. Streptococcal pharyngitis is the most common cause of pharyngitis in children, and the first step in any case of pharyngitis is to do a rapid strep test. Oral penicillin for 10 days is the treatment of choice.
981. Streptococcus pneumonia is the most common cause of acute sinusitis in childhood, followed by Haemophilus influenzae and Moraxella catarrhalis.
982. Sinusitis is a clinical diagnosis in children and is treated with oral amoxicillin in uncomplicated cases.
983. Acute lymphoblastic leukemia is the most common leukemia in children. Diagnosis is mainly based on more than 25% lymphoblasts in the bone marrow.
984. Immune thrombocytopenic purpura typically presents in early childhood aft er a viral infection with easy bruisability and petechiae. Labs show thrombocytopenia and normal Hb, WBC, PT and PTT.
985. A positive Coombs' test points towards autoimmune hemolytic anemia, and a positive osmotic fragility test points towards hereditary spherocytosis.
986. The intraosseous technique is an excellent site for IV access in children.
987. In children who develop thrombocytopenia after a viral infection, one should suspect immune thrombocytopenia, which is a relatively benign condition.
988. In a newborn in the NICU, abdomen distension, bloody diarrhea, elevated WBCs, that occur after feeding, usually represents necrotizing enterocolitis.
989. The organ system with the highest morbidity and mortality after HUS is the kidneys.
990. In a child who presents with a sudden onset of abdominal pain, bloody diarrhea, and a triad of anemia, thrombocytopenia and renal failure, one should suspect the hemolytic uremic syndrome.
991. In a febrile child who presents an isolated seizure, one has to think of a febrile seizures. They are benign and need to be adressed with reassurance and antipyretics.
992. Trachoma, caused by Chlamydia trachomatis is the most common cause of blindness in the world. The diagnosis is usually made by the presence of lymphoid follicles on the conjunctiva, scarring and limbal follicles.
993. In a patient with sickle cell trait, some protection against malaria is obtained.
994. Asthma when it cannot be controlled by medications, should be an indication for mechanical ventilation. Know when to intubate a patient.
995. Bordetella pertussis presents in children with paroxysms of cough, which can last up to two weeks. The coughing spells are so severe that rectal prolapse and pneumothoraces can ensue.
996. In a patient with severe bouts of coughing and subcutaneous emphysema, a pneumothorax must be ruled out by obtaining chest X-rays.
997. In a patient who presents with symptoms of an upper respiratory tract infection and later develops a rash after exposure to ampicillin, one should think of infectious mononucleosis caused by Epstein-Barr virus
998. When a child presents with chorea, sore throat, fever, pericarditis and subcutaneous nodules, one should suspect Group A streptococcus. It is the leading cause of rheumatic fever.
999. In an infant with meningitis from Neisseria meningococcus, a sudden vasomotor collapse and skin rash is due to adrenal hemorrhage, known as the Waterhouse-Friderichsen syndrome.
1000. In a neonate with signs of meningitis and a petechial rash, one should suspect meningococcemia.
1001. Pyloric stenosis is a surgical condition. However, surgery should be undertaken only after the infant has been resuscitated and electrolytes replaced.
1002. In a young child of 2-5 years age with a localized abdominal mass and hematuria, one has to think of Wilms tumor. If the child age is less than 1 year think of neuroblastoma.
1003. The drug of choice for nocturnal enuresis is DDAVP. Bed-wetting is considered normal until the age of 4-5 years. But if it persists either DDAVP or imipramine is used.
1004. Childhood obesity is a risk factor for development of type 2 diabetes later in life.
1005. Most cardiac murmurs in childhood are benign and require only observation
1006. DiGeorge syndrome is associated with cyanotic heart disease, craniofaci al anomalies, thymic hypoplasia, cognitive impairment and hypoparathyroidism. It is essential to monitor the calcium levels in these infants.
1007. In a child who has proximal muscle weakness and exhibits a Gowers sign, with depressed reflexes and pseudohypertrophy, a muscular dystrophy must be suspected
1008. Turner syndrome is associated with a higher incidence of coarct ation and bicuspid aortic valve. The clinical presentation is that of short stature, short webbed neck and a low posterior hairline. The chest is broad with widely spaced nipples.
1009. Duodenal atresia can present with bilious vomiting and 2 large air bubbles on an x-ray. Remember its association with Down syndrome
1010. A typical presentation of TOF individuals is squatting, which increases the systemic vascular resistance and forces blood into the lungs, thus improving cyanosis.
1011. Gall Stone Ileus: Plain abdominal x-rays reveal ed distended loops of small bowel consistent with partial small bowel obstruction, and gas in the biliary tree and gallbladder. US confirmed gas in the biliary tree, but could not identify the gallbladder and could not determine the cause of intestinal obstruction.
1012. The treatment of recurrent aortic coarctation is balloon angioplasty.
1013. Down syndrome patients are prone to endocardial cushion defects, which can rapidly cause pulmonary hypertension.
1014. In a child presenting with failure to thrive and steatorrhea, with a history of neonatal jaundice, cystic fibrosis must be ruled out. The diagnosis of cystic fibrosis is made after evaluating the sweat chloride.
1015. In a young child who presents with recurrent upper respiratory tract infections and bilateral nasal polyps, cystic fibrosis must be ruled out.
1016. The most common cause of amblyopia is strabismus. Other causes include errors of refraction, and opacity of media along the visual axis. The standard of treatment is occlusion of the normal eye.
1017. Thyroid dysgenesis is the most common cause of congenital hypothyroidism in United States.
1018. Mongolian spots could most commonly be found in dark-skinned populations, present from birth and usually fades and then disappears in several years.
1019. Neonatal chlamydial conjunctivitis is treated with systemic erythromycin because of the risk of pneumonia.
1020. Anemia of prematurity is the cause of anemia in premature and low birth weigh infants. The pathology involves a combination of diminished RBC production, shortened RBC life span, and blood loss. Iron supplementation does not prevent falling hemoglobin and is not the cause of anemia of prematurity.
1021. Vaginal discharge in newborn is due to the effects of maternal estrogens and reassurance of the mother is all that is required.
1022. Osteogenesis imperfect a is caused by mutations in type 1 collagen and its typical features are blue sclera and recurrent fractures.
1023. Painless gross hematuria is the most common presentation of sickle cell trait.
1024. Hydroxyurea is indicated in patients with frequent, acute, painful episodes,
s it tends to increas e Hb F levels.
1025. Dactylitis is the earliest manifest ation of vaso-occlusive disease in sickle cell anemia.
1026. Pubertal gynecomastia is seen in about one-half of adolescent boys, at an average age of 14 years; it is often asymmetric or transiently unilateral, frequently tender, and just needs observation.
1027. All children with recurrent episodes of nocturnal vulvar itching should be examined for pinworms and may be treated empirically.
1028. Neonatal tetanus is generally seen in infants born to unimmunized mothers, frequently following umbilical stump infection, and is characteri zed by poor suckling and fatigue, followed by rigidity, spasms and opisthotonus in first two weeks of life.
1029. DBS is a macrocyt