PREPARED BY SANTOSH DHUNGANA

UWORLD SYNOPSIS FIRST: step 3 usmleworld.com

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

15.
In a pt with high LDL and TG, the first step is always targeting
LDL with statin, then add fibrates if statin doesnt decrease the TG.
Cholestyramine can increase TG so is contraindicated.
16.
Post CABG angina, with permanent ECG changes- do
radionuclide perfusion imaging and not stress EKG or even stress Echo, as we cant
interpret the Echo with previous wall motion abnormality due to previous MI or
ischemic cardiomyopathy.
17.
Inc fibrinogen >2.7 7 puts patient at high risk of MI; and
lovastatin and atorva both increase fibrinogen. So if the patient has elevated
levels of fibrinogen, change to either prava or simvastatin, as they have no effect
on fibrinogen.
18.
Wt loss is the single most imp measure to dec BP, more than
stopping smoking, or dec salt or alcohol consumption or exercise
19.
Preop cardiovascular risk assessment; age above 70 yrs 5 points,
MI<6 mo ago 10 points, MI>6 mo 5 points; angina on walking 1-2 blocks 10
points, angina at rest 20 points, and critical aortic stenosis 20 points
20.
Drug lupus with hydralazine, mdopa, CPZ, IFN a, diltiazem,
minocycline, penicillamine, procainamide, INH- starts with flu like symptoms,
fever, malaise, arthralgia and facial rash.
21.
Asymptomatic hypoNa in CHF patients- water restriction is the
TOC, even if NA <115; hypertonic saline only for symptomatic pts. Isotonic saline
and oral salt tablets are contraindicated as they will increase the fluid overload.
22.
Pt with unstable angina 2 weeks back- sent home from Er- do
straightaway cor angio and then intervention. No need for stress testing.
23.
If stress testing shows no change in EKG and we still suspect
CAD, do stress perfusion scan.
24.
MRI is the inv of choice for coarctation, not TTE. TEE is inferior
to TTE for aorta. Coarctation is usually associated with bicuspid aortic valve and
ESM murmur.
25.
Lone AF, without any cause found, aspirin is the treatment.
Warfarin if prosthetic or rheumatic AF, ticlopidine, dipyridamole and clopid if
allergic or intolerant to aspirin. Ticlopidine causes neutropenia.
26.
Monomorphic nonsustained VT- usually either
MVPS/DCM/LVH or CAD; do Echo and Stress test.
27.
Long QT syndrome, hypomag, hypokal, they cause polymorphic
VT.
28.
Pt on warfarin with increased INR upto 5- withhold warfarin; if
between 5 and 9- give a small dose of vit k oral, if more than 20 only then give iv
vit k or FFP.
29.
External pacemaker means temporary one. Mobitz II needs
permanent transvenous pacemaker insertion.
30.
Multifocal atrial tachycardia in COPD, dec K or Mg,
aminophylline or isoproterenol- P wave of 3 or more morphology with narrow
complexes, variable PR and RR- always check pulse oximetry first too rule out
hypoxia; correct underlying cause, then if it doesnt subside give metoprolol. In
COPD pts, give verapamil instead of metoprolol

31.
HTN crisis can present with flash pulmonary edema. Administer
morphine, oxygen and lasix, then start iv nitroglycerine or nitroprusside for the
HTN. Since many heart diseases like acute MR or AR can present with flash PE,
echo should be performed. If recurrent episodes of flash PE and HTN, then do
renal duplex scan, esp in young patients.
32.
A case of postop inferior MI with significant bradycardia (ie
symptomatic, for eg causing pul edema)- start atropine first, and if it is recurrent
do transvenous pacing. Dont do pacing initially as the brady is usually transient.
Dont use dopamine or norepi as they increase cardiac oxygen demand.
Thrombolysis or heparin cannot be given upto 2 weeks postop. DONNO ABOUT
PTCA.
33.
AF with hemodynamic instability- synchronized cardioversion.
Also for VT. Asynchronised for VF and Torsades. In chronic AF or stable AF, rate
control with metoprolol or diltiazem is preferred. Using iv load of digoxin then
regular digoxin was the idea of the past. Stable AF can also be cardioverted either
with defibrillation or chemically with class III drugs. Prior anticoagulation needed
for cardioversion of chronic AF. Diltiazem is preferred as it has fast OOA and low
DOA, except if CHF or heart block, where digoxin is needed. The problem with
even iv digoxin in acute cases of AF is that it takes hours to act.
34.
ACEI is the DOC in CCF, even more so in elderly with dementia,
in whom digoxin and spironolactone etc can cause delirium.
35.
Elderly with multiple risk factors coming with an episode of
syncope should be admitted for continous ECG monitoring, to assess for possible
ICD placement to prevent SCD, as arrhythmia is usually the cause. Also do cardiac
enzymes to rule out CAD, Echo to see left ventricular function.
36.
Young patient with acute MR and flash pul edema, is either due
to IE or trauma or idiopathic rupture of chordate tendinae, the last being the most
common re, esp if he has features of EDS like pes planus, hernias, cigarette paper
scars on the skin due to easy bruisability, and rubber man syndrome with skin and
joint hyperflexibility. Marfan usually causes chronic progressive MR and not acute
one.
37.
Diffuse ST elevation and PR depression are the hallmark of acute
pericarditis postMI. Dressler syndrome is autoimmune pericarditis and pleuritis
after weeks of MI or cardiac surgery. NSAID in former, steroid in latter, tho steroid
has been shown to increase LV aneurysm formation.
38.
CABG TOC for multivessel disease or lt main disease, esp if DM
coz in them the chance of restenosis with PTCA is very high.
39.
Thrombolysis- within 12 hrs of symptoms if ECG shows ST
elevation >1mm in 2 contiguous leads, after nitroglycerine is given to rule out
coronary spasm. Also in pts with new LBBB. No benefit in NSTEMI. C/I with
BP>180, recent surgery or ischemic stroke. ST depression occurs with ischemia,
strain, digitalis, hypokalemia and hypomagnesemia, so is not an indication, unless
it is due to posterior MI.
40.
Poor R wave progression- if the R remains same through V1 to
V4. Seen in COPD, RVH, LVH, ant infarction, blocks and cardiomyopathy.
41.
Prolonged QT means more than half of RR, seen in antiarrythmic

drugs, TCA, hypokalemia, seizure and stroke.

42.
Metformin should be stopped before coronary angio or other dye
related procedures that can harm kidney and cause lactic acidosis. Also in renal or
hepatic failure, CCf, sepsis and alcoholics.
43.
Aspirin should be stopped 7 d before most procedures, but
neednt be stopped for coronary angio or cath.
44.
TCA overdose is treated with sod bicarb. Lidocaine is the DOC
for any vent arythmia that occurs. Procainamide, disopyramide and quinidine are
membrane stabilizer, hence increase TCA toxicity re. Also ppnl is contraindicated,
as it dec conduction and inc arythmogenic potential of TCA re.
45.
Pt can resume sexual activity 6 weeks after uncomplicated MI- ie
if he recovers without any post MI chest pain, CCF or arythmia.
46.
Severe symptomatic AS (area <1cm2) is treated with valve
replacement, as balloon valvulotomy is associated with transient efficacy and high
procedural morbidity.
47.
Radionuclide ventriculography (RVG) or Angiography (RNA) or
MUGA (multigated cardiac blood pool imaging) is done before and after chemo
with anthracycline to detect early cardiotoxicity, before and after cardiac transplant
and in severe CCF. 2D echo in children instead to prevent nuclear exposure, but
less accurate and operator dependent.
48.
CCB have no use, and infact are harmful in patients with acute
MI- only indication is when there is intolerance of b blockers, postMI angina
refractory to b blockers or nitrates.
49.
Torsades: prolonged QT caused by liver, renal failure, dec Mg or
K, sotalol, macrolides, pentamidine, cotrim, antipsychotics, TCA, terfenadine,
astemizole. TOC is asynchronised defib, as the patients are almost always unstable,
then followed by MgSO4 whether or not the Mg level is low. That is because we
cannot measure ionized Mg. Transvenous pacing if refractory to Mg. Lidocaine
and isoproterenol are second line drugs if pacing is unavailable.
50.
Adenosine perfusion imaging with thalium or adenosine Echo or
ECG is always the choice in patients with CAD who cannot exercise.
Dipyridamole can be used. But in patients with COPD or asthma, both cant be
used, so use dobutamine. In unstable angina, however, directly go for coronary
angio.
51.
INR in mechanical aortic and mitral valves should be in 2.5 TO
3.5; If superadded AF more than 3.5, and if embolism occurs even on warfarin,
then add aspirin and increase INR above 3.5.
52.
WPW: PR<0.12; QRS>0.12; Verapamil and b blockers are
contraindicated as they will slow down the AV nodal conduction, thus causing
increased conduction in accessory pathway, which can lead to VT.
53.
Acute arterial embolism suspect- first thing to do is iv heparin.
54.
Cardiac tamponade: Becks triad of hypotension, muffled sounds
and elevated JVP; ECHO shows diastolic collapse of both rt atrium and ventricle,
cardiac catheterization shows equalization of pressure in all chambers, and ECG
shows low voltage with alternating sizes of QRS, aka electrical alterans.
55.
Elderly patient comes with DCM and CCF, first thing to do is

Cardiac stress test to rule out IHD, as it is the most common cause.
56.
ACEI has shown survival benefit when given for several weeks
following MI, usu 6 wks, but not indefinitely.
ENDOCRINE
1. Only symptomatic subclinical hyperthyroidism needs treatment, or those with
AF or low bone densities or MNG who have subclinical hyperthyroidism. Else, an
asymptomatic pt needs only follow up with TFT.
2. Asymptomatic subclinical hypothyroidism on the other hand doesnt require
treatment. Do antibody profile first. Treatment is warranted if antibodies are
present, if lipid profile is abnormal, or if menstrual irregularity or TSH>10.
3. Immobility is a common cause of hypercalcemia, esp in adolescent and those
with pagets disease, who have high bone turnover, due to uncoupling of bone
turnover, ie more resorption and less formation. Subsequent hypercalcemia will
suppress PTH, and low PTH in turn suppresses D3 levels. Biphosphonates can be
used in these patients to prevent this.
4. For every 1 g/dl decrease below 4 of serum albumin, add 0.8 mg to the total
calcium level.
5. Paraproteinemia can increase the bound calcium, hence the total calcium in the
serum.
6. Hypoglycemia with high C peptide can be both due to insulinoma and
sulfonylurea overdose. History and context is imp. To differentiate, measure
serum proinsulin levels. Also checking for sulfonylurea level in urine and plasma
can be helpful.
7. Autoimmune hypoglycemia due to insulin antibodies which bind to insulin
receptors, or release excess insulin into circulation
8. Diabetic for planned CS section- dont stop regular dose of insulin night
before, to prevent ketoacidosis, even if she is npo. Then start insulin infusion
during the surgery, with D5,1/2NS and KCL. Insulin requirement will drop
following delivery of the placenta. Switch to scheduled sc dosage as soon as the
patient starts tolerating food.
9. DKA management- continue NS and insulin till blood glucose is 250, then
change to DNS with KCL, and decrease the insulin infusion dose. Dextrose
infusion is very imp to decrease ketone levels. Start KCL regardless of serum level.
Switch to oral feed and sc insulin only after the anion gap has corrected,
HCO3>10m and precipitating factor like infection is corrected. But always start sc
insulin 1 hr before discontinuing iv insulin, as sc insulin needs time to act, so
otherwise it might precipitate DKA again if we dont overlap the insulin.
10.
Pt with hyperthyroidism with chief complaints of palpitationtreatment is ppnl and not PTU
11.
Preop patient for emergency surgery like CABG for unstable
angina is found to have hypothyroidism- its not a contraindication for surgery, tho
there is higher risk of ileus, hyponatremia and oversedation with narcotic. Only
after the surgery, start with low dose T4 as the patient has CAD.
12.
DM pt on metformin develops anion gap acidosis, and there is no
leukocytosis or hyperamylasemia- implies its probably lactic acidosis and not
DKA- so do ABG and blood lactate level, instead of ketone level and urinalysis, or

instead of starting DKA treatment.

13.
In patients with thyroid cancer in remission, T4 supplementation
should be used to suppress TSH below normal range (ie between 0.1-0.3). If
distant mets, even lower, to undetectable levels, tho that increases the risk of AF
and bone loss. T3 is only used short term and never used for long term
management of hypothyroidism. Hormone supplement should be taken on empty
stomach.
14.
Mental state change in elderly- always do TFT for diagnosing
apathetic hyperthyroidism.
15.
A pt on prednisone for RA develops infection and then
hypotension- acute adrenal insufficiency. Administer fluid and dexamet, as it is
long acting and doesnt interfere with measurement of serum cortisols. Then do
cosyntropin test. Mineralocorticoids arent used, because, one- they are not
deficient, two- they take a longer time then just simply infusing saline.
16.
Amiodarone- monitor patients TFT 6mthly; if it causes
hypothyroid, no need to stop amiodarone. Just give larger dose of T4, as
amiodarone prevents peripheral conversion of T4 into T3. But check TSH first. If
hyperthyroid, it can be either due to induction of Graves disease, which is treated
with PTU or methimazole, or it is due to induction of destructive thryoiditis, in
which case the treatment is steroids.
17.
Female on HRT for hot flashes develops DVT- should stop HRT,
then give warfarin for 3 mo as this DVT has a precipitating cause and is the first
episode. DVT without precipitating cause, or subsequent episode should get
warfarin for 6 months. Increasing anticoagulation for continuing HRT is not
justified, neither does tamoxifen help with postmenopausal symptoms.
18.
Urinary metanephrines and catecholamines are better test then
VMA for pheochromocytoma. Alpha blockade should be started only after the
test, as it can falsely increase the level of the CA. Only after biochemical
confirmation we do CT/MRI to confirm location. Both have equal sensitivity, but
MRI is useful for extraadrenal foci, and also to differentiate benign from malignant
ones. MIBG scan can be used if either of the above three tests are equivocal and
we still suspect pheo, or one test shows pheo but the other doesnt. Treatment is
with alpha blockade, only then start beta blockade. Long acting
phenoxybenzamine is used before surgery, along with liberal salt and fluid intake
to increase the intravascular volume. The common complication after surgery is
hypotension- use normal saline bolus and infusion. Dopamine doesnt help as the
alpha blockade will blunt the response to vasoconstrictors.
19.
Pt with Hashimoto develops rapidly enlarging thyroid and
SVCO- probably thyroid lymphoma. Treatment is RT.
20.
Long acting sulfonylurea induced hypoglycemia- treat with D50
bolus, then D5 infusion is required to prevent rebound hypo due to the D50
induced insulin release. If refractory to this treatment, start octreotide sc.
Somatostatin is iv and is short lived so not used. Giving D10 or D50 infusion for
long time is not recommended as they can cause thrombophlebitis. Glucagon is
also not recommended as it is short acting, plus increases insulin release causing
reboud hypo. Glucagon is hence only used in acute mgmt of hypo with mental

obtundation, and the patient is given readily absorbed carbo after gaining
consciousness.
21.
Pt on amiodarone can have inc T4 and low T3 due to decrease in
conversion from T4 to T3. Ppnl also does that, but not atenolol. Aspirin displaces
T4 from albumin, so dont use it as an antipyretic in the treatment of thryotoxic
storm.
22.
AF due to Grave disease is treated like any other AF- with b
blockers and anticoagulation. So antithyroid drug or RI ablation is not the answer.
23.
Effect of tight glycemic control on microvascular complications
is proved, but not macrovascular. It reduces the incidence of neuropathy, but there
are conflicting evidence for reversing previous neuropathy.
24.
Fahr syndrome: pseudohypoparathyroidism, with Albright
hereditary osteodystrophy (short stature, round facies, short metacarpals and short
neck); they have hypocalcemia with hyperphosphatemia, latter causing basal
ganglia calcification and cataract. Their PTH is also elevated. Patients with
hypopara will have low ca, high phosphorus and also low PTH. Vit D deficiency
causes low ca and phosphorus both, and inc PTH. Acute hyperphosphatemia like
with rhabdomyolysis, seizures, ARF can cause decrease in calcium, but no basal
ganglia calcification and cataract like in chronic hyperphosphatemia.
25.
Hypercalcemia due to sarcoidosis- , due to 1a hydroxylase
enzyme, vit D increases, PTH is suppressed, hence urinary calcium is increased.
Treatment is glucocorticoid and not pamidronate.
26.
Exercise increases non insulin mediated glucose uptake by
muscles, so can cause hypoglycemia in a patient on insulin. Avoid insulin injection
to the exercising limb, and lower the dose of insulin.
27.
Medullary Ca thyroid, post surgery rise in calcitonin level
indicates residual metastatic disease- first step is HRCT of neck and chest with
HRUSG of neck, with surgical resection if possible. If these dont show any lesion,
HRCT abdomen and bone scan, or iodine 111-octreotide scan and PET may be
required. Total body iodine scan is for follicular and not medullary cancer, as the
parafollicular cells dont take iodine. Thallium scintiscan is also nonspecific.
28.
Dont take thyroxin with calcium or iron over the counter
supplements.
29.
Pt with amenorrhea, low FSH and LH with high alpha subunit,
high prolactin and a pituitary mass- probably has gonadotroph adenoma, with lack
of functioning beta subunit. Increase in prolactin is probably due to compression
effect. Treatment is surgery as bromocriptine works only with GH or prolactin
secreting tumor. RT is never the first choice due to delayed risk of hypopituitarism.
Octreotide is also not much effective.
30.
Pituitary incidentaloma with no symptoms shouldnt be treated,
only followed up with regular MRI.
31.
To diagnose spurious hyperthryroidism due to external intake and
to differentiate it from primary thyrotoxicosis, do the thyroglobulin level. It is
decreased in external thyrotoxicosis. RAIU study doesnt help, as the intake is
decreased also in different thyroiditis, iodine or amiodarone induced
thyrotoxicosis.

32.
Subclinical hypothyroidism- treat if TPO AB present, as they
have high rate of conversion to overt hypothyroidism. Also treat if symptomatic
subclinical (ie inc TSH but normal T4).
33.
HTN with hypokalemia- do aldosterone to renin ratio to
differentiate hypo and hyperreninemic hyperaldosteronism. In Conns syndrome,
the ratio is >30, with high aldosterone level also needed for diagnosis, as essential
HTN can also suppress renin. Patients present with polyuria and polydipsia due to
hypokalemia induced DI. If hyperreninemic, then do MR angio of renal arteries,
with fibromuscular dysplasia giving a beaded appearance, and is the most common
cause of RAS in young patients. Suppression of both renin and aldosterone in a pt
with hypokal and HTN is probably due to apparent mineralocorticoid excess
(AME), so obtain a serum cortisol level.
34.
Pt with DM, NASH due to hyperTG, and obesity- TOC is
metformin, as it causes wt loss,, and helpful in hyper TG and NASH. Glitazones
are contraindicated as they cause wt gain, partly due to fluid retention, as well as
they are hepatotoxic.
35.
Subacute thyroiditis- thyrotoxicosis with painful thyroid
enlargement. Tt is NSAID and beta blocker, and steroid rarely if severe. Since
preformed thyroid hormones are the cause of the problem, antithyroid drugs and RI
are not effective. Its not difficult to differentiate from bacterial suppurative
thryoiditis, as in the latter case, people arent usually thyrotoxic as it involves the
center of the gland, as well as USG will show multiple abscesses.
36.
Hyperthyroidism in pregnancy- PTU is the TOC, as methimazole
is teratogenic. If PTU doesnt work, or cause neutropenia, surgery is indicated, else
she can have thyroid storm during the stress of childbirth.
37.
Asymptomatic thyroid nodules: first step is to, do TSH- if
normal, and if <1cm need f/u with yrly USG, >1cm need FNAC. If TSH is
decreased, then RAIU study- if hot nodule, only observation. If symptomatic, then
antithyroid drugs.. RAIU is seldom used in management of thyroid nodule, as
most of cold nodules are benign, though most of malignant nodules are also cold.
Since most of the nodules are benign, all nodules dont need surgery, only FNAC
is enough. Still, if we have done RAIU, then all cold nodules must be biopsied. IF
the nodule is toxic or if there is carcinoma on FNAC, then the patient needs
surgery.
38.
CT of neck is less sensitive than USG for nodular thyroid
diseases.
39.
If pt has papillary cancer on FNAC, then he needs NTT- near
total thyroidectomy, and then RI ablation therapy for residual tissue and mets, then
RAIU study to see for remaining mets, then lifelong Thyroxine to suppress TSH.
Also thyroglobulin can be followed up as a tumor marker. TSH should be
suppressed below the normal range, tho this can risk AF and bone loss. Doing only
subtotal thyroidectomy is ineffective, as it is difficult to ablate the remaining gland
with RI, and we cant also use thyroglobulin as a marker when lot of thyroid tissue
is still left in the body.
40.
If medullary cancer, first test for RET to see for MENII
syndrome, or do urine metanephrine/CA or abdominal CT to diagnose any

concomitant pheochromo. Then start the pt on alpha blockade for a few weeks
before surgery then beta blockade only after alpha blockade (else there will be
vasomotor crisis), then do surgery- total thyroidectomy with central neck
dissection.
41.
DM with autonomic dysfunction, gastroparesis- its difficult to
adjust insulin because due to delayed gastric emptying, pt will be hypoglycemic
just after meal. Plus problems of postprandial bloating and constipation. Treatment
is metoclopramide, or cisapride or erythromycin, and small frequent, low fat
meals. Cisapride is especially shown to be beneficial, tho it is not freely available
due to incidence of QT prolongation and Torsades. Last resort is feeding
jejunostomy. Metoclopramide cant be used for long due to side effects and
tachyphylaxis, so cisapride is the TOC re. High fiber diet will increase the
constipation.
42.
Octreotide can be given in intractable diarrhea in DM
gastroparesis patient.
43.
DM neuropathy- amitryptiline is the DOC, but since most
patients have heart disease also, beware- use gabapentin instead.
44.
Erectile dysfunction with normal morning erection- its
psychological impotence. Erectile dysfunction is never a normal part of aging, so
dont tick that.
45.
Pt of hypoparathyroidism- Tt is high dose of vit D( calciferol)
and calcium; high dose because conversion to calcipotriol is defective. We dont
use calcipotriol as it is expensive. Calcipotriol has a rapid OOA, and can be used in
hypercalcemic crisis, or if pt is refractory to calciferol. Pts thus treated with vit D
and Ca for hypoPTH usually develop high urinary excretion of Ca, due to lack of
PTH, which can lead to nephrocalcinosis. So adding THIAZIDE not only helps
reduce urinary calcium, but also increases the serum calcium effectively.
46.
Hypercalcemia with high PTH- can be either primary hyperPTH,
lithium toxicity or familial hypocalciuric hypocalcemia. If hyperPTH, surgery is
indicated if Bone mineral density is less than 2.5 SD (ie T score below -2.5), overt
bone disease or fracture, kidney stone, reduced creatinine clearance, Ca level more
than normal by 1, urinary calcium >400 mg/d, or if young than 50 years. For eg a
postmenopausal woman with T score of -3 comes with hypercalcemia and high
PTH, then she probably needs surgery. Alendronate is not as effective as surgery in
preserving the BMD.
47.
Those with hyperPTH who dont need surgery are managed with
periodic msmt of ca, Cr, and BMD. Pt can continue their vit D and Ca supplement,
as research hasnt shown any aggravation on calcium level with those.
48.
Acromegaly: COD is cardiac- LV dysfunction, asymmetric septal
hypertrophy, CAD, HTN and myocardial fibrosis; these changes may be reversible
with treatment. Also increased risk of colon cancer.
49.
Offspring of mother with DM I has 3% risk, if father then 6% risk of having

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

Old male comes with hip pain- XR shows thick outer cortex with sclerosis,
and Tm scan shows increased uptake- its Pagets disease. Biphosphonates are
indicated if intolerable pain, involve wt bearing bones, hypercalcemia, or CCF.
Calcitonin and steroids are not useful.
HAEM/ONC
1.
Pt of NHL comes with epidural spinal cord compression( radicular
pain)- give high dose steroid, obtain an MRI to confirm diagnosis, then start
RT. If only back pain due to vertebral mets, only RT. If saddle anesthesia or
bowel bladder involvement, immediate decompressive surgery.
2.
Patient comes with metastatic ER/PR + cancer with occult primary
in breast- no need for multiple core biopsy of breast or RM- only do chemo and
hormonal therapy. Tamoxifen is preferred, with fulvestrant in those not
responding to tamoxifen. Trastuzumab (HERceptin) in Her + ones.
3.
Pt with AML gets multiple platelet transfusion, still the platelet
count doesnt increase- its called platelet refractoriness, due to
alloimmunisation (formation of anti-platelet antibodies). If initial increase in
platelet and then decrease within 24 hrs, think DIC or sepsis or active bleeding
or antiplatelet drugs.
4.
Pt with lung tumor with FEV1 and contribution of each lung giventhe best next thing to do is still to do CT staging. PET/ bone scan can be used
too. CT is best as it gives mediastinal and chest wall invasion, mets to adrenal
and liver, and can also help in CT guided biopsy.
5.
SVCO: dyspnea, persistent cough, hoarseness, dysphagia, syncope,
chest and neck pain, cyanosis, collateral veins in thorax, ocular proptosis,
lingual edema- best thing is CT with contrast. MRI only if dye cant be used.
6.
If imatinib is not in the choices, then BMT is the TOC for CML,
aka HCT( hematopoietic cell transplantation.) IFNa will lead to cytogenetic
and not molecular remission. CPS is used to prepare for BMT to prevent
GVHD.
7.
HIT usually presents as thrombosis- very tricky- type I is less
severe and occurs early, type II more severe and occurs after 4-10 days, due to
heparin-platelet factor 4 complex antibody, decreases platelet upto 30,000, can
lead to limb gangrene, mesenteric ischemia, cerebral sinus thrombosis.
Prevention of HIT is by using LMWH or danaparoid, or using heparin for less
than 5 days; while treatment is using DTI like lepirudin or argatroban. LMWH
are not the treatment of HIT, as they can also rarely cross react with the
antibodies and increase the problem.
8.
Prostate cancer post treatment- f/u with PSA. If rising PSA or if
skeletal complaints, do bone scan.
9.
Pts on tamoxifen should be screened for endometrial hyperplasia
with annual Pap and detailed history. TVS has a lot of false +ve leading to
unnecessary endom biopsy, so not recommended.
10.
Plt transfusion are useless in ITP, as they will also be rapidly
destroyed. Only use in life threatening emergencies as intracerebral and
massive GI hemorrhage. Steroid are the TOC in most cases, with IVIG in

severe cases ( IVIG is not the first answer). Plasmapheresis is for HUS and
TTP.
11.
Alcohol and colon cancer are strongly linked than remote smoking
history, so beware if the pt is smoking currently. NSAID and hormone
replacement are protective. Alcohol probably causes the risk by interfering
with folate absorption.
12.
Among inherited thrombophilia, factor V leiden is the most common,
dont tick antiphospholipid syndrome, that is not inherited. Methyl
tetrahydrofolate reductase gene mutation is related to homocystinemia, and is
another risk factor. Any patient with inherited thrombophilia and spontaneous
thrombosis should be on lifelong warfarin. Also those with life threatening
VTE like massive PE, or unusual site like mesenteric or cerebral venous
thrombosis should also be on lifelong warfarin.
13.
Primary vs secondary polycythemia- WBC and platelet count will
also increase in the former. If secondary cause is suspected, eg in a pt with
COPD, first test is pulse oximetry after minimal exertion, and sleep study to
determine nocturnal desaturation.
14.
Pt with RA has pneumonia and found to have anemia- ferritin is high
( can be due to both infection or due to ACD), transferring and TIBC are low
(can be due to both IDA and ACD). In these patients, do BM biopsy to
differentiate ACD and IDA.
15.
Pts requiring frequent transfusion might develop antibodies to RH,
Kelly and other antigens, causing acute transfusion reaction. Rx is hydration,
stopping transfusion. Dopamine and osmotic diuresis can be used.
16.
Of all the features of Pancoast syndrome, chest movement
asymmetry with asymmetric lower leg DTR is the most dangerous, as it
signifies phrenic nv involvement with possible iv foramina invasion and
imminent cord compression.
17.
Pt of CRF comes with esophagitis and massive bleedingDesmopressin is the TOC as it releases VIII/VWF from the endothelium, after
that dialysis. Cryoppt can be used but associated with infections. Estrogen can
be used too.
18.
Pt with prostate cancer comes with back pain due to mets- TOC is
hormonal therapy- LHRH analogue with flutamide to counter the initial flare,
if back pain is unresponsive to this, then EBRT followed by chemotherapy.
Radionuclide bone scan is the most effective diagnostic modality. DES reduces
LHRH release from the hypothalamus too, but increases MI, PE and stroke.
19.
SCC skin- surgery first line, RT if pt refuses surgery, and 5FU is the
third line treatment.
20.
Pancoast: RT with surgical resection is the TOC, but if there is
evidence of distant mets, or brachial plexus involvement, or positive bone scan,
then RT alone.
21.
AIDS with PCNSL- best therapy is HAART itself, tho RT and
corticosteroid help, they dont increase life expectancy. The most important
prognostic factor is the increase in CD4 count.
22.
CholangioCa, even if Klatskin- if with mets, is inoperable, so the

treatment is ERCP and stenting for the pruritus and jaundice. PTC only if
ERCP fails. Ursodeoxycholic acid doesnt help as it doesnt relieve the
obstruction.
23.
Pt comes with diarrhea, sclerotic bone lesions, eosinophilia and
peptic ulcer- Systemic mastocytosis.
24.
Lobular CIS of breast- it is multicentric and bilateral, so the best
treatment is close observation, annual mammogram and tamoxifen which has
shown dec risk of progression to overt carcinoma. Surgery, If at all, has to be
bilateral prophylactic mastectomy. Local excision is useless.
25.
Pt with ACD- low iron, high ferritin, normal or low transferring and
transferrin saturation. BM is diagnostic, and shows normal or increased iron in
macrophages, and decreased no of sideroblasts. Do EPO level, if it is low, EPO
is the treatment. If EPO is already high, then periodic blood transfusion is the
treatment. Plus treatment of the underlying disease with close f/u might be the
right answer.
26.
Pt with ESRD and ACD, doesnt respond to EPO- first thing is to do
iron study to rule out iron deficiency. Then see for folate deficiency, systemic
inflammation and Al toxicity. Avoid BT in them, as that can risk causing
allogenic graft rejection after kidney transplant.
27.
Advanced gallbladder Ca with neuropathic pain in right thigh- for
sharp pain, DOC is carbamazepine, second line being valproate or gabapentin.
For dull pain, desipramine is the DOC. Not narcotics.
28.
Pt treated for SCLC comes with features of acoustic neuroma, its
probably not neuroma but mets. Contrast MRI showing the multiple well
circumscribed mass with local edema is the investigation of choice.
29.
A pt with normocytic anemia- first thing to do is retic count- if high,
its hemolysis, if low its hypoproliferative Electrophoresis and Coombs for
earlier, BM for the latter.
30.
Myaesthenic syndrome means Lambert Eaton- treatment is
plasmapheresis and immunosuppressive therapy. Electrophysiological studies
confirm incremental response with repetitive stimulation. DTR are lost unlike
in myasthenia gravis or polymyositis re.
31.
Breast cancer metastasis to brain- stereotactic surgery if single,
EBRT if multiple. Chemo dont penetrate, steroid help, and prophylactic
anticonvulsant are not indicated.
32.
Sickling crisis- during mens, alcohol, nocturnal hypoxemia- mainstay
of treatment is hydration. Morphine or iv ketorolac for pain.
33.
Sickling crisis with splenomegaly- beware of splenic sequestrationdramatic fall in hemoglobin causing hypovolemic shock. So CBC should be
monitored in these pts. CXR, blood and urine culture are followed by iv
antibiotics esp if the pt wasnt on prophylactic penicillin. Avoid contact sports.
GASTRO
1. If polyps are found in sigmoidoscopy, next thing to do is colonoscopy
to see for synchronous lesions and remove them. Double contrast enema is
inferior, plus doesnt allow intervention also.

2. TPN: average need is 30Kcal/d and protein 1g.kg.d, but in

malnourished or critically ill patients, its 35-40 and 1.5 respectively.
Overfeeding leads to hyperglycemia, hyperinsulinemia, inc TNF. PEG
(percut gastrostomy) should be considered if pts need TPN for a long time.
3. LGIB: urgent colonoscopy is the procedure of choice due to diagnostic
and therapeutic advantage. IF there is poor visualization due to bleeding,
then do Tm tagged RBC scan, which is better than angio to localize the
site. Vasopressin is inferior as bleeding recurs after stopping, and it can
cause ischemic damage to organs and arythmia. Octreotide works only in
variceal bleeding. Urgent colectomy might be needed, but only after
localization of the site of bleeding.
4. Chronic pancreatitis: low fat diet is the most effective method to stop
steatorrhea, while enzyme supplement is inferior.
5. Mallory Weiss tear that has stopped bleeding needs no intervention.
Hiatal hernia is a very frequent predisposing factor for the tear, and can
occur during blunt abd trauma, CPR and endoscopy too.
6. Mesentric angina- duplex USG is the screening test done first, as it has
a high negative predictive value. Angiography is the gold standard, but is
done only after duplex.
7. Mild pancreatitis- manage with pain control and iv fluid, npo, ng
aspiration to prevent further pancreatic stimulation. Hypoechoic mass in
pancreas doesnt mean abscess unless there are systemic signs. Antibiotics
have been shown to be useful prophylactically only in severe pancreatitis
(Ranson criteria), or necrotizing pancreatitis or large peripancreatic fluid
collection. Imipenem or cefuroxime penetrate pancreas well. No indication
of daily CT scan or CT aspiration unless features suggestive of infected
necrosis. Surgical debridement if severe necrosis, biliary pancreatitis, lack
of response to therapy or complications. ERCP if concurrent dilatation of
biliary system or elevated LFT.
8. If the patient with pancreatitis develops fever, then take blood culture
and start imipenem, piperacillin, quinolones. IF pt fails to improve after 1
week of antibiotic therapy, a CT guided aspiration of the tissue for C/s is
done.
9. Acute HepB needs only supportive treatment, as most resolve on their
own. Only chronic active hepatitis needs lamivudine and adefovir.
Conversion to chronic stage depends on age- 90% if perinatal, 20-50% if
below 5 and <5% if adult. Interestingly, if PT remains normal during the
acute infection, then the infection will likely resolve with no sequelae.
10.
Isolated gastric varices without esophageal varices in a pt
with chronic pancreatitis is due to splenic venous thrombosis. It may also
present with noncirrhotic portal HTN, ascites, massive splenomegaly and
hypersplenism. Portal vein thrombosis is similar, but will have esophageal
varices also.
11.
Hepatic venocclusive disease is due to occlusion of
terminal hepatic venules and causes postsinusoidal portal HTN, with
hypatomegaly, jaundice and ascites. This is similar to Budd Chiari, but in

the latter there is thrombosis of major hepatic veins.

12.
Pseudomembranous enterocolitis suspect: rapid
immunoassay for C difficile toxin is very popular, but its sensitivity is low,
so that if one is negative, repeat it if the pretest probability of infection is
high. Stool cytotoxin test and stool culture are outdated. Culture is useless
also because many nontoxigenic strains of C Difficile exist. Tt is metro. IF
relapse, again metro, coz relapse is due to inadequate treatment more than
resistance. Vanco if more than one relapse.
13.
Febrile transfusion reaction can be prevented by washing
the cells, using leukocyte depletion filter, and preferring packed RBC to
whole blood.
14.
First test in chronic diarrhea is stool examination for
leucocytes, parasites, blood, fat, ph, osmotic gap.
15.
Duodenal endoscopic biopsy is needed for diagnosing
celiac disease, showing villus blunting and increased lymphocytic infiltrate
in the mucosa. Avoid wheat, rye and barley. Can take soyabean, rice and
corn and potatoes. Plus might need to supplement iron, folate and calcium.
16.
Chronic constipation- bulk laxative like psyllium,
methylcellulose and dietary fiber is the mainstay of treatment. Magnesia is
c/I in CRF, castor oil and bisacodyl are laxatives and cause electrolyte
imbalance. Docusate is a softner but not used long term.
17.
Triple therapy for H pylori failed- give quadruple therapy.
Best way to see eradication is urea breath test or fecal antigen test 4-6 wks
after therapy. Fecal antigen test is best. Early testing might produce false
negative, as Helicobacter can transform into urease negative coccoid form.
Serology is uselss coz it doesnt differentiate past and present infection.
Endoscopic biopsy is not warranted to document care.
18.
Complete resection of a <2cm polyp which proved to be
dysplastic, but with cellfree margins, no vascular or lymphatic
involvement- we dont have to do anything. Screening colonoscopy every
three years is safe in those with previous polyp. IF >2cm sessile, or if
poorly differentiated, f/u colonoscopy in 4-6 mon.
19.
Scleroderma- atrophy of muscle layer with fibrosis on
HPE, dec peristalsis wave and dec LES tone. Achalasia: dec peristalsis but
inc tone, and hypertrophied muscle in HPE. Diffuse spasm: inc peristalsis
and inc tone.
20.
Kava can cause hepatitis and cirrhosis. Gingko can cause
platelet dysfunction. Ginseng can cause SJ syndrome and psychosis.
21.
Pt of celiac disease not improving with gluten free diet
must be suspected to have intestinal T cell lymphoma. It can be nodular or
ulcerative, leading to perforation peritonitis. Pain, wt loss, diarrhea are
typical, with malabsorption and anemia. Tt is surgery and chemo, but
prognosis is poor.
22.
Post chole: no change in diet is needed, not even low fat
diet. Giving CCK is useless, as it is already produced by duodenal mucosa.
23.
ALS pts need PEG gastrostomy, and not TPN, as it is

i.

irreversible. It is better than NGT as it doesnt interfere with breathing and

speech, and it doesnt cause sinusitis; tho risk of aspiration is the same with
both.
24.
Protease inhibitors can be used to prevent ERCP induced
pancreatitis.
25.
Child Pugh criteria:
i. Albumin- <2.5, 2.5-3.5 and >3.5- score 1, 2 or 3 accordingly
ii. Bilirubin- <2, 2-3 and >3
iii. Ascites- None mild and moderate
iv. Delayed PT- <15 sec, 15-17 and >17 sec
v. Encephalopathy, none, stage 1-2, or stage 3-4
Liver transplant if score is >7, ie class B or C in child pugh classification. Class A is
<7

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

8.
Warfarin is given for 3-6 mo for PE that occurred in the setting of
reversible risk factors, like OCP or immobilization; 6 mo atleast if idiopathic,
atleast 12 mo ifmalignancy or anticardiolipin syndrome; indefinitely if
recurrent or continuing risk factor like antithrombin deficiency.
9.
VQ is the first investigation in suspected PE; esp if pretest
probability is high like in immobilized, cancer patients, OCP, etc; if it is
negative and suspicion is high, then do lower limb Duplex to calculate the
pretest probability of PE before jumping to CT angiogram. Pul angiogram is
the gold standard, but not done usually. D dimer has high negative predictive
value, so some say it should be done first of all.
10.
OSAS: first rule out hypothyroidism, esp if there are suggestive
symptoms in a patient, then refer for sleep study (polysomnography). MRI and
nasopharyngoscopy before uvulopalatoplasty.
11.
Sarcoidosis- hypergammaglobulinemia, depressed CD4: CD8 ratio ie
depressed cell mediated immunity and activated humoral immunity, and
cutaneous anergy is common. BAL however shows high CD4. Hypercalciuria
is much more frequent sign then hypercalcemia, and can cause
nephrocalcinosis and CRF
12.
Wedge shaped infarcts seen in subsegmental PE are seen as
Hamptons hump in XR.
13.
Peripheral lung nodule- risk of malignancy is high if >3 cm, irregular
or speculated border, reticulate, punctate or eccentric calcification (vs regular,
concentric, laminated, central, diffuse homogenous or popcorn calcification of
pul hamartoma). Doubling time of benign lesion is either less than 20 days in
acute conditions, or more than 450 days, anything in between is malignancy, so
checking for previous XR is always the first step. If no earlier XR available,
and current XR is inconclusive, HRCT has to be done, which can show the
morphology and the mediastinal node involvement. If high suspicion for
malignancy after this, then VATS and excisional biopsy is the TOC for
peripheral nodule. FNAC is less sensitive, while PET scan has high sensitivity
but low specificity.
14.
Think carcinoid if nonsmoking patient comes with recurrent
postobstructive pneumonia. Fiberoptic endoscopy with lavage and /or biopsy is
the next best step. Sputum cytology is very insensitive. Other causes of
nonresolving pneumonia are CEP( chronic eosinophilic pneumonia), alveolar
proteinosis, bronchiolitis obliterans organizing pneumonia (BOOP).
15.
Magsol is no more recommended for asthma.
16.
Asthma patient develops fatigue, diaphoresis, confusion, use of
accessory muscles with sterna retractions, marked tachy, pulsus paradoxus,
PaCO2>40, PEFR <25% of personal best: indications for intubation and
ventilation.
17.
Pts with PE can have fever and neednt be treated, unless very toxic,
or with inc WBC with bandemia.
18.
ABPA criteria: underlying asthma, skin test reactivity, serum
antibodies to Aspergillus,, inc IgE and eosinophil in blood, lung infiltrate and
central bronchiectasis. Cough, fever, sputum, wheezing are typical symptoms.

First thinkg to do is skin prick test as it has high NPV. If it is positive, measure
total IgE and antibodies to Aspergillus. HRCT is last to detect bronchiectasis.
Steroid is the TOC to prevent bronchiectasis and lung fibrosis.
19.
LTOT: PaO2<55 on room air, or SaO2<88. Or if PaO2<60 but with
cor pulmonale, RHF or HCT>55. So before deciding for LTOT, ABG should be
done, as PaCo2 has prognostic value also.
20.
Primary PHTN; all pts need anticoagulation because of increased risk
of pul thromboembolism, due to slow pul blood flow and dilated rt heart. Also
vasodilators like CCB are used, but before that should do vasoreactivity test,
because using dilators who are not reactive to NO or CCB show acute
cardiopulmonary decompensation if oral vasodilators are used. The commonest
complication of PPHTN is cor pulmonale.
21.
Stable COPD need only hx and ex preoperatively, and dont need
PFT, ABG or spirometry. These are needed if lung resection is planned, or if
c/e shows airflow limitation or suggests that the patients are not at their
baseline lung functions.
22.
CEP (Chronic Eosinophilic Pneumonia)- Xr shows peripheral
infiltrate that are the photographic negative of pulmonary edema is very
characterstic. Pt comes with symptoms of asthma, and can have allergic
rhinitis. BAL shows eosinophils. ANCA is negative, but antibodies to
aspergillus may be positive (doesnt mean its ABPA). Churg Strauss syndrome
is similar, with asthma and rhinitis, plus peripheral neuropathy in most of the
patients, and involvement of other organs like kidney. Glucocorticoids are the
treatment in all three conditions, ie CEP, ABPA and Churg strauss. Loeffler
syndrome presents with migrating pulmonary infiltrates.
23.
Lymphangioleiomyomatosis is a rare condition in women, presenting
with dyspnea, chest pain and reticulonodular infiltrates on XR, plus effusion
and pneumothorax might be there.
24.
LT antagonist like zafirlukast are associated with Churg Strauss.
They also cause BM suppression and idiosyncratic hepatitis, so monitor LFT.
25.
Silicosis- glasswares or pottery, small nodules in upper lung, with
eggshell calcification in hilar LN. Annual PPD testing and INH prophylaxis in
the condition of seroconversion is important, as silicosis is highly associated
with TB.
26.
Diagnosis of sarcoidosis- biopsy of parotid or superficial LN should
be preferred to hilar LN biopsy.
27.
Asthma with PEFR 25% lower than the patients baseline: after beta
inhaler, oral steroids are the next step. Admit if PEFR is 40-50% lower.
Intubate if danger signs or PEFR <25% of normal.
28.
Cough induced by forced expiration is very suggestive of asthma, ie
bronchial hyperreactivity.
29.
Recurrent pneumonia- first do CXR to rule out a mass, if
inconclusive, then do HRCT, then only bronchoscopy, as it is an invasive
procedure.
INFECTIOUS DISEASES

1. Rabies can be transmitted by aerosols from bats in caves. It is

universally fatal once patients are symptomatic.
2. HIV prophylaxis indicated for exposure to genital fluids and blood, but
not urine, sweat, sputum, tears or saliva.
3. TSS- treatment is heavy fluid loading, with clindamycin with or
without nafcillin to prevent recurrence of TSS
4. Human bite- Strep, Staph, Eikenella corrodens( main one, GNB),
hemophilus, bacteroides, peptostreptococcus, actinomyces and
fusobacterium. Treatment is ampicillin-sulbactam after cleaning
thoroughly. Pasteurella multocida in cats and dogs bites.
5. Elderly in nursing home presents with pneumonia, and XR shows right
lower lobe fluffy infiltrate, its probably aspiration pneumonia.
6. Erysipelas as a consequence of sinusitis- beta hemo strep, but these
days penicillin resistant strep and staph are increasing, so the TOC is
shifting from iv penicillin to anti-staph penicillin.
7. HRCT and DLCO measurement are highly useful for pneumocystis,
but still bronchoscopy and BAL is the diagnosis of choice, with or without
transbronchial biopsy to increase the yield. Treatment is oral cotrim if mild,
and iv cotrim if moderate to severe, with steroids, to prevent hypoxic resp
failure. Giving only antiretroviral can worsen the resp failure due to
immune reconstitution phenomenon. Steroids indicated if A-a gradient>35
or if PaO2<70.
8. Type I necrotizing fasciitis is polymicrobial, seen in DM and PVD
patients, and microbes include Staph, Bacteroides, E coli, GAS, Prevotella.
Type II is associated with laceration, IVDU, blunt trauma or surgery, and
typically caused by GAS (pyogenes). Severe pain in the absence of
significant skin change is the initial presentation, with later bulla formation
and systemic toxicity. Staph alone is not associated with NF.
9. Treatment for type II NF is iv clindamycin, with surgical debridement.
10.
Meningoencephalitis, splenomegaly, pneumonia triad in
immunocompetent host is Chlamydia psittaci UPO, esp if vet, poultry or
bird breeders. Presents like culture negative endocarditis, confirmed by
serology. Treatment with doxycycline. Admit if danger signs, hypoxia, old
aged or immunocompromised.
11.
Pt on antiepileptic- avoid imipenem, monobactam,
penicillin, cephalo and quinolones as they can cause seizures. Esp if pt has
old age, renal insufficiency, preexisting CNS disease.
12.
Gingko biloba- used in intermittent claudication, ARMD
and Alzheimers; can cause diarrhea, seizures, irritability but more
importantly bleeding, esp if pt is on anticoagulant. Its bcoz it inhibits PAF.
13.
Saw palmetto acts like finasteride in BPH. Kava is used
for anxiety and insomnia, and is sedative and hepatotoxic. St Johns wort
for depression, and each has been proved to be effective than placebo.
Garlic for lipid disorder- and can cause platelet dysfunction like Gingko.
ST John wort can cause GI distress, dry mouth, anorgasmia, etc. Chinese
wt loss herbals have artistolochic acid which is nephrotoxic.

14.
Glucosamine used for OA can cause problem with
glucose control in diabetics.
PREVENTIVE MEDICINE
1.
Person exposed to active TB should immediately get baseline PPD,
then repeat PPD at 3 wk- 3 mo to see conversion. If conversion occurs, then
CXR- if CXR negative, monotherapy with INH prophylaxis, and if CXR is
positive, then DOTS.
2.
Close contact of meningococcal patients should receive rifampin to
eradicate pharyngeal carriage, for eg woman working in a nursery. But if she
can take rifampin coz she is on OCP, then a single dose of cipro is sufficient.
Health care worker exposed to such cases, however, dont need it.
3.
Fasting glucose to screen for DM is advised in everyone after 45
yrs, 3 yrly, or yrly if risk factors like f/h, metabolic syndrome, African or
Hispanic or PCOD is present, or if h/o IGTT or gestational DM.
4.
Total cholesterol >200, first step is to order a complete lipid profile,
which will give HDL and TG. Calculate LDL by TC-(HDL+TG/5). Primary
goal is always treating LDL, so use ator even if TG is much higher than LDL.
Only if the statin cant control TG with LDL, then add fibrates. In a pt on HRT
and high TG, however, the first step is stopping the HRT.
5.
Influenza vaccine- above 50 yrs (65 since 2005 due to low budget),
chronic diseases like COPD, asthma, CRF, DM, HIV, malignancy; nursing
home residents, 2-3 trimester, healthcare worker, household member of person
at high risk of developing complicated influenza, like if children have CF, 6-23
mo child, or older if on long term aspirin treatment, household contacts of
<6mo child. Young normal individuals dont need vaccine, as even if they
contract influenza, it is not going to be complicated. C/I if egg allergy.
6.
Abrupt cessation is preferred to gradual decrease in smoking (cold
turkey), with nicotine patch as the first choice, and then bupropion if needed.
7.
Children who have high lipid( TC>240) or CAD in family should
have TC screening at 2 yrs of age, then fasting lipid profile if TC is high, or
directly fasting profile if there is h/o CAD in family. Repeat 5 yrly. Below 2, no
use of screening as the diet is rich in fat at that time.
8.
A decrease of BP by 5 mm decreases the risk of stoke by 40%.
Neither aspirin or statins or diabetes control or smoking cessation are as
effective as control of BP.
9.
Screening for prostate cancer with DRE and PSA should be done in
males 50-70 yrs of age. Begin at 45 if high risk, ie African or with f/h of 2 or
more first degree relatives). Repeat annually.
10.
FAP: ideal is total colectomy before the age of 20 yrs.
11.
Smoking cessation has far better effect on preventing osteoporosis
than exercise or dec alcohol. HRT is not preferred these days due to risk of
breast and endo cancer and cardiovascular diseases.
12.
Wellness examinations- should counsel about safe sex, vaccines,
importance of screening, seatbelt, exercise, wt loss, alcohol, smoking and
drugs. Chlamydia screening in all women below 25 who are sexually active, or
above 25 with multiple or new sexual partner, or pregnant below 25 yrs.

Gonorea is very uncommon these days, so no need of screening.

13.
Colonoscopy is preferred to FOBT, and should be started at age 50,
40 if f/h of colon cancer, 25 if lynch syndrome and 15 if FAP. (not sure.) repeat
10 yrly, or 5 yrly if sigmoidoscopy.
14.
Self breast exam has no benefit, clinical breast exam alone also has
no benefit, but should be combined with mammogram, after 40 yrs of age, till
70 yrs. After that the probability of dying from other causes is higher. Repeat
1-2 yrly. Breast lump after the age of 35 should be evaluated with
mammography.
15.
Pts with antitrypsin deficiency should be f/u 3 monthly with
spirometry. Enzyme replacement therapy only if radiological evidence of
panacinar emphysema or if the patient is symptomatic.
16.
Baby born to HBV positive mother- HBIG and vaccine at 12 hrs,
then at 2mo, then 6 mo, then test for antigen and antibody at 9 mo to see if he
has gone into chronic hepatitis, or if the vaccination has to be repeated again.
17.
ETHICS
1.
Truck driver with DM on metformin drinks alcohol- what will you
say? Dont drink alcohol is paternalistic, and total abstinence is not required
either with DM or in patients on metformin; Total abstinence is preferable only
if f/h of alcoholism, pancreatic or liver or heart disease or hyperTG or previous
alcohol related problem. You can drink, but in a moderate manner is wrong as
this justifies drinking which can cause many complications. Best response is
we must talk about your drinking and how it affects your driving. He must be
screened for alcoholism, as it predisposes to hypoglycemia, which is specially
dangerous in his profession. Those on metformin and with liver, renal or
cardiac compromise, or old than 65 yrs should avoid alcohol to decrease the
risk of lactic acidosis.
2.
Medical care for braindead patients is important till he is
transported to transplant center to keep the organs viable- so pt should be kept
euvolemic, normotensive, normothermic (not hypothermic), and shouldnt be
hypoxic or hypercapnic. Pt should be kept in ICU. Hypotension is common due
to loss of sympathetic tone, fluid loss and DI, so fluid replacement, and if
necessary pressors and inotropes are needed.
3.
Send to hospice if life expectancy is six months or less, also in
patients with end stage COPD, pul fibrosis and cardiomyopathy.
4.
Patient is taking unknown herbal medication on which no adequate
research has been done- say dont take the medicine, as its benefit has not
been proved, and it might cause harm as a physician duty is to protect from
harm. If known herbs like ginseng, which has adr, obtain a written agreement
which releases the physician from any liability, but continue to follow the
patient up to identify and treat any complication.
5.
Eg, ma huang is the Chinese name for ephedra used for wt loss.
6.
Be the patients advocate- an old woman unable to care for herself,
has serious illness- advise her against living alone. If no relatives where she
can live with, send her to nursing home. Even if she refuses, adult protective

services can prohibit her from returning home alone.

7.
If a cometent adult woman says that her husband will sign the
consent to any surgery for example, let it be- she has a right to choose her
surrogate. Means surrogate are not only for end of life decisions.
8.
PT who is diagnosed with life threatening diseases like Huntington
and Tay Sachs refuses to tell his family, putting other family members and
siblings at jeopardy- you neednt inform the family, but make the patient sign
the refusal document.
9.
If multiple first degree relatives disagree on the treatment of an
unconscious patient, go to hospital ethics board, and then if necessary to court.
10.
A specialist is fed up with the drug seeking patient who slaps nurses
and wants to leave him- he cant do that without prior notice and arrangement to
transfer him to another specialist. Nobody can leave a patient, however
difficult, in the middle of a treatment.
11.
A dehydrated depressed elderly is probably abused- first thing to do
is admit to distance from the abuser and to rehydrate, then inform the adult
protection services.
12.
Braindeath- absence of respiratory drive off ventilator for a duration
that is sufficient to produce hypercarbic drive (PCO2 of 50-60). Body temp
above 94, EEG isolectric for half hour, no cerebral circulation on Doppler, and
24 hrs in observation with anoxic or ischemic brain damage with negative drug
screen. Braindead patients can still have leg or arm movements due to spinal
reflex, and this should be explained to the family.
13.
Health care proxy or surrogate have the right to know all information
of the patient, but if they call, talk only briefly and ask her to come in for
personal visit.
14.
Tell the truth not only to the patient, but also to the insurance
company- else it will be insurance fraud.
15.
Jehovas witness is refusing exchange transfusion to a diseased
neonate which might develop kernicterus- since it is not emergency but is
urgent, consult the hospitals ethics committee about seeking court injunction
to mandate exchange transfusion.
16.
A patient refuses basic life support and cardioversion in case he goes
into arrhythmia during surgery, and signs the advance directive- its ok to
transfer the patient to another specialist, due to nonreconciliable difference
between the physician and the advance directive- it is incorrect to proceed with
the surgery, as it has the possibility to harm due to patients refusal of basic life
support. THIS IS NOT THE SAME AS END OF LIFE SUPPORT.
SURGERY
1. A pt involved in MVA couldnt be extricated from the car, is unconscious and
he started coughing up blood- first thing to do is secure the airway without spinal
manipulation by jaw lift manuver. Only then suction and stabilisation of neck.
Intubation is not needed as the patient has spontaneous respiration.
2. Thompson test in Achilees tendon rupture: no foot plantarflexion on calf
muscle compression.
3. Cholangitis: ampigenta or monotherapy with imipenem or levofloxacin. If not

responsive, do decompression with ERCP.

4. MVA pt after intubation doesnt have satisfactory oxygen saturation, and on
examination has hypoventilation on one side of the chest. The first diagnosis
should be bronchus intubation. So try to check the ETT placement, and withdraw it
a few cm. If that doesnt help the oxygen saturation, then think about
pneumothorax, and do a needle decompression.
5. Pt with acute colonic ischemia are not due to embolism like mesentric
ischemia, but due to hypotensive state. IT presents with lateralised abdominal pain
(periumbilical pain in mesentric ischemia), and with hematochezia.
6. Pt who die due to lightning strike usually have asystole, so if they dont
respond to CPR, then epinephrine should be tried, atropine comes next.
Defibrillation will not help in asystole patients.
7. All animal bites should be thoroughly cleaned with NS, debrided, Xred to see
the presence of foreign body or bone involvement, and shouldnt be primarily
closed (except if dog bite on face, due to its vascularity infection and nonhealing is
not common in the face). Also puncture wound, cat and human bites shouldnt be
closed primarily.
8. Only TT if contaminated would and <5 yrs since vaccination, or clean wound
and >10 yrs since vaccination, no TT if clean wound and <5yrs since last dose, TT
and ATS if contaminated and >10yrs since last dose, or if vaccination history is not
known.
9. Scrotal trauma with hematoma formation on examination, surgical exploration
should be done immediately, and not USG as USG has not been shown to be
reliable.
10.
Inhalation injury without any surface burn- the most dangerous
complication is supraglottic edema. Fibreoptic laryngoscopy should be done, and
intubation if necessary.
11.
Laparoscopy can be used to evaluate tangential gunshot wound,
but perforating GSW needs laparotomy. Exploration under local anaesthesia for
stab wound.
12.
Compound clavicle fracture should be repaired by ORIF
13.
MVA patient with bradycardia, bradypnea and HTN has cushing
reflex- and the first thing to do is secure an airway with ETT to prevent respiratory
arrest. Hyperventilation to reduce ICP is contraindicated in those with head injury
and ischemic stroke, as it can worsen the neurological injury due to
vasoconstriction.
14.
Polytrauma patient with shallow breathing, tachycardia, chest
bruises, cyanosis with intact Breath sound probably has flail chest- hypoxia is
caused due to associated pul contusion and inc work of breathing due to muscle
spasm.
15.
Pt comes with knife sticking in his head- first thing to do is not
CT but coagulation profile and blood match and cross match.
16.
Aortic injury is the most common cause of sudden death in
steering wheels injury, and occurs in the area of lig arteriosum, aortic root and
diaphragmatic hiatus.
17.
Pt who underwent lidocaine injection for PIVD came with fever,

and leg paralysis and anesthesia- he has epidural abscess. First step is MRI with
gadolinium contrast. CT myelography is an alternative. Antibiotic should be
started, guided by CT aspiration or biopsy culture. Immediate surgical exploration
is needed.
18.
Pneumatic compression alone is not sufficient in high risk
patients to decrease risk of DVT, because they can still have pelvic vein DVT.
19.
<5mm renal stones pass spontaneously. Removal is mandated if
small but causing persistent pain even after analgesics, or if urosepsis or renal
failure. ESWL is preferred for small proximal ureteric calculi, while ureteroscopy
with laser lithotripsy for large >1cm proximal stones.
20.
Post communicating artery aneurysm- diplopia, ptosis and
anisocoria. PICA aneurysm- ataxia and bulbar dysfunction.
21.
Scaphoid fracture on presentation- first thing to do is not casting,
but CT or bone scan to rule out fracture. If fracture is really present, then thumb
spica cast with wrist in slight radial deviation and neutral flexion. Most common
complication is nonunion and not AVN.
22.
Sister cannot be considered legal guardian of a child- so in
emergency if parents are not around, we should treat the child anyway, and we
dont take the sisters consent.
23.
Elderly with BPH comes with protruding rectal mucosa with
bluish discoloration and fraibility- its rectal prolabpse with strangulation and
gangrene- immediate surgery (rectosigmoidectomy) is needed. If not strangulated,
can try digital reposition under sedation, or application of granulated sucrose to
decrease the edema.
24.
Reflex sympathetic Dystrophy, aka Complex Regional pain
syndrome (CRPS)- immobilisation after sprain or fracture, causing allodynia,
hyperalgesia, some edema, changes in skin blood flow and sudomotor activity
(sweatin), later leading to atrophyof tissues. This is due to SMP (sympathetically
mediated pain), causing vasoconstriction and ischemia. Early treatement with a
blockers like phenoxybenzamine, chemical or surgical sympathectomy within 3
months and early physiotherapy helps to reduce its incidence.
25.
Plica syndrome- crepitus, snapping and effusion related to
prominent medial plica of synovium which gets trapped in the knee joint,
presenting like torn medial meniscus or maltracking patella.
26.
PSA over 4 needs urology referral for biopsy.
27.
Proximal nonmetastatic rectal cancer can be treated with
sphincter sparing surgery, while distal can be locally resected only if mobile, small
and nonulcerated. Big tumors can be given neoadjuvant chemoradio to make them
resectable.
28.
Smooth, round, soft, mobile, mildly tender breast mass implies
cyst and not fibroadenoma- so the best step is FNAC, if pt refuses it, then mammo
if over 35 yrs of age, or USG if under 35.
29.
Silicone breast implant havent been associated with any
connective tissue disease, any problem in fetus or in breastfeeding. Only problem
is contracture of the capsule, pain and sometimes rupture needing extraction. It
also doesnt affect the mammogram criteria, though the calcifications along its

capsule can rarely lead to a false positive result. It doesnt obscure mammogram or
decrease its sensitivity.
30.
Multinodular thyroid in a patient with short neck can be
retrosternal and cause symptoms of dysphagia- treatement is surgery. Iodine or
thyroxine dont help, as there is already considerable fibrosis in the gland. RAIU
and Antithyroid drugs can infact cause initial enlargement of the gland, so are
contraindicated.
31.
Undescended testis, or varicocele can cause infertility due to the
effect of temperature on the spermatozoa, but not hypogonadism as the Leydig
cells are not affected.
32.
Pt with bilateral or right sided varicocele, or varicocele that
doesnt disappear in the supine position, should be investigated for clot or tumor
obstructing the inferior venacava. Varicoceles are common in the left side due to
the drainage of veins.
33.
March fracture: XR can be unremarkable for 2-4 wks, so do bone
scan or MRI
34.
Pt showing multiloculated cyst in pancreas on Ct- no need to do
CEA and CA 19-9, as they are very nonspecific. Directly send the patient to
surgery.
35.
Barometric surgery- if BMI >40, if decreased quality of life, eg
OA and sexual dysfunction, OSAS, movement limitation or brittle diabetes.
Benefits of gastric bypass or gastric banding include better DM control, better lipid
levels, sleep improvement, depression decline, etc.
36.
Pt with hard nontended scrotal mask suspected to be tumorFNAC or biopsy are contraindicated. Referral to urology for radical inguinal
orchiectomy is the TOC. Before that, CT of abd and pelvis to detect LN metastasis,
and tumor markers can be done.
37.
Testis usually descends spontaneously within 6 mths, else surgery
is indicated, at most before 2 yrs. Even after surgery, the risk of malignancy is still
high, but it makes it easier to examine the testis. Orchiopexy does decrease the risk
of infertility.
38.
Breast lumps can be examined 4-10 days after menstruation for
regression in size, which implies fibrocystic disease. If palpable and patient is
anxious, FNAC should be done, and fluid sent for HPE if bloody. Reexamine in 46 wks for any regression or recurrence.
39.
Congenital hernia due to persistent processus vaginalsis should
be repaired as early as possible to decrease the risk of incarceration.
40.
CT or nuclear scan to see for remnant thyroid tissue is needed
before Sistrunk operation for thyroglossal cyst, else we might remove the only
functioning thyroid tissue inside the cyst. CT is preferred.
41.
Epididymitis: mild pain, (severe in orchitis), usu due to
Chlamydia these days, cremasteric reflex is absent, Prehns sign positive (ie pain
subsides on elevation), testis is high riding, transillumination usually shows
unilateral hydrocele due to reactive effusion, Doppler USG if equivocal, and
treatment is xone and doxy.
42.
Recurrent abdominal or thigh superficial tumor with mild pain is

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

43.
ESWL for gallstone if only 3 or less stones, ursodeoxycholic acid
if small stones with functioning gall bladder, electrohydraulic lithotripsy is very
cumbersome, and surgery is the TOC.
44.
Dumping syndrome: high protein diet in small doses and frequent
interval is the TOC, low carb diet, alprazolam helps for neurovegetative symptoms
(dizziness, sweating and dyspnea), metoclopramide increases gastric emptying and
exacerbates the problem.
45.
Retrograde ejaculation is the most common complication of
TURP. Urinary incontinence and erectile dysfunction are the complications of
nerve damage due to suprapubic radical prostatectomy, which should be done if the
TURP specimen shows evidence of malignancy, even if only adenocarcinoma in
situ ! It should be done with LN dissection following sentinel LN sampling using
technetium radiolabelling. Chemo, bicalutamide antiandrogen therapy and radio
are reserved for advanced lesions.
46.
Raloxifen (SERM) used for osteoporosis, can cause hot flashes
and more importantly DVt. So should be stopped 72 hrs before any elective
surgery.
47.
Klinefelter syndrome predisposes to male breast cancer, but not
testicular cancer, tho the testis undergo atrophy.
GYNAECOLOGY
1. Shoulder dystocia- first thing is to tell mother not to push, then reposition the
fetus, and then suprapubic pressure. If it fails, McRoberts maneuver, ie flexing the
mothers knee towards the abdomen; or Rubin or Woods maneuver or delivery of
posterior arm first. Zavanelli maneuver is replacing the fetus head in the pelvis
before performing a CS.
2. Lesbians- have lower risk of contracting all STD, including cervical cancer.
They should still be given HBV vaccine.
3. After the first baby of a twin is born, then positioning and heart rate of the
second should be assessed with USG. If labor is halted, start oxytocin. Forceps is
c/I if second amniotic sac is intact. Internal podalic version can be done to revert
breech into cephalic position re
4. HELLP syndrome- treatment is again Magsol, to prevent seizure. Plasma
exchange transfusion in persistent HELLP.
5. LSIL on Pap- do colposcopy. IF colposcopy is satisfactory (ie entire lesion and
transformation zone visible), expectant management with repeat cytology 6 mthly
or HPVDNA testing at 1 yr. If the lesion is persistent after 1 yr, or there is
progression, or if colposcopy is unsatisfactory, or if HSIL, treatment with either
ablation or excision is needed. Ablation can be cryo or laser, and excision can be
knife or laser conisation or LEEP (Loop Electrosurgical Excision procedure).
LEEP is the most favored procedure. Ablation is done in low risk lesion, without
evidence of invasion and satisfactory colposcopy.
6. Condyloma are not c/I for vaginal delivery, as long as they are not large
enough to cause obstruction. HSV is an contraindication however.
7. Risk of repeat preeclampsia is atleast 7 times higher, or even more if the

previous preeclampsia occurred earlier, or pt has chronic renal disease or HTN.

8. Most effective strategy for severe preeclampsia is delivery, tho the next best
step is magsol, as preeclampsia has other complications besides seizures, and
magsol only controls the seizures. IV hydralazine or labetalol for BP control. Even
after eclampsia occurs, magsol is more beneficial than phenytoin in preventing
seizure. Diazepam if magsol is c/I, eg due to myasthenia.
9. Retinal hemorrhage is considered the most ominous sign of preeclampsia.
Also PGI2 dec, TXA2 inc, NO dec, Endothelin inc.
10.
Fasting glucose target in GDM is 60-90 and postprandial <120. If
higher, start NPH at bedtime, with regular or lispro before meal. Glargine is
contraindicated as it is teratogenic.
11.
Postpartum endometritis- TOC is clindamycin and gentamicin, as
metron is c/I in breastfeeding women, and ampigenta dont cover lactamase
producing anaerobes. The most important risk factor for endometritis is route of
delivery, not PROM.
12.
Pap should be started only 3 yrs after assuming sexual life, or at
21 yrs of age, as HPV needs 3-5 yrs to cause SIL
13.
No consent needed from parents in treating a minor for STD,
pregnancy, abortion !!, contraception, drug use and emotional problems like
anorexia and depression.
14.
Menorrhagia is the most common complication of norplant,
others being TTP, vaginal spotting (less common), DVT, PE, stroke, MI, and breast
cancer.
15.
Postmenopausal women- start vitd and Ca supplement, HRT has
fallen out of favor due to cardiovascular risk. Use raloxifen or alendronate only if
documentation of low BMD, or history of fragility fractures.
16.
HGSIL on pap- do colposcopy with endocervical curettage- if
this confirms HGSIL, then ablation or excision.
17.
ASCUS on pap- best next step is HPV testing. If it shows high
risk HPV, then colposcopy, else f/u in 1 yr. Some recommend accelerated pap for
ASCUS, every 4-6mth, if second pap is abnormal, then colposcopy, but this
requires greater no of visit and delays diagnosis.
18.
PPH- first thing to do is pelvic examination for retained placenta,
then bimanual massage, if this is not effective, only then oxytocin.
19.
Athletes having amenorrhea due to low GnRH can result in
osteoporosis, vaginal and breast atrophy and infertility. Treatment is improving
caloric intake, and if this doesnt help, then vitD/Ca and OCP.
20.
Levonorgestrel is preferred to combined estrogen/prog for after
morning pill, valid upto 120 hrs. If after 120 hrs, use copper T.
21.
Absolute c/I to OCP- h/o of thromboembolism or stroke, active
liver disease, h/o estrogen dependent tumor, pregnancy, DUB, smokers> 35 yrs,
hyper TG. Relative c/I are migraine, poorly controlled HTN and anticonvulsant
therapy. Diabetes and f/h/o malignancy are not c/i.
22.
20% women with CF are infertile, due to thick cervical mucus
and amenorrhea due to malnutrition, 95% of male are infertile due to impaired
development of Wolffian duct, and poor sperm transport.

23.
Annual pap is recommended even in lesbian, tho the interval can
be increased to 2 or 3 yrs after 3 or more consecutive normal pap.
24.
Trichomonas in postpartum period- give 2g single dose of
metron, and withheld breast feeding for one day. Also treat the partner. Local
vaginal therapy are less efficacious coz it doesnt reach the urethra and the
periurethral glands.
25.
Stress incontinence- alpha agonists like amitryptiline can help by
increasing the sphincter tone. Anticholinergic like oxybutinin and biofeedback are
for urge incontinence.
26.
UTI in pregnancy- cephalexin, amoxicillin or nitrofurantion.
Even asymptomatic bacteriuria has to be treated to prevent preterm birth and
neonatal sepsis and endometritis, and risk of progression to pyelonephritis. After
treatment, eradication should be documented with urine culture. Pyelonephritis is
treated with 10-14 days xone or ampi/genta, followed by low dose nitrofurantion
or cephalexin prophylaxis for the remainder of the pregnancy.
27.
If Pregnancy is detected early in first trimester in HIV patients,
its better to withheld HAART. If in second trimester already, continue HAART.
HIV patients shouldnt breastfeed, even if on treatment.
28.
In pregnancy or if on OCP, the dose of Thyroxine has to be
increased due to inc TBG in the body, plus increased body mass and VOD in
pregnancy. Monitor TSH and try to keep it at normal level.
29.
Subchorionic hematoma are diagnosed by USG, and should be
observed with repeat USG in 1 week. The most common complication of such
hematoma is spontaneous abortion. Preterm birth and IUGR are also possible.
30.
Gabapentin and valproate are safe to be used in pts on OCPother antiepileptics will decrease the efficacy of OCP.
31.
Pregnancy is still possible in Turners, tho the chance is very
small.
32.
A lady with hemophiliac husband is worried and asks what is the
risk of her child having hemophilia? The answer should be none, as the child
will be only a carrier if a female, and normal if male.
33.
Hyperreflexia is an ominous sign of severe preeclampsia and
heralds eclampsia- treatment of severe preeclampsia is hydralazine or labetalol,
plus magsol.
34.
Physiologic changes of skin are the commonest cause of general
body pruritus in pregnant wome. Other cause is herpes gestationis, aka pemphigoid
gestationis, which manifests are urticarial veriscles around umbilicus, and is not
due to viral infection. PUPPP (popular urticarial papules and plaques of
pregnancy) is another and involves the stria gravidarum. Treatment is
antihistamine, topical steroid, emollient, etc. Topical steroids are the DOC.
35.
Contraindication of exercise in pregnancy are pul or cardiac
disease, cervical incompetence, twin, abruption placenta, placenta previa,
Premature labor, preeclampsia. Scuba is c/I as it can cause decompression sickness
in the child
36.
Limb reduction defect associated with CVS depends mostly on
the age- higher risk with earlier age.

37.
Weight reduction is the TOC for PCOD infertility. After that is
clomiphene, and if it doesnt work, then gonadotropins. Metformin is not studied
enough, so is usually not the answer.
38.
Adolescents dong comply with OCP mostly because of concern
over wt gain, tho there is no hard evidence.
39.
Testicular feminization- pt has breast development but no axillary
or pubic hair, unlike in constitutional delay, where such asynchronous delay is not
found.
40.
Laparoscopy is always the first step in suspected endometriosis,
to rule out other pathology, and to see the extent of the disease, plus it can be
therapeutic too with bipolar coagulation.
41.
Unilateral nipple discharge is cancer UPO, so do mammogram,
even if it is serous. It can be f/by FNAC or biopsy, and cytology of the discharge if
it is bloody.
42.
CVS doesnt help with detecting NTD, as it is only for cytogenetic
studies and doesnt measure AFP levels.
43.
NTD needs immediate surgery to prevent infection of CNS,
followed by orthopedic evaluation to correct patients posture and promote
ambulation.
44.
All pregnant women should be screened for Chlamydial
infection in the first prenatal visit, and repeat in third trimester if the patient is
below 25 yrs of age (donno why)- coz it can lead to endometritis,
chorioamnionitis, conjunctivitis and pneumonia in the baby, preterm delivery,
PID, ectopic. If positive, treat mother with erythromycin base (estolate is c/i)or
amoxicillin for 7 days; and father with azithro single dose.
45.
The MCC of postmenopausal bleeding is atrophic vaginitis, then
endometrial ca, while cervical cancer is a very rare cause.
46.
Rosette test can be done to detect fetal RBC in mother in cases
of isoimmunisation, and if present, then quantify how much fetomaternal bleed
has occurred by Kleihauer Betke test. Adjust the dose of anti RH globulin
accordingly.
47.
Sickle cell disease- OCP are not preferred due to
thromboembolic risk, progesterone pills cause breakthrough bleeding and
aggravate anemia, IUD also increases bleeding, so the best contraceptive is
DMPA or norplant. Almost half of pregnancies are complicated by either acute
crisis, endometritis, pyelonephritis or thromboembolism.
48.
Pt on antiepileptic becomes pregnant- never change the drug.
Add folate (though benefit has been shown only in animal studies) and offer
screening for NTD with serum fetoprotein, amniocentesis and USG, and
termination if affected. Also antiepileptic is not a c/I to breastfeeding, though
Phenobarbital and diazepam can be stopped for a few weeks if the child becomes
irritable or sleepy.
49.
Eisenmenger syndrome is absolute contraindication to
pregnancy- elective termination of pregnancy should be advised. The sudden drop
in systemic vascular resistance with delivery will cause cyanosis in the mother.
Also higher risk of spontaneous abortion and preterm delivery. Only treatment is

heart lung transplant, or lung transplant with intracardiac repair.

50.
Gestational transient thyrotoxicosis (GTT) has mild increase in
free T4 and only slight decrease in TSH, due to the effect of hCG on thyroid
stimulation. If TFT are normal, and pt has typical symptoms of hyperthyroidism,
she probably has anxiety disorder or something else. Subacute lymphocytic
(postpartum) thyroiditis causes only transient hyperthyroidism, and shows
reduced RAIU test.
51.
DMPA is the contraceptive of choice in pt with VWD or
hemophilia, as it decreases the menstrual flow, unlike IUD or minipill which
increases bleeding. It also dec risk of PID and endometrial cancer, and is useful in
those with fibroid.
52.
Downs diagnosis- increased nuchal translucency on USG in 10
wks, PAPP-A in the first trimester, quadruple testing ( with dimeric inhibin A) in
second trimester, and karyotyping with CVS in 10 wks and amniocentesis in 16
wks.
53.
A pt recently started on OCP comes with spotting, just reassure
her that is normal breakthrough bleeding, and nothing needs to be done. Just
continue the OCP. Some patient may complain that there is no withdrawl bleeding.
That is normal too, initially. Advice her to use condoms if she forgot to take her
pill for 2-3 days.
54.
Clonidine is useful for hot flashes, esp if there are any c/I to the
use of HRT. Progestin has also been shown to be effective for hot flashes, but
causes mood disturbances.
55.
Any preterm labor- always administer prophylactic penicillin for
GBS. Also betamethasone if between 24 to 34 wks.
56.
Intrahepatic cholestasis of pregnancy is associated with still birth,
so in a ICP suspect, do LFT to rule out other causes, and then undergo fetal testing
and early delivery.
57.
Elderly with burning, dyspareunia and a butterfly like atrophic
white lesion on the vulva, has lichen sclerosis. Treatment is potent topical
testosterone !!
58.
Breastfeeding suppresses estrogen release from ovary, and that
can result in vaginal dryness and dyspareunia.
59.
Air travel is c/I after 36 wks, or if h/o HTN, preterm delivery,
poorly controlled DM or sickle cell anemia.
60.
A pt comes with primary amenorrhea, no other symptoms like
abd pain, and normal secondary sexual characteristics. This is probably uterine
agenesis and not imperforate hymen (Mayer Rokitansky Kuster Hauser syndrome)
61.
Meigs syndrome- TOC is unilateral oophorectomy and not
TAHBSO, as it is caused by a benign ovarian fibroma. Tricky.
62.
Regularly timed but heavy periods imply adenomyosis, endo
hyperplasia or polyp or fibroid. Anovulatory DUB is characterized by irregular
cycles.
63.
If a pt comes with PROM at say 28 wks, then expedited delivery
is not warranted, tho prophylactic antibiotics can help prevent amnionitis. Delivery
should be delayed until sign of infection develops to promote further fetal growth

and development.
64.
c/I to daily aerobic exercise in pregnancy are significant heart
disease, HTN, preeclampsia, preterm labor and PROM, restrictive lung disease,
incompetent cervix, twins, placenta previa.
65.
A pt with normal mens hx comes with abnormal bleeding. It is
most probably due to pregnancy, and not anovulatory bleeding. PREGNANCY
always comes first in d/d.
66.
Pt comes with severe pv bleeding, hypotension and anemia- Tt is
iv estrogen, vasopressin if needed, BT, followed by oral estrogen which is
gradually tapered. If above 35 yrs, do endometrial sampling before starting
estrogen to rule out endometrial hyperplasia or Ca.
67.
Rapid onset virilisation with clitoromegaly and frontal baldingits probably ovarian or adrenal androgen secreting tumor and not PCOD. So the
first investigation is USG pelvis.
68.
LH:FSH ratio is not a very sensitive test for PCOD re. Amazing.
69.
Below 40 yrs, breast lump if dismissed as having no abnormality
by USG or mammo, has 1% chance of malignancy, so nothing needs to be done.
But if more than 50 yrs, it has >40% probability of being cancer, so even if
mammo is negative, still have to do biopsy or fine needle aspiration.
70.
Postpartum telogen effluvium is common after 2-6 mo of
delivery.
71.
The preferred therapy for inpatient PID is iv cefoxitin and iv
doxy, +/-metron if vaginal smear shows trichomonas. Alternative is iv clinda and
iv genta. Beware of options with oral doxy. Admission is needed in pts with
peritoneal signs, n/v precluding oral treatment, pregnancy, etc.
72.
All SSRI are excreted in breast milk, so only short acting ones
should be used in postpartum period, so that patient can refrain from breastfeeding
till the drug is in her system.
73.
Shoulder dystocia and obstructed labor- first thing to do is call
for help. Then McRoberts maneuver by pushing the mothers leg as far back as
possible. Then epi, supriapubic pressure, Woods corkscrew manuvre, heel knee
position, and finally pushing back the fetal head and CS if everything else fails.
74.
IUD protects against endometrial cancer
75.
HRT increases HDL and lowers LDL, thus dec cardiovascular
mortality long term, but it has been shown to increase coronary event in the short
term.
76.
After the first trimester, advise not to exercise in supine position,
as it can compress IVC, dec CO and cause uterine hypoperfusion.
77.
Fragile X is a X linked dominant syndrome due to triple repeat
expansion, which is a type of mutation. If the permutation is transmitted from the
mother, it has a higher chance of expansion than if from father. Huntington on the
other hand is autosomal dominant.
78.
Breastfeeding is usually successful after reduction or
augmentation mammoplasty or breast implant.
79.
If a pt is profusely bleeding pv, D&c gives a faster response to
stop the bleeding than iv estrogen.

80.
Screening for DM starts at 45 with three yearly RBS, for lipid
disorder starts at 45 if no risk factor, but as early as age 18 if has risk factor like f/h
of MI.
81.
A pregnant mother is diagnosed with sec syphilis in her second
trimester. The baby will be born with ? snuffles, rhagades and neurosyphilis
(features of early congenital syphilis), not saber shin/Hutchinson teeth, as these are
manifestation of late congenital syphilis. Also can have meningitis, hydrocephalus,
optic atrophy.
82.
Maternal obesity increases the risk of NTD, tho the reason is not
known. It also increases the risk of GDM, macrosomia and stillbirth, so wt loss
before conception is advised.
83.
Tubal ligation: failure rate is 5% and not 0.1%, 5-20 % pts regret
later doing the ligation.
84.
The presence of endocervical cells on Pap is regarded as adequate
sampling. If these cells are absent, then in a no risk patient, repeating may be
deferred till next years Pap. If it is high risk patient, then repeat immediately.
85.
After an episode of pyelonephritis in pregnancy, the pt should be
put on prophylactic antibiotic for the rest of her pregnancy.
86.
A pt comes with IUGR, ie <10 percentile, then the first thing to
do is Doppler velocimetry of the umbilical artery. If the flow is absent or reversed,
then immediate delivery is warranted, else not.
87.
ER+ breast tumor needs tamoxifen for 5 yrs to reduce recurrence
after surgery, chemo and radio. Lifelong tamoxifen is not used as it can cause
endometrial cancer.
88.
Pregnant women shouldnt consume too much fish, due to risk of
mercury poisoning, and ACOG has actually set limits on the amount of fish in a
week a pregnant woman can take. Also carnivorous fishes like shark are c/i.
89.
In a patient with partial spinal cord transaction, the biggest threat
during pregnancy is developing autonomic dysreflexia. It can manifest with
malignant HTN, brady, arythmia, sweating, resp distress, uteroplacental
vasoconstriction, etc. Patients are unaware of labor due to absence of pain, and
only way of knowing is abd or leg spasm and SOB that accompanies labor.
90.
Cranberry juice prevents UTI by inhibiting E coli from adhering
to the urinary epithelium.
91.
None of the radioimaging are c/I in pregnancy except for
radioactive imaging. The modality with highest exposure to the fetus is a barium
enema, then a CT abdomen.
92.
Ondansetron is effective only if given before chemo. For late
onset emesis, metoclopramide is more effective.
93.
No alteration in sexual practice is needed during pregnancy,
except if pt has PROM, placenta previa or premature labor history. Even supine
position is not c/I re.
94.
Chronic vestibulitis is a cause of chronic vulvar pain and extreme
tenderness. Tt is low dose amitryptiline.
95.
IF a HIV elisa comes positive, the most important factor of the
test that concerns the patient is the PPV of the test, ie how many with positive test
th

actually have HIV.

96.
Tt of condyloma in pregnancy is TCA. Podophyllin is c/I in
pregnancy. IFN and laser ablation in case of resistant infection.
97.
Bicornuate uterus needs no treatment before pregnancy. Septate
uterus needs hysteroscopic excision of the septum, and didelphys needs
reunification process.
98.
Dysuria with low level WBC in urine, low bacteruria and
negative leucocyte esterase is consistent with urethral syndrome. Interstitial
cystitis has a normal examination of urine. Traumatic cystitis occurs sex,
diaphragm use or catheterization, and presents with hematuria without pyuria.
99.
pt with Anticardiolipin Ab can present with livedo vasulitis in the
lower limb, which presents with painful purupura in the lower limb, which ulcerate
and heal leaving atrophic scars, livedo reticularis with telangiectasia, erythema and
hemosiderin hyperpigmentation. Livedo can occur with hep C, protein C
deficiency also. Treatment is low dose aspirin, nifedipine, dipyridamole,
pentoxiphylline or mini dose heparin. Heparin is preferred in pregnancy, with one
dose every 2-3 days.
100.
A pt with menarche comes with heavy bleeding and shock- its
probably not DUB but VWD, so do ristocetin cofactor assay. Tt is OCP,
desmopressin, antifibrinolytic and VWF concentrates.
101.
Pt with bac vaginosis on pap dont need treatment if they are
asymptomatic, even during pregnancy, as the treatment hasnt been shown to be
effective. Metronidazole is okay for 2 trimester use.
102.
Gestational thrombocytopenia is one of the commonest cause.
103.
DMPA is the best contraceptive in a pt with sickle cell anemia, as it
has shown to decrease the pain crisis. Estrogen is relatively c/I as it increases the
vasoocclusive crisis. IUDs are also not good, due to high rates of infection.
104.
80 yr female with stroke develops incontinence. Post void residual
volume is 70ml (normal). This is functional incontinence due to impaired mobility
so that the pt cant go to toilet. Best treatment is communicating with caregivers
about accessing the toilet.
105.
Young woman on ACEI should be using contraceptives.
nd

DERMATOLOGY
1. In pt with alopecia, if the hair shows split ends, aka trichoclasis, then it
signifies traumatic alopecia, due to trichotillomania, or chemicals.
2. Psoriasis is treated with potent local steroid, and low potency steroid like
hydrocort if on face or intertriginous area. Systemic steroids are not used as they
can induce pustular psoriasis. Extensive disease is managed with UVB with or
without coaltar (Goeckermann regimen). Severe or psoriatric arthritis is treated
with MTX.
3. Pressure ulcers are treated with moist saline soaked gauze packing. Dry gauze
is not used as the fluid is thought to contain growth factors needed for
reepithelialisation.
4. Topical metron is the TOC of rosacea, with or without oral doxy, mino,
erythro, tetra like in acne. Topical isotretinoin in popular or pustular lesions, and

permethrin has shown to help, as demodex mites are frequently found in the
lesions. Rosacea can be associated with conjunctivitis, keratitis, chalazion and
scleritis.
5. Erythrasma caused by corynebac minutissimum, reveals coral red fluorescence
in Wood lamp.
6. Photoaging causes coarse deep wrinkles (fine and superficial only due to
aging), actinic keratosis, telangiectasis and brown liver spots. Treatment is
isotretinoin, which will remove the brown spots also. Smoking exacerbates
photoaging.
7. Tattoo removal- deramabrasion, laser, cryo, cautery- laser can cause scarring
and hypo/hyperpigmentation.
8. Wearing protective clothing is more important than sunscreen since childhood
to decrease the risk of melanoma. Sunscreen with SPF 15 have shown to reduce
the incidence of only BCC and SCC, not melanoma.
9. Oral Terbinafine 6wks for fingernails and 12 for toenails are the TOC for tinea
unguium. Itraconazole can be used. Oral fluconazole is once weekly and easy to
take, but is not as effective.
10.
Lindane used for scabies was found to cause aplastic anemia and
seizures, and hence is replaced by permethrin.
11.
A pt went hiking, was bitten by insect, and scratched with a
wooden stick, followed by draining lesion- its sporotrichosis, as it is the only
fungus which can get inoculated. Blastomyces and Coccidiodes both have to be
inhaled.
12.
Minocycline doesnt cause photosensitivity, but can cause lupus
like syndrome, pseudotumor cerebri, vertigo and tooth discoloration
13.
NSAID and hydration are the treatment for sunburn, whether
induced by drugs or otherwise. NSAID also limits the damage to the skin.
Diphenhydramine for itchng, and topical steroids can be used
14.
Oral Isotretinoin can cause hyperTG,so monitor LFT and lipid
profile, and stop if severe hyperTG, as it can cause pancreatitis.
15.
Psoriatic lesions are exacerbated by beta blockers, ACEI, lithium,
NSAIDS- stop the medicine and replace from another group.
16.
A pt on OCP with chronic HCV comes with painless blisters on
hand, and hyperpigmentation, hypertrichosis and fragility of skin. Its porphyria
cutanea tarda. Dx is by inc urinary uroporphyrins. Treatment is phlebotomy or
hydroxychloroquine, or IFN alpha in those with HCV infection.
17.
Mild acne is treated with topical retinoid. Moderate( or refractory
mild) with topical retinoid and either benzoyl peroxide or topical antibiotic. More
severe with all three of them, or systemic antibiotic with topical benzoyl peroxide
or retinoid. If no response in 3-6mo, start oral isotretinoin. Microcomedones need
8 wks to mature, so wait for 2 months for any therapy to work before switching.
Pregnancy is c/I with even topical isotretinoin, though no LFT and lipid
monitoring needed with topical therapy.
18.
Microsporum canis ectothrix infection is fluorescent in Woods
lamp, unlike the endothrix infection with T tonsurans.
19.
Trichotillomania is characterized by bizarre pattern of broken

hair strands of varying length.

PAEDIATRICS
1.
DTaP vaccine c/I if anaphylaxis of encephalopathy within 7d. If
high fever, shock, inconsolable crying and seizure within 24 hrs, then give
under caution. There are no contraindications to pneumo, polio or Hib
vaccines.
2.
MMR c/i- severe febrile illness, anaphylaxis to neomycin or
gelatin, severe immunodeficiency (not just HIV status), thrombocytopenia after
first dose, previous IVIG administration within 3-11 mo, as it decreases the
efficacy of the vaccine, pregnancy. f/h/o seizures, breastfeeding, TB, PPD
conversion, asymptomatic HIV infection, allergy to mercury (thimerosal) and
egg are not considered contraindications.
3.
Chemoprophylaxis for PPD conversion following contact with
MDR TB- if resistant to only INH, give rifampicin 4mo or RZ 2mo, if resistant
to H and R, give ZE or Z with quinolone for 4 mths.
4.
If neonate at birth has polycythemia in capillary heel blood test,
then repeat in venous blood- if still elevated, repeat in 12 and 24 hrs, as it
resolves on its own. If it persists, and the child develops drowsiness, jaundice,
hypoglycemia, apnea, hypotonia, poor feeding, cyanosis, then hydration and
exchange transfusion is needed.
5.
Children need 1300 mg calcium daily, so apart from diet, 1gm
calcium supplementation should be done in all. Adults typically need less,
while the requirement in old age again increases.
6.
Strawberry aka capillary hemangioma in places other than face can
be left to regress by themselves, while face can be treated with laser for
cosmetic reason. Steroid and interferon sc have also been useful in large
hemangiomas.
7.
Kawasaki disease- TOC is Aspirin and IVIG. HSP- supportive,
steroids if severe. HUS supportive and IVIG, peritoneal dialysis. TTPplasmapheresis. ITP- mild cases are self limiting, steroid short course for
severe cases, and IVIG for very severe cases.
8.
Diaper rash is due to overhydration and friction, eg following
diarrhea, treatment is to keep dry by frequent change of diapers, and barrier
creams like petrolatum and ZnO, or low potency steroid. Candidal infection
involves skin fold, is painful, and is persistent after the above treatment.
Bacterial superinfection presents with fever, pustular drainage and
lymphangitis.
9.
Flexible kyphosis is commonly seen in adolescent, and is
correctable by voluntary extension and prone extention test, and doesnt need
treatment. If there is sharp angulation seen on forward bending, it is structural
kyphosis, aka Scheuermann disease, and needs Milwaukee brace if angle <7080, or surgery for more severe angulation, pain or neuro abnormality.
10.
Dx of CHPS aka IHPS is by usg, or second choice is barium meal
showing double track sign.
11.
Mother found bat in the room of her child, but the child has not been

bitten- PEP with Ig and rabies vaccine is needed, immediately unless the
animal can be captured and observed for signs of rabies or sacrificed and
autopsied. PEP should be given within 5 days, or with head and neck bites,
within 3 days (72 hrs)
12.
Xone is not used in neonatal sepsis as it can displace bilirubin and
aggravate sepsis induced cholestasis. Same for cotrim. So TOC is ampicillin
for Listera (tho uncommon in US) and cefotaxime.
13.
Child comes to Pediatrician with epiglottitis- first thing to do is
arrange for ambulance to send to ER, for possible intubation
14.
In immunocomp patients, herpes zoster might resemble HSV, so
diagnosis needs PCR or IF of scraping, else tests are not needed for diagnosing
zoster.
15.
Nocturnal surge in LH and enlargement of testes are the first signs of
puberty. Delayed puberty is diagnosed if >14 yrs of age. It can be constitutional
if positive family history, and bone age is lower than true age, and other
systemic illness are absent. Pt with Klinefelter has normal puberty, but then he
develops testicular atrophy and hypogonadism. Constitutional puberty delay
can be managed with testosterone mthly im injection for 3-6 mo (short therapy
doesnt affect bone growth), esp for psychological reason. HCG with HMG can
be used in central hypogonadism like kallmans syndrome- or GnRH pump.
16.
Child with diarrhea should be given normal diet, with limited sugars
and fat, which increases osmolality. Clear liquid like juice has sugar.
Loperamide can cause paralytic ileus, toxic megacolon and CNS depression.
17.
Normal Tympanic mb with decreased mobility signifies effusion, and
can persist for 3 mo after an episode of AOM. So watchful waiting only is
needed, unless if the effusion is bilateral, or has persisted for longer. First line
therapy for AOM is amoxy, second line is clavam, cefuroxime axetil or im
xone, tympanocentesis or myringotomy with culture if second line also fails.
Hearing evaluation should be done if effusion lasts for more than 3 months.
18.
Lead levels>44 needs oral chelatoin, and >70 needs hospitalization
and iv chelation. Less than 44 needs only environmental and behavioral
interventions. Blood lead levels are more sensitive than erythroporphyrin
levels.
19.
Criteria for admission of pts with anorexia nervosa- dehydration,
electrolyte abn, brady, hypotension, hypothermia, acute food refusal,
wt<75%of average, arythmia, psychosis, seizure, suicidal ideations and
pancreatitis.
20.
Enuresis normally resolves by 5-7yrs, so nothing needs to be done
till then (right answer is to assure that the behavior is normal!). Behavioral
modifications can be used to increase chance of success. Only after that
investigations like USG to see residual urine, VCU to see if obstruction or
neurogenic bladder (latter appears as trabeculated bladder with Christmas tree
appearance), cystoscopy and urodynamic studies.
21.
Erythro oint or sulfa drops are TOC for bac conjunctivitis,
quinolones for contact lens wearers and corneal ulcer to cover Pseudomonas.
Keep at home till discharge is cleared, or if not possible, atleast 24 hrs after

starting antibiotics.
22.
Sydenhams chorea can present after 2-8mo with pronator drift,
delayed patellar reflex, dec tone, crying or laughing inappropriately, facial
jerking, etc. treatment is again penicillin re.
23.
If there is microcephaly, it cant be due to IUGR, has to be due to
intrapartum infections.
24.
Childhood Absence Epilepsy (CAE), has a good prognosis, good
response with treatment and remission with age, esp if GTCS are absent. JME
(juvenile myoclonic epilepsy), by contrast has absence episodes with
myoclonic activity, and life long seizures.
25.
A lean and thin patient with secondary amenorrhea, with dec axillary
and pubic hair, myalgia, asthenia, amenorrhea, axillary freckling,- its probably
not anorexia but Addisons disease. Lack of pubic hair points toward hormonal
imbalance. Hyponatremia, hyperkalemia, acidosis, hyperchloremia are present
in aldosterone deficiency also, but the hyperpigmentation and amenorrhea
points to Addisons.
26.
VCUG is indicated in all children <5 with febrile UTI, any age with
first UTI, recurrent UTI or those who dont respond to treatment. USG, Renal
Scintigraphy and IVP are not routinely recommended.
27.
Downs syndrome predisposes to endocardial cushion defect,
duodenal atresia and polyhydramnios, Hirschsprung disease, atlantoaxial
instability and hypothyroidism, and leukemia.
28.
Benign premature thelarche is common in girls at 18-24 months age,
not accompanied by other features of isosexual precocious puberty like ht,
bone age, pubarche, adrenarche and menarche. Hypothalamic hamartoma
secrete GnRh and cause central isosexual precocious puberty, while adrenal
tumors cause heterosexual precocious puberty in female (virilisation), and
isosexual precocious puberty in male. McCune Albright syndrome has cae au
liat spots, fibrous dysplasia and ovarian cyst producing estrogen causing
precocious puberty.
29.
Parents can deny vaccinations to their child, the doctor should
document and sign the refusal. Thimerosal present in many vaccines were
linked with autism, but no evidence supports it.
30.
NF1- axillary freckling, lisch nodules on iris, optic glioma, bone
dysplasia, other CNS tumors, developmental problems. IF we suspect NF1,
first thing to do is ophtho consultation, then MRI or neurosurgery as needed.
31.
Always suspect child abuse if the child presents with new onset
behavioral problem like sleeping poorly or wetting of bed, esp if the parents
are alcoholic or uses drugs. Depression can be second possibility.
32.
Erbs palsy has a 80% chance of spontaneous remission. Symmetric
palmar grasp reflex, even with asymmetric Moro, reflects that the lower roots
are intact. Serious complication is phrenic nerve involvement. Horner
syndrome is seen with lower root injury in Klumpkes paralysis.
33.
Sickle cell disease rarely presents before 6 mo due to fetal
hemoglobin. Splenic sequestration is the most common complication, others
being ischemic complications like asplenia due to infarction, dactylitis and

ischemic stroke. Hb electrophoresis is the DxOC. Acute coronary syndrome in

these patients may be difficult to d/d from acute chest syndrome.
34.
Alarm is more effective than medications in enuresis, esp if
augmented by other behavioral approaches, and also has lower rate of relapses.
35.
Acute bronchiolitis- TOC is respiratory isolation with
bronchodilators (albuterol, epinephrine), hospitalization if hypoxic or unable to
feed (ng or iv feeding). Dx is by rapid antigen detection of RSV in nasal or
pulmonary secretions using ELISA antigen capture technology. Serology
doesnt help as it detects maternal antibody. Pt has increased risk of AOM, and
asthma in the long run. Apneic spells are very common in bronchiolitis.
36.
No increased recurrence of Turners is seen with women who had
previously delivered a Turner, nor is there any increased risk with increasing
age like Downs or Klinefelter.
37.
Lumbar meningomyelocele is associated with increased bladder
dysfunction, ultimately causing renal dysfunction. Sacral involvement can
cause fecal incontinence.
38.
Dural ectasia is the most common finding of Marfan syndrome re,
along with MVPS which can cause acute MR and CHF, requiring valve
replacement; Aortic root dilation causing aortic dissection and ectopia lentis. If
aortic root >4.5 cm, then aortic valve replacement is indicated to prevent
dissection.
39.
Due to TSH surge in baby after delivery, T4/TSH should be routinely
tested after 1 d of delivery, and immediately treated if hypothyroid, to prevent
neurologic defect. IF TSH is found to be high in the screening done from heel
prick, the next step is to do a regular blood draw, only then start the treatment.
They also need higher dose of thyroxine than the adults!!
40.
Only symptomatic patients with Giardia in stool should be treated.
Asymptomatics should be treated in special situations as outbreak control,
prevention of household transmission by toddlers to pregnant women, and
those with CF and hypogammaglobulinemia.
41.
Symptomatic ITP with plt<30,000 should be treated with steroids,
and IVIG if severe. Platelet is useless.
42.
Pt with abd pain and HCO3<15, suspect DKA.
43.
Baby on honey and fruit juice develops poor sucking, constipation,
lethargy and weak cry- botulism. See for diminished gag reflex in examination,
which needs airway protection to prevent aspiration. Baby can also contract it
from contamination with spores in the soil. Most improve fully but need long
hospitalization for months.
44.
TTP- pentad of thrombocytopenia, MAHA, fluctuating mental status,
ARF and fever. Pt/PTT are normal, LDH is elevated. Both TTP and HUS are in
the same spectrum, and both need plasmapheresis emergently.
45.
Viral encephalitis- commonly due to enteovirus or Arbovirus, like
EEE, WEE, California encephalitis, st Louis encephalitis, Colorado tick fever.
Adenovirus or CMV only cause meningoencephalitis in immunocompromised
patients, while HSV are usually seen only in adults.
46.
Severe Malnutrition- lethargic, severe wasting, edema- needs

hospitalization, warming, correction of dehydration and electrolyties, and NG

feeding, esp if vomiting, impaired consciousness and painful oral ulcers. High
calorie or protein shouldnt be started early as it can lead to heart failure, and
iron shouldnt be used in first week as it can cause GI ulcer and oxidation
injury.
47.
2mo child presents with pneumonia, with interstitial pattern on XR,
eosinophilia, and inspiration between cough (staccato cough), its probably
Chlamydia. Search for h/o conjunctivitis in the neonatal period.
48.
Breastfeed a newborn every 4 hrs, and watch for him to take his
fingers to mouth to know that he is hungry.
49.
TBM should be treated for 12months, and upto 18 months if resistant
strain.
50.
Open TB patients are considered noncontagious only after 3
consecutive negative sputum smears, and not based on duration of receiving
therapy.
51.
USG is the DxOC in CHPS, while AXR in duodenal atresia or
malrotation. Continuous nasoduodenal feeding can be used as an alternative in
those who are poor surgical candidates. Erythromycin use, eg in prophylaxis
against pertusis, even if given to the breastfeeding mother, has been shown to
increase the incidence of CHPS
52.
Cellulitis is in between subcut tissue and fat, so local anesthesia will
not be helpful, so shouldnt be used.
53.
IV cotrim is the treatment in PCP pneumonia in AIDS patient, later
changed to oral. IV pentamidine if intolerant to cotrim, and iv trimetrexate if
intolerant to both. Aerosolized pentamidine has low efficacy and shouldnt be
used in treatment, only in prophylaxis. Atovaquone can be used too.
54.
FB ingestion- if it is lodged in any esophageal constriction, then
immediate removal by endoscopy or fluoroscopy guidance is indicated. If it
has already gone to stomach, no intervention is needed mostly. Pyloric
obstruction can present with persistent vomiting in some cases.
55.
Febrile seizures in 6mo to 5yrs, temp>38, usu first day of fever- only
reassurance to the parents is needed. Lumbar puncture is indicated if <18mo of
age to rule out meningitis. Simple febrile seizure has no focal features, lasts
<15 min, and is associated with mild increased risk of epilepsy, tho there is
significantly increased risk of recurrent febrile seizures. Complex febrile
seizure is accompanied by focal features like postictal paresis, duration>15
min.
56.
Transient aka toxic synovitis of hip- child has pain on passive motion
of the hip, is usually preceded by respiratory infection, USg is the diagnostic
modality, and aspiration is warranted if child has fever with hip effusion.
57.
3 wk child comes with purulent conjunctivitis and pneumonia- its
Chlamydia. Fever and wheezing are rare, which helps differentiate it from
bronciolitis. This is the reason why pregnant women should be screened and
treated for Chlamydia. (Erythromycin is the treatment)
58.
Neonate presents with hemolytic jaundice- Coombs negative, it is
probably G6PD and not abnormal hemoglobin states like sickle cell or

thallassemia, as the latter dont present early due to presence of fetal

hemoglobin.
59.
After starting Amoxycillin for AOM, if the pain and fever persists,
then its treatment failure- start coamoxiclav for drug resistant Pneumo.
Tympanostomy and tubing is indicated if OME persisting more than 3 months,
severe AOM, or if recurrent AOM despite prophylactic antibiotics with half
dose amoxy or sulfisoxazole.
60.
Prune belly syndrome- multiple urologic abnormality, constipation,
weak cough.
61.
FB in resp tract- back blows and chest thrusts after holding the baby
upside down, if <1yr old, Heimlich if more than 1 yr.
62.
Acute severe anemia in sickle cell pt can be due to either splenic
sequestration crisis, or acute hemolytic crisis, or aplastic crisis. To differentiate,
see the retics count.
63.
Cleft lip- rule of 10 says surgery at 10 wks of age, 10 pound wt, and
10 g hemoglobin. Recurrence risk in subsequent pregnancy is 50%.
64.
Epiglottitis suspect- the first thing to do is not antibiotics, but to
arrange for direct laryngoscopy and intubation under anesthesia.
65.
In any case of trauma to the nose, even if no external deformity, ant
nasal cavity should be examined to rule out septal hematoma. If it is present, it
should be drained to prevent infection and saddle nose due to cartilage
destruction. Radiographs of nasal bones are not indicated, as clinical
examination is better to find displaced fractures, and if there is undisplaced
fracture, it doesnt need treatment.
66.
Choanal atresia suspect- do axial CT, as it shows the atresia best, as
the atresia is oriented in a coronal plane. It is assoc with CHARGE syndrome,
with coloboma, heart anomaly, atresia choana, retarded growth, genital
hypoplasia and ear anomaly.
67.
Intoeing usually improves on its own, and needs no investigation and
treatemtn. It is usually due to internal femoral torsion or metatarsus varus.
68.
Adolescent well visit should include dietary history. Very imp. AAP
doesnt recommend routine drug screen.
69.
OM in sickle cell pt- its probably Staph and not Salmonella, as Staph
is overall the commonest cause.
70.
ELISA antigen test on stool is the test of choice for Giardia, as it
needs 3 stool examination is needed for visualization.
71.
Spinal curves like scoliosis need attention only if they are rapidly
progressive or painful. Absolute coobs angle is not a criteria for intervention.
3-4 caf au lait spots dont indicate NF, it needs more than 6.
72.
Blunt trauma to the eye- always refer to ophthalmologist even if no
apparent anomaly, as he can have commotion retina, hyphema, retinal tears and
lens subluxation.
73.
Ca requirement is 500 for 4 yr child, 800 for 8 yr, and 1300 for 12 yr
old
74.
4 wk infant present with acute bronchiolitis like picture, and
conjunctivitis- beware, it can be Chlamydia pneumonia. It might even have

hyperinflation and eosinophilia.

75.
A child is brought with alcohol accidental poisoning- the biggest
threat is hypoglycemia. Also cerebral edema and seizure can occur.
Hypocalcemia with nephrocalcinosis occurs with antifreeze poisoning.
76.
Mild diffuse gingival inflammation and swelling- its probably bad
hygiene and not vit C deficiency- prescribe regular brushing and dental
flossing.
77.
Abrasions over dorsal aspect of hands over knuckles signify bulimia,
and the sign is called Russell sign.
78.
A 16 yr male comes with rhinorrhea, occasionally bloody, and c/e
shows boggy turbinates- its probably cocaine abuse.
79.
Turner syndrome- if asked what is the most common complication,
its primary amenorrhea (100%) and not coarctation (only found in 20%)
80.
Anorexia nervosa pts have brady, hypotension, hypothermia,
constipation, but overactivity and cold intolerance.
81.
After starting iron in IDA, first sign is increase in retic count. Serum
ferritin is the last to change.
82.
If a child is obese and short its usually endocrine disorder. In normal
obesity, he doesnt have growth delay, they enter puberty early and are tall.
83.
Erythema infectiosum is not infectious after the appearance of the
rash, so the child can go to school , tho if his mother is pregnant, she should be
warned of fetal death and hydrops.
84.
In girls, breast development precedes pubarche, so if pubic hair is at
higher tanner or sexual maturity rating scale, then there is a problem.
85.
Copper deficiency can present as hypochromic anemia, neutropenia,
esp in those with TPN for a long time.
86.
In any male presenting with gynecomastia, first thing to do is
examine genitalia for tanner staging.
87.
Lactose hydrogen breath test is superior to stool test or clinical trial
in diagnosing lactose intolerance.
88.
VZIg neednt be given to contacts unless they are
immunocompromised. Isolation of contacts from immunocompromised
relatives is required though.
89.
A pt comes with thyroid nodule- first thing to do is FNAC, it is
diagnostic if its a solid lesion and therapeutic if its a cystic one. USG, I scan
are not the best answer.
90.
A 10 yr boy is diagnosed with ALL and has life expectancy of 6 mo.
His parents implore not to tell him. What to do? Ask the parents why they dont
want to tell him, listen to their fears, then say that telling him will make it
easier for them to provide him the best care. The pt must be told.
91.
Tick bite- tick remains for days, and produces a papule with
erythematous halo, or can later produce foreign body reaction. It can also
transmit Lyme and erythema chronicum migrans can develop at the site of bite
later. Relapsing fever, rickettsial infection, babesiosis and tularemia are other
associated conditions.
92.
A child of 4 wks comes with a solid mass on his sternomastoid-

which is slowly growing. Its probably fibromatosis coli, which if not treated
will cause congenital torticollis. So stretching exercise is needed, or surgery
with splinting can be offered if exercise doesnt help. D/d is branchial cyst.
93.
A pt comes from Haiti with complete immunization for well child
visit. He has got BCG also. He is asymptomatic, still he needs a PPD placed re.
94.
In males<6mo and females<2 yr with fever without any apparent
cause, urine culture from suprapubic tap or catheterization should be done first,
even in the absence of any urinary symptoms.
95.
A child who is throwing too much temper tantrum- TOC is to give
him a choice- stop the tantrum and you can go out for an icecream, or keep
doing it and face the consequence re. time out can be used, but not more than 5
min each time.
96.
All close contact of a pt with Meningo meningitis must receive
treatment, including hospital staffs involved in intimate care like intubation or
suctioning, and parents, but not casual visitors or his frens.
97.
A pt comes with mental retardation without any other systemic
features, the investigation with the highest yield is chromosomal study, as
25%of the time there will be an anomaly.
98.
A pt with mental retardation, obesity, short stature, muscle hypotonia,
and hypogonadism, excessive appetite and temper tantrums- think Prader Willi
syndrome. Most pts need growth hormone supplementation.
99.
Hirchsprung suspect- the next best step in diagnosis is suction biopsy
of rectum, and not anorectal manometry re.
100.
A baby is born with blueberry muffin spots, petechiae all over,
cataract, deafness, hepatospleno, osseous defects on XR, its congenital rubella
syndrome, due to Togaviridae. The blueberry spots are points of
extramedullary hematopoeisis, also seen in those with congenital
toxoplasmosis, CMV, neuroblastoma, congenital leukemia, erythroblastosis and
twin transfusion syndrome.
101.
In a child with c/f of sinusitis, transillumination and sinus XRs are not
done, very low yield as the sinuses arent developed that much. Start antibiotics
straightaway.
102.
Child comes with decreasing grades in class, behavioral problesm
(neuropsychiatric symptoms),
103.
Until baby is 20 lbs, place the baby in a rear facing seat in the car,
only after that in a front facing seat. Dont use microwave to heat the milk, as it
heats the milk unevenly, and that can cause esophageal and tracheal burn. Hot
water less than 120F will prevent any scald burn.
104.
Child who received chemoradio in early childhood are at risk of
developing premature ovarian failure.
105.
Downs child is at risk of atlantoaxial subluxation during horse riding
and other things. Also hypothyroidism.
106.
Simian creases are found in 5% normal infants also, so without any
other feature, it doesnt demand any investigation.
107.
Recurrent otitis media- myringotomy tube helps reduce the frequency
and severity, plus allows delivery of topical antibiotic. So in those with tube in

place, only topical antibiotic can be used first. Switch to oral or iv if no

response only.
108.
If the baby is having rotaviral diarrhea, AAP recommends that he can
be sent to daycare if his stool can be contained in his diapers and dont spill
over. Careful handwashing with ethanol is the prevention. Only boiling water
wont help. Laundering clothes will not help (its for scabies only). Vaccine was
developed, but was associated with intussusceptions.
109.
A child who likes to be very neat comes with constipation. Ask about
whether he avoids school bathroom. Then do disempaction of stool, f/by
balanced diet and behavior modification. If its Hirschsprung, then the rectum
will be devoid of stool, unlike in functional constipation.
110.
A pt is diagnosed with recurrent ankle sprain. On examination, there is
a bony growth along medial malleolus. This is talocalcaneal coalition. Initially
the bar is unossified, but after ossification it limits subtalar motion and causes
heel pain. It needs CT to diagnose, XR wont show. Oblique XR shows
calcaneonavicular coalition however. Remember CT for TC coalition.
111.
A person with h/o sore throat comes with guttate psoriasis- do ASO
and rapid strep testing. Treatment with penicillin will limit the psoriasis also.
112.
A pt with vit D deficiency and marked genu varum- he not only needs
dietary supplement, but also long leg wt bearing XR and ortho consult.
113.
Nursemaids elbow due to radial head dislocation- tho many reduce it
without any investigation, its better to obtain an XR to document no other
fracture like supracondylar fracture or physeal separation is present.
114.
PANDAS- pediatric autoimmune neuropsychiatric disorder associated
with streptococcal infection. It presents with OCD like syndrome and tics.
Treatment is iv antibiotic and IVIG.
115.
Cradle cap in an infant is a type of seborrheic dermatitis- treatment is
brushing with a toothbrush to remove the scales, and daily bath with baby
shampoo, and applying baby oil or ointment before bathing to remove all the
scales. Scales in eyebrows can be removed with a cotton tip applicator dipped
in shampoo and then rinsed with water. Dont use high potency steroids like
betamethasone. It can cause atrophy, telangiectasia, steroid acne, glaucoma,
cataract and systemic absorption due to high surface to volume ratio of the
infants.
116.
A resident suspects child abuse and wants to speak to the child alone,
but the parents wont allow. What should you advise? Let the parents be there,
that will ease the examination. Then after hx and c/e, if abuse is suspected, then
separate him from the parent and contact the authorities.
117.
IHSS- treatment in symptomatic case is with negative inotropes like
verapamil or beta blocker, which slows the heart rate, which allows increased
LV filling, and dec force of contraction, which decreases flow velocity and
consequently decreases the degree of obstruction. Myomectomy of the septum
is the last resort in case of severe heart failure.
118.
Calcaneovalgus foot might be normal in early infancy, but if found at
2 yrs of age, ortho referral is needed. By contrast, flat foot, metatarsus
adductus, overriding 4 toe or toe walking are all benign and dont need
th

referral.
119.
Neonatal gonococcal conjunctivitis- apart from topical antibiotics,
systemic antibiotics for both gonorrhea and clamydia should be given.
120.
A pt comes with short stature, delayed puberty on examination, but
normal growth velocity (eg height velocity)- do wrist XR first to find if the
bone age coincides with the pubertal age (chronological age is not imp). If it
does,then its only constitutional delay, and the parents have to reassured that he
will gain a normal adult height eventually, depending on his parents final
height.
121.
A 6 wk baby with bilious emesis, slight distension of abdomen,
dehydration- suspect midgut volvulus. Usually the clinical picture is so classic
that imaging is not needed, so the TOC after rehydration is laparotomy. Delay
in treatment will result in shortgut syndrome, and TPN for the rest of life, with
its resultant complications like liver cirrhosis. If the pt is stable enough for
evaluation, then a upper GI series with follow thru will demonstrate the
abnormal position of the ligament of trietz.
122.
A pt with positive Barlow and Ortolani at birth- neednt do USG as it
is a clinical diagnosis, and USG can be negative falsely. XRs are useless before
4mo as the femoral head is not ossified. So the TOC is putting the baby in a
Pavlik harness, and then ortho consult.
123.
A child ingests a battery and is now stuck at mid esophagus level. IT
should be removed, as it has corrosives. Same for safety pin. If it is just a
coin,then we can do f/u XR to see its safe passage.
124.
A toddler comes with hyperthermia, tachycardia, tachypnea, vomiting,
diaphoresis, and he has a minty smell in his breath. Its oil of wintergreen
ingestion with salicylate poisoning.
125.
A child comes with pink eye, desquamation of hands and feet,
strawberry tongue- its Kawasaki disease. Thromobocytosis is an acute phase
reaction seen in the blood.
126.
A pt comes with acute bronchiolitis- the TOC is nebulised albuterol.
Steroids help in croup but not in bronchiolitis. Ribavirin is used only in those
with underlying disorders like bronchopulmonary dysplasia, prematurity or
congenital heart disease. NS nebulisation can act as an irritant and aggravate
the condition.
127.
Neonatal herpes- common in scalp and face area, can cause hepatitis,
pneumonia, coagulopathy, meningitis, paralysis, opisthotonus, and fatal if not
treated. Dx Is by Tzanck smear, or viral culture of skin lesion.
128.
Wood lamp will accentuate the pigmentation of epidermal nevus, but
not of dermal nevus.
129.
Congenital hydroceles only warrant observation- as most resolve by
themselves.
130.
Cat scratch disease- Bartonella; Tt is cotrim, or cipro or rifampin as
alternative.
131.
A child comes with cough during daytime only, worse on Mondays,
without any h/o allergy, and no response to medication, but is otherwise doing
well- its probably psychogenic cough (not exactly school phobia, as this is not

a scientific term)
132.
Rubella- evanescent rash that disappears within two or three days, post
auricular and postoccipital LN. arthritis in many, ITP and encephalitis in some.
Congenital Rubella syndrome if contacted during the first trimester.
Vaccination at 12-15 mo and then at 11-12 yrs. Live vaccine, so c/I during
pregnancy.
133.
Incubation period between contact with TB patient and tuberculin skin
test conversion is 2-12 weeks.
134.
Admission in burn in infants is mandated if BSA > 10% or 15% in
older child, but also in critical area involvement like face, hand, pubic area,
perineum, and electric burn. Remember all scald burns are not abuses- see if
the pattern matches the history or not.
135.
Pt with IDDM can deteriorate during his puberty due to different
hormonal changes. Honeymoon period refers to mth after dx before insulin is
needed.
136.
Human IG can be given for PEP to measles to children at special risk
only.
137.
Forscheimer spots are enanthem in Rubella.
138.
A child comes with abdominal mass that seems to arise from inf
venacava, its probably wilms tumor. 11p13 deletion is the most imp cause. By
contrast neuroblastoma is due to mutation in Nmyc gene, and presents with
fever, wt loss, abd mass, anemia and bone mets.
139.
A 12 yr comes with low grades in school, and language delay. He has
microcephaly. First thing to do is TORCH screen. Language delay can be due
to both mental retardation and hearing problems.
140.
BP msmts are initiated after 3 yrs of age, or earlier if born with renal
disease.
141.
A child comes with scarlet fever- all other ill siblings should also
undergo rapid strep testing and treatment. No need to test asymptomatic
siblings though. 24 hrs of antibiotics is enough before going to school.
142.
A physician is approached by a neighbor for an advice about his child,
he advises for free, and later the child deteriorates, and the neighbor decides to
sue the doctor. The court will hold the doctor liable, coz once you have given
advice, you have entered a doctor patient relation, and its your duty to fully
examine the patient.
143.
Pityriasis rosea- no treatment available, but UVB exposure can hasten
the recovery. These patients are very sensitive to irritants and friction, so only
lukewarm bath and no rubbing with towel.
144.
Pregnant with Giardia can be treated with paramomycin.
145.
First episode of concussion during sports- pt can get back to sport if
asymptomatic for 15 min. second episode, he should return to sports only after
a week.
146.
Erythema toxicum neonatorum- HPE shows eosinophils accumulation
around the pilosebaceous follicles in the dermoepidermal junction. D/d are
keratosis pilaris seen with atopic dermatitis, and neonatal pustular melanosis
which will show neutrophils, and leaves a hyperpigmented macule with scales

after the pustule ruptures.

147.
Girl comes with a pedunculated lesion on her face for a month- bleeds
with scratching. Its pyogenic granuloma, and is a vascular reaction to infection.
Treatment is destruction with curettage or electrodessication, liquid nitrogen or
pulse laser. It recurs after treatment .
148.
MOHS is used in melanoma if tissue sparing is a concern, if
recurrence in a scar, or location in planes of embroynal fusion.
149.
Bullous impetigo, especially following other dermatoses or
chickenpox, are caused by Staph aureus. Treat with ether topical mupirocin or
oral cephalosporin.
150.
Azelaic acid can be used for hyperpigmented lesions like
postinflammatory cases or melasma. Hydroquinone also blocks
melanogenesis, but prolonged use is associated with yellow brown permanent
pigmentation, called ochronosis.
151.
Cavernous hemangioma, even only cms wide, can cause DIC and
consumption coagulopathy with thrombocytopenia. Its called Kassabach
Merritt Syndrome. So early treatment is important with large hemangioma.
Another danger is compression of vital structures by rapidly growing
hemangioma, like esophagus or trachea.
MISCELLANEOUS FROM KAPLAN QBOOK
1.
When a pt with RA comes with erosions on XR, then he needs
DMARD- MTX is the DOC, as it is cheap, but it can cause hepatotoxicity- so
monitor LFT regularly and give pyridoxine with it ! Low dose prednisone is
used only if DMARD dont show adequate response.
2.
Pts with chronic hep C shouldnt be given iron supplementation, as
they are at risk of hemosiderosis for unknown cause.
3.
Charcot foot in a DM pt with neuropathy starts initially in acute
inflammatory stage like cellulitis with warmth, erythema, edema which
disappear on elevating the foot which is pathognomonic. Then it goes into
acute stage where there are periarticular fractures, then joint dislocation, then
comes subacute stage with bone resorption and finally fusion in chronic or
reparative phase. Tt is to limit wt bearing wth braces and cast. This can be seen
with tabes, and with pernicious anemia also.
4.
First thing to do in a new onset AF is TSH measurement.
5.
Inferior Mi patient develops brady and hypotension due to SA node
suppression, first thing to do is give atropine. If it doesnt help in 3 doses (total
2 mg), then temporary pacemaker is indicated. Volume replacement and
dobutamine if hypotension doesnt correct even after correcting the
bradycardia.
6.
Hyperprolactinemia and amenorrhea cant be due to anorexia- get a
MRI.
7.
Azelaic acid inhibits tyrosine kinase, so can be used for
hyperpigmentation or melasma.
8.
Steroid for long time for psoriasis is not recommened due to side
effect and due to tachyphylaxis. UVA with either coaltar (Goeckerman regime)

or antralin (Ingram regimen) can be used, but if there are systemic and joint
involvements, then the best thing is to start MTX.
9.
Unstable angina is the dx if pt comes with chest pain and s/s of
failure, like s4, rales, edema, etc- starting heparin is the TOC. Before
discharge, do a stress testing to quantify the risk. Coronary angio is not
indicated in all angina, only in those who report symptoms despite aggressive
management. Statins, aspirin, b blockers, ACEI, BP control and smoking
cessation have shown to increase lifespan in pts with angina, but not nitrates.
10.
Thyroid nodules that are not palpable but found on CT or USG need
only f/u, no FNA or f/u CT. thyroid scan is indicated only if hyperfunctioning
nodule, not in asymptomatic nodules.
11.
Pt with pancreatitis develops fever- promptly take blood culture and
start antibiotics (ampigentametro), only then do CT to see for any necrosis, if
necrosis is present and pt is febrile, then do CT guided aspiration for culture of
the pancreatic necrotic material.
12.
Guttate psoriasis can occur after Strepto throat infection.
13.
A pt with quadriplegia cannot ask for voluntary refusal of fluid and
food, he can be force fed, coz quadriplegia is neither a terminal condition, nor a
progressive one.
14.
ALT elevation asymptomatic, need only f/u after some months, other
investigations are warranted only if >3-5 times raised, if there are evidence of
chronic liver disease, or has persistent elevation on further testing. If no clear
diagnosis after serology for viruses, and autoimmune screen and USG, then we
have to do liver biopsy.
15.
Hampton hump is the opacity due to intranecrotic hemorrhage seen
in XR after PE.
16.
Asymptomatic sarcoidosis with only erythema nodosum and hilar
LN need no treatment.
17.
Nevus of Ota- oculodermal melanocytosis involving face and sclera
on one half of the face, esp along the branches of trigeminal nerve, has
increased risk of melanoma of choroid, brain, iris, skin and optic nerve.
Fatigue, stress and mens has shown to increase the pigmentation of the nevi.
18.
Immunocompromised pt develops pneumonia which progresses from
interstitial edema to necrotizing bronchopneumonia and then cavitation, its
Pseudomonas. Pt develops necrotizing skin lesion with blisters and pus
discharge- its ecthyma gangrenosum. No debridement is needed however, only
iv antibiotics after skin biopsy and blood culture are taken. It affects apocrine
skin specially, ie in the glabrous parts of body.
19.
Lichen planus, with white lacy streaks on buccal mucosa (Wickhams
striae) in a sexually active patient- do hepatitis panel, as it is associated with
hep C infection.
20.
Offer HepB vaccine in all with STD, and also in gay men, dialysis
patients and household contacts of pt with chronic HepB.
21.
Pt with DKA may have hyponatremia due to ECF dilution due to
water shift from intracellular to ECF. So the hyponatremia needs no treatment.
22.
A court summons you to talk about your patient- what do you do ?

first talk to patient as to what information he wants you to divulge. If pt doesnt

want any information to be given, still appear in the court but dont say
anything about the patient.
23.
A pt getting hydrotherapy for arthritis presents with itchy skin- its
asteatotic dermatitis, aka xerotic eczema- treatment is to avoid the
hydrotherapy.
24.
Butcher develops bright red lesion due to an accidental cut on hand,
with vesicles and smooth shiny plaques, its Erysepaloid due to Erysipelothrix.
Treatment is penicillin oral, or Erythro with rifampicin if pt cannot tolerate
penicillin. Debridement is not needed.
25.
Imipenem lowers seizure threshold
26.
Allergic alveolitis, aka acute Hypersensitivity pneumnitis, in a person
who clears bird cages- treatment is to avoid exposure. Psittacosis presents with
similar clinical and radiological picture, but has more systemic features like
fever, and is treated with doxy.
27.
Necrobiosis lipoidica diabeticorum: erythematous papule,
telangiectasia, atrophy, ulceration, scarring, treatment is local steroid and not
diabetes control.
28.
Arsenical keratosis in a patient who worked in smelting furnance,
electronics industry, preservatices or paints and pesticides- hyperkeratosis of
palm and sole (like corn), raindrop hyperpigmentation, exfoliative dermatitis,
Mees lines, polyneuritis, peripheral vascular disease culminating in blackfoot
disease (gangrene), and cancer of skin (
BCC and SCC), and liver angiosarcoma.
29.
Pt taking isotretinoin for acne- 2 pregnancy test should be negative,
should use 2 contraceptives, cannot donate blood upto 1 mo after stopping it,
shouldnot wax skin upto 6 mo due to risk of scarring, and should be warned
about myopathy and about driving in the dark, as many have decreased night
vision.
30.
Pt receiving Radioiodine for Graves disease shouldnt have close
contact with children, eg in day care job.
31.
Hyperthyriodism in elderly maynot have tremor.
32.
Lanolin in different over the counter creams can cause allergic
contact dermatitis.
33.
Trichophyton tonsurans is the MCC of black dot tinea capitis in
children, and the adult can then contract the same on his skin from the child. M
canis is less frequently seen these days, and causes inflammatory patch in the
scalp with broken hairs. Epidermatophyton flocossum affects glabrous skin like
in athletes foot.
34.
Corynebac minutissimum causes erythrasma in glabrous skin, like
groin and axilla, and is known for coral red fluorescence on woods lamp.
35.
Self breast examination is no more recommended, as it has no
benefit.
36.
Minimum screening age for cholesterol is 18, or 30 by most panels.
Total cholesterol panel is these days recommended instead of screening random
cholesterol.

37.
Hemoccult test positive in an elderly patient with hemorrhoid can
still be due to colonic polyp or malignancy- so colonoscopy is still indicated
38.
A pt on alprazolam for anxiety for yrs comes with BZD overdoseflumazenil shouldnt be used in pts with physical dependence as it can
precipitate seizures. Flumazenil is only useful in acute overdose cases.
39.
Pt who is not braindead but who is certain never to recover his
functions, and who can never be weaned off ventilator, can be discontinued, on
grounds of FUTILITY.
40.
A PT on treatment for pyelonephritis doesnt respond to antibioticsdo CT to rule out perinephric abscess.
41.
Contact dermatitis- treatment is oral prednisolone, esp if hands and
face are involved, as you cant use potent steroid over those sites.
Methylprednisone can be used in low dose with acute taper, but shouldnt be
repeated for fear of significant rebound flares.
42.
Pt on risperidone, elderly, can cause chronic fecal impaction and
overflow diarrhea, treatment of constipation by fiber supplementation is the
treatment of choice. Mineral oil is c/I as it can cause lipoid pneumonia due to
aspiration, as well as rectal leakage. Mag salts can cause excess and dangerous
fluid shifts in elderly.
43.
Pt with recurrent outbreak of herpes genitalis, should be put on long
term acyclovir oral. After about a year, discontinue to see the frequency of
outbreak, and if the frequency has decreased considerably, then stop the drug.
Lifelong treatment is not needed. Pt should use barrier contraception to prevent
transmission.
44.
A pt with symptoms of pneumonia but has normal XR- rehydrate him
and then repeat the XR. The pneumonia might show up.
45.
Data is given for effect of drug in lowering BP, with mean, median
and SD. Then asked to find the degree of benefit of a patient. If the mean is
very different from median, then it is a skewed distribution, so the rule of
confidence interval doesnt apply, so the answer would be cannot be
determined from the given data.
46.
Pt comes with postconcussive syndrome, olfactory hallucinations
signifying temporal lobe epilepsy- the best next step is to refer to a neurologist.
47.
Mild concussion in a game, without LOC player can return to the
game within 30 min if normal exam and without symptoms- vomiting or
headache are not indications for further investigations, unless they are
persistent.
48.
Chloral hydrate displaces warfarin from protein binding sites,
causing overcoagulation or hypocoagulation.
49.
In a pt getting methylprednisolone for multiple sclerosis, monitor his
blood sugar, keep him on insulin sliding scale, even if not a diabetic, and a
diabetic diet should be used.
50.
Transient global amnesia is a cryptogenic condition without any
treatment.
51.
In a pt with HIV and multiple stressors, if he comes with gait
disorder but normal neuro exam except for a wide based gait, its probably

psychogenic gait disturbance.

52.
Stye needs only antibiotic drops and warm compresses- not IND
53.
In a meningitis suspect, first thing to do is starting antibiotic, then CT
to rule out mass lesion like abscess, and then only do LP.
54.
A pt comes with headache. Examination is normal. You consult a
neurologist on phone, he asks to discharge the pt on analgesic. Later the pt dies
of aneurysm. The court will indict the neurologist if he has directly spoken
with the pt over the phone, coz that will make them doctor pt in relation, else
he has no liability.
55.
Wife caring for a demented husband- providing respite for the wife
(with use of home services or nursing home for a short period of time) can
delay permanent admission of the pt into a nursing home re.
56.
Donepezil is the DOC in Alzheimers due to least side effect.
Gallantamine is c/I with hepatic or renal impairment. Rivastigmine has caused
severe vomiting and even esophageal rupture. Tacrine can cause serious
hepatotoxicity and is rarely used these days.
57.
Ultraviolet keratoconjunctivitis in pts who ski.
58.
A nursing home wants to use a test inmates for highest risk of
developing Alzheimers. For the test to include maximum patient s with risk of
Alzheimers, the nursing home should use the test with the highest sensitivity,
and not highest specificity or highest PPV. Think.
59.
Cerebral palsy usually occurs in baby with normal wt at birth, and
normal POG. There is very poor correlation with perinatal asphyxia or low
APGAR scores.
60.
A pt who is undergoing CABG develops amaurosis fugax- should
undergo carotid ultrasound before surgery because these patients can develop
stroke on bypass machine if they have carotid stenosis.
61.
Daily metaxalone is useful for tension type headaches.
Some more
1. A pregnant patient comes with paralysis below the umbilicus, but reflexes are normal
and MRI is normal too. This is conversion disorder related to the stress of pregnancy.
Best way is to reassure the patient that it will get better on its own. Support is better than
confronting the patient with the diagnosis.
2. CT urogram ie with iv contrast is preferred over IVP nowadays for intial
investigation of asymptomatic hematuria (if pt has s/s of infection or stone, then detailed
investigation is not needed). Next step is cystoscopy and then urine cytology.
3. Clinda and genta is the TOC for postpartum endometritis, coz metro isnt to be used
in breastfeeding, tho it can be used in pregnancy with caution.
4. For condyloma acuminata, TCA acid and not podophyllin, coz the latter shouldnt be
applied to mucosal surface.
5. PMDD (dysphoric disorder) is the severe form of PMS- 15% are resistant to
fluoxetine, in those cases alprazolam is the second line drug.
6. LEEP is the TOC for HSIL or CIN II and higher. Ablation is less reliable than
excision in high grade lesions, thats why LEEP is preferred over laser/cryo or even cold
knife conisation.
7. neonates to 1 year- N/4 saline, 1 to 4 yr- N/3 saline, 5- 10 yr- N/2 saline, >10 you

can give NS.

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

overridden by will- and shirt isnt considered as a will.

21.
A pt tried to kill himself by striking his car on a tree, and is now
refusing surgery to stop his bleeding. What to do? Do the surgery. A patient in
acute stress, and who attempts to kill himself, is NOT competent to make his own
decisions. Therapy can change his mind later, so save him first. Thats the same
logic why suicidal patients can be detained against their will.
22.
A pt is refusing to tell his divorced wife and kids that he has FAP.
What should you do? Inform the wife!! Confidentiality ends when sb else would
be harmed.
23.
A patient wanting romantic relation with you- say, I cant date
you now, maybe I can after you get a new doctor. Atleast the doctor patient
relationship has to end before you can date her.
24.
A bus driver with sputum+ TB consistently refuses to take
DOTS. What to do? Remove the patient from his duty and incarcerate and treat
him in the hospital till his sputum is clear, as he is jeopardizing the health of
others.
25.
A pt has no healthcare proxy or living will and gets unconsciousthere is no agreement among the family members about the best step in
management. What to do? Go to ethics committee, and then to the court if
necessary.
26.
You donot have to agree with an adult patients wish, but you
have to comply with it!! Hmm nice.
27.
Your patient refuses a treatment, and you are not comfortable
with it- you can transfer the patient to another colleague. Eg you are religious and
oppose abortion, then you can refer your patient to somebody who is comfortable
with it.
28.
Never postdate your note. If you find error in your earlier note,
write a new note with the correction.
29.
A pt is unconscious and has no proxy or will- if the family
members can be in unison about the substituted judgement about the care of this
patient, they can order anything, and can stop any treatment.
30.
DNR doesnt mean discontinuing ventilation, NG and fluids in an
unconscious patient.
31.
A doctor unintentionally gives wrong dose to a patient- he is
responsible, as are the nurses and the pharmacist.
MISCELLANEOUS AGAIN.
32.
HRCT and not USG is the investigation of choice for renal stones.
33.
Beta blocker, including labetalol, are contraindicated in patients with
cocaine overdose.
34.
Best initial step for stopping drug abuse is sending the patient to drug
rehab, and not to group therapy. Group therapy like AA is for maintaining abstinence and
preventing relapse once detoxification is done.
35.
BP control is most important to prevent cerebrovascular mortality. Lipid

control is the most important in preventing cardiovascular morbidity.

36.
Screening for DM with FBS and not RBS is recommended 3 yrly in all
patients above 45 yrs of age, and earlier if risk factors like HTN, family history of DM in
first degree relatives, dyslipidemia, overweight, inactivity, PCOD, GDM, vascular
disease, or African American or Hispanic race.
37.
PSA screening for prostate cancer begins at age 50, but for those with
family history, it should begin at age 45.
38.
A pt with borderline personality says her doctor is the best and saved
her life- its primitive idealization, a part of splitting. So tick the former in mcq!!
39.
Dialectical behavioral therapy is one of the most effective treatment
for borderline personality! TCAs are c/I as these patients have high rate of suicide.
40.
Interpersonal therapy is used for depression. Also CBT.
41.
SSRI are the TOC for depression, even before psychotherapy. OCPs
have no relation with depression, DMPA is suspected to have, but the evidence till date is
inconclusive.
42.
Repeated hospital admission with polymicrobial(including anaerobic)
bacteremia should be considered factitious disorder, with patient injecting himself with
fecal material.
43.
Iron studies should be done in patients with restless leg syndrome, as
IDA might be the cause.
44.
Urine immunoassays (and not gas chromatography) are employed for
drug screening.
45.
An elderly started on fluoxetine comes with severe side effects and want
another drug with better s/e profile- start him on sertraline and not nortryptiline or
imipramine, as the latter have improved safety compared to amitryptiline, but still are not
as good as SSRI. TCAs are less preferred in elderly also coz they are at high risk of
suicide.
46.
Pts with AICD implantation-if they have PSVT due to panic attack,
they can get repeatedly shocked by the ICD.
47.
A pt has symptoms of mania with type A schizophrenic symptoms like
delusions and hallucinations- he is having schizoaffective disorder! Like a person who is
manic at one time, and other time thinks that a famous popstar will marry him and sings
only for him.
48.
Reactivation with herpes zoster increases with age!
49.
Paroxetine, citalopram, sertraline and new tetracyclic maprotiline all
cause weight gain, and should be substituted instead of fluoxetine if the wt loss due to
the latter is troublesome to the patient.
50.
Hepatorenal syndrome- urine Na<10 and urine osmolality>serum
osmolality are diagnostic. Not FENa.
51.
Pt comes with gross hematuria 3d following URTI, and there is no
HTN- its IgA nephropathy and not PSGN.
52.
Priapism can cause ischemic necrosis and impotence- first treatment is
ice packs, then phenylephrine injection every 5min (or epinephrine). oral terbutaline is
also effective but not TOC.
53.
Pt with shock, pre-renal ARF with hyperkalemia and acidosis, use D5W
with low amt of bicarb as treatement.

54.
DM patients can have emphysematous pyelonephritis due to E coli
and Klebsiella- with gas present in perinephric area. Nephrectomy is immediately
warranted.
55.
Cimetidine, Probenicid and Trimethoprim cause inhibition of tubular
secretion of creatinine, causing isolated rise of creatinine in the serum, with normal
BUN!
56.
A 75M comes with insomnia after the death of his wife- treat it like
insomnia with psychotherapy. Avoid drugs in elderly, as it increases the risk of falls and
fractures.
57.
Lithium can cause alopecia, but doesnt cause split hairs. If there are
split hair ends visible, aka trichoclasis, its due to chemical reaction or due to
trichotillomania.
58.
Corneal foreign body frequently test positive for coagulase negative
Staph.
59.
Patient with DM comes with hyperosmolar coma-the increased
osmolality of blood will draw intracellular water causing dilutional hyponatremia, and
after the water is diuresed, there will be hypernatremia. So for every 100 mg/dl of
glucose above normal, add 1.6 mmol/l to the Na concentration. So in these patients
hydration should be with half NS.
60.
Hypocalcemia presents with increased DTR, convulsions, muscle
cramps etc. Hypomagnesemia causes similar, but is seen after diuresis, NG aspiration,
alcoholism and diarrhea.
61.
In a critical patient on dextrose drip and intubation, PO4 depletion can
cause severe muscular weakness (as no ATP can be formed), and inability to wean from
the ventilator.
62.
Zn deficiency causes decreased wound healing and skin rash.
63.
Patellofemoral pain syndrome aka chondromalacia patella is like
Osgood Schlatters disease but in adults from 20-40 yrs, associated with overuse, with
theater sign positive (climbing stairs or getting up after prolonged sitting), crepitus and
pain on deep pressure on patella. Osgood causes pain over tibial tuberosity and not
patella. Patellar tendinitis, aka jumpers knee, has tenderness in infrapatellar region.
Anserine bursitis causes pain on the medial aspect, while prepatellar bursitis causes
anterior knee pain with signs of inflammation.
64.
Trick question- a pt who fulfills 4 criteria for SLE, but has dsDNA
negative and RA positive, its still SLE. This is because dsDNA is highly specific, but
only 70% sensitive, ie there can be many false negatives. MCTD needs RNP antibody,
with features of systemic sclerosis, polymyositis and SLE all.
65.
CPK shouldnt be routinely ordered in pts on statins, coz exercise can
cause rise in CPK too. Stopping statin is only needed if it is increased more than 10 fold.
66.
A pt with diffuse systemic sclerosis- most effective measure to prevent
renal disease is monthly BP measurement re. Steroids can infact increase the damage if
used in high does, and ACEI and ARB are only used if the patient presents with renal
crisis.
67.
Premature atherosclerosis is the MCC of cardiovascular mortality in
patients with SLE.
68.
In the absence of symptoms, never do ANA, as it has a high false

positivity rate. IF it comes positive, and the patient has no symptoms, no need to follow
up with dsDNA too.
69.
Parvoviral arthritis can present with weak RA factor positivity, but it
usually lasts for less than 6 weeks. So before 6 weeks have elapsed, dont label anybody
as RA.
70.
Low back pain in <50 has <1% of being anything but musculoskeletal.
So only bed rest and physical therapy. But if he doesnt respond in 6 wks, then do ESR
to rule out malignancy or infection. If it is raised, only then do lumbar XR.
71.
If seronegative spondyloarthropathy is suspected, eg reiters arthritis
associated with UTI, then the first thing to do is XR of pelvis. Though HLAB27 is
positive in many, its not specific and hence is not recommended as the first step. Arthritis
due to IBD wont have conjunctivitis. Rx of Reiters is antibiotics, MTX or sulfasalazine
and progressive exercise.
72.
XR pelvis is preferred to HLAB27 even in ankylosing spondylitis
suspect, as evidence of sacroileitis is needed for diagnosis. Life expectancy is not
reduced and there is no overall functional disability re !!!!
73.
Sjogren is associated with B and not T cell lymphoma.
74.
NSAID are the TOC in adult Stills Disease, with evanescent salmon
colored rashes and spiking fever with myalgia and arthralgia. Steroids only in severe
disease with myocarditis etc. Monitor LFT in patients on long term NSAIDS.
75.
Occupational rehab is important for patients with carpal tunnel
syndrome who dont respond to night time splinting of hand, NSAID and steroid
injection. Ergonomic keyboard have been proven not to help.
76.
Tarasoff I is informing the person who is about to be harmed. Tarasoff II
is protecting the person from harm by detaining the threatening patient.
77.
Thyroid nodule- first do TSH. If normal, ie cold nodule, do FNAC. IF
low, do RAIU- if the latter shows hot nodule, then RAI ablation or followup if
asymptomatic. IF RAIU shows cold, FNAC again. IF TSH high( rare, due to Hashimoto),
do USG to see if this is the only nodule or if it is the dominant nodule. IF USG is
suspicious, FNAC again. IF FNAC shows malignant, surgery, if inconclusive, do FNAC
again; if its benign, then no treatment or thyroxine to suppress TSH for cosmetic reason.
78.
For thyroid incidentalomas found on USG, FNAC only if >1cm of size,
alarm features like microcalcifications, irregular shape, hypoechoic, or if f/h of thyroid
malignancy.
79.
Pts with cirrhosis admitted for variceal bleeding are at increased risk of
SBP, and other infections too- hence should be put on prophylactic ciprofloxacin for a
week !
80.
Pt on oral retinoids for acne comes with pancreatitis- simple hydration
with dextrose will increase endogenous insulin secretion, which will help in metabolizing
the hypertryglyceredemia that is causing the problem. If this doesnt work, then dextrose
insulin infusion can be started.
81.
Symptomatic AS should be promptly treated with valve replacement,
even in 70 yr elderly, and shouldnt be left out considering it as sclerosis of the valve.
82.
If a pt on CCB comes with MI, stop it, coz there is no benefit, and
infact possibility of harm with CCB in such patients.
83.
Acute aortic dissection- iv labetalol is the DOC. Dont use

nitroprusside without beta blockade, as it causes reflex tachycardia which can increase
the dissection.
84.
An adult comes with syncope, has no other risk factors- the first thing to
do is not Holter but a simple hx and ex and an ECG !
85.
In all patients with torsades, give magsol irrespective of the magnesium
level. If magsol cannot prevent the recurrence, then do transvenous temporary pacing.
86.
Stop metformin in pts undergoing diagnostic cardiac cath, as the
contrast agent can precipitate renal failure.
87.
For acute rate control in AF, use diltiazem or B blockers and not
digoxin, as the former when given iv will act within 5 min, while digoxin even if given iv
will take hours to act.
88.
Goal INR for mechanical aortic and mitral valves is 2.5 to 3.5.
89.
Verapamil inhibits tubular secretion of digoxin, causing 100% increase
in its levels and toxicity. Amiodarone and quinidine also cause digoxin toxicity, so does
spironolactone.
90.
Orthostatis hypotension- 20 mm fall in SBP, or 10 in DBP
91.
In pts with preexisting heart disease like CAD and AF, amiodarone is
the DOC for keeping the patient in sinus rhythm for long term! Rhythm control is
preferred in patients who are still symptomatic on rate control, eg with palpitation,
dizziness, dyspnea. Amiodarone even if pt has hypothyroidism!! This is because other
antiarrythmics can easily cause fatal arrhythmia in someone with preexisting heart
disease, while amiodarone is very safe in this regard.
92.
Aspirin is sufficient to prevent stroke in patients with lone AF, which is
diagnosed after all other causes of AF have been ruled out. Warfarin has more risks than
benefit in such setting.
93.
Angina at rest and critical AS carry 20 points on preoperative
cardiovascular risk assessment. These are the highest risk factors. Also JVD.
94.
Amiodarone with warfarin- decrease warfarin dose by 25%
95.
MRI is the best modality to diagnose suspected coarctation of aorta,
better than CT
96.
Thiazides are sulfonamides, so can cause photosensitivity rash- thiazide
should be discontinued in that case.
97.
BMI of 30 with HTN and smoking and alcohol- the most effective
nonpharmacological intervention for this patient is weight reduction, more than reduced
Na diet.
98.
Radionuclide imaging is preferred over stress ECHO in patients with
angina and previous revascularization, previous MI which precludes use of ECG, and
residual wall motion abnormality due to previous MI precluding the use of ECHO.
99.
A pt with h/o severe angioedema with DM and HTN, prescribe
metoprolol and not losartan- as there is a low but present danger of angioedema even
with ARBs.
100.
Pt on hydralazine- advice to report any flu like symptom, coz that can
herald the development of SLE.
101.
Ator and lovastatin should be changed to pravastatin in patients with
hyperfibrinogenemia, as this is an independent CAD risk factor.
102.
Recent onset angina is unstable angina, and the best thing to do is early

coronary angio, and not stress testing, especially if the pt is diabetic, coz diabetics have
a very extensive coronary blockade.
103.
If INR is high in a pt on warfarin, but not above 5, then only holding the
Coumadin for a few days will do. Higher than that needs oral vit K. FFP and iv vit K is
only needed if the pt is actively bleeding.
104.
Reducing LDL is the most effective way of decreasing the CAD risk, BP control
comes second, then DM control and smoking cessation. But DM is the single most
important predictor of bad cardiovascular outcome, still glycemic control hasnt been
proved to be much useful. Thats why DM is categorized as CAD equivalent.
105.
In a pt with subclinical hypothyroidism, do antithyroid antibodies. If they are
positive, then even subclinical disease needs thyroxine replacement.
106.
A pt who got intraarticular steroid for gout 7d back comes with deranged
glyccemic control. The derangement is due to the stress and not steroid itself, as the
steroid disappears from blood within a few days.
107.
Pt on HRT comes with DVT- dont fall for the trap where answer says
discontinue HRT immediately. It should be tapered off, not discontinued abruptly. So
the best thing to do is start the patient on unfractionated heparin. Warfarin is needed for
atleast 3mo in patients with reversible risk factor, 6mo if no risk factors identified, and
lifelong if repeated.
108. Refractory hypoglycemia due to sulfonylurea is treated with sc octreotide.
109.
A pt on glargine and lispro wants to exercise, but is facing hypoglycemia after
exercise in the morning, and when she tried reducing her evening glargine, then her
prelunch and predinner sugar went up. The mgmt is insulin pump, which gives much
flexibility to the patient. Also advise for snack before exercise.
110.
Insulin shouldnt be stopped in the preop night in DMI even if NPO, as this can
cause DKA.
111.
DM pt on metformin comes with acidosis and weakness- with normal glucose
and no hyperamylasemia, then its not DKA but lactic acidosis- so send ABG and lactic
acid levels.
112.
Pt with hypothyroidism shouldnt postpone emergency surgery. Oral thyroxine
can be replaced after surgery. T3(liothyronine) is not indicated for hypothyroidism re!!
113.
PAD (PVD) is a CAD equivalent. So if LDL is above 100, start diet and
atorvastatin stat. Also for exercise pain, the best therapy is supervised exercise program.
Cilostazol also decreases the pain but is used only if supervised exercise fails.
Pentoxifylline is a third choice. If this pt has MI, then he should be put on beta blockers,
but dont use metoprolol, use combined alpha-beta blocker as they will not cause
vasoconstriction, like labetalol and carvedilol.
114.
Clopid has been shown to be more effective than Aspirin in reducing
cardiovascular mortality in patients with PAD (and probably other risk factors also).
115.
Ant epistaxis- Littles or Kasselbach plexus; post- Woodruffs plexus, formed by
sphenopalatine artery, and common in adults with HTN. The posterior bleeding is usually
more severe.
116.
A pt with allergic rhinitis is going for scuba diving. He shouldnt fly within 24
hrs of diving to prevent barotraumas, especially because his ETT wont function properly
due to the edema related to the rhinitis. Also use of topical pseudoephedrine has shown
to decrease barotraumas by 75%.

117.
T1 laryngeal tumor is treated with RT mainly, to preserve the vocal cord.
Excision with CO2 laser can be done too. Hemilaryngectomy for T2 or those involving
anterior commissure. In t3, induction chemotherapy f/by RT can be tried to preserve the
Vc, and if it fails, then total laryngectomy should be done.
118.
Otitis externa with lots of wax- first step is to clean the wax and debris with
cerumen wire loop or cotton swab! Irrigation only if TM is visible and intact. Only then
topical antibiotics.
119.
A pt comes with allergic rhinitis- the best next step is to do nasal cytology re!
Eosinophils point to allergic rhinitis, and if absent, point to vasomotor rhinitis !
120.
A patients seems to be brain dead, but has hypothyroidism, or electrolyte
anomaly or hypothermia- in such patients in whom the criteria is not met, do technetium
brain perfusion scan as the second confirmatory test apart from the apnea test and
caloric testing and CT. Other secondary tests that can be used are EEG, carotid Doppler,
cerebral angiography, and evoked potential in median nerve!
121.
Upright supine position is more effective than left lateral in preventing aspiration
in coma.
122.
Tick borne paralysis after hiking in the woods can resemble GBS- dx is by
finding tick after careful skin examination. Eg Rocky Mountain wood tick and American
dog tick.
123.
A pt who is hypothermic or in shock or hepatic or renal failure can have severe
hypocalcemia when being transfused blood, as the citrate cannot be metabolized by the
liver and the kidney.
124.
Headache doesnt need cT or MRI unless it is debilitating, or doesnt imrove
with appropriate medication, or starts after exertion like sex, especially in elderly.
125.
Pts on disease modifying drugs for MS like glatiramer or interferon should be
using contraceptives, as these drugs are shown to be teratogenic. MS patients who present
initially with only sensory or optic symptoms have good prognosis than other
presentation.
a. A pt with terminal cancer (and Cheyne Stokes) respiration shouldnt be resuscitated,
on grounds of futility.
b. Start selegiline first in patients with mild symptoms of Parkinsonism- it delays the
progression of disability. It is a disease modifying drug. If its effectiveness
decreases,then add levodopa. Amantadine and trihexiphenidyl are not the first
choice.
BIOSTATISTICS

1. Suicide rates in physicians are found to be higher than in general public.

This is because of the confounding by high socioeconomic status. To find
the true effect, we have to calculate the adjusted rates, aka standardized
rates.
2. One study found high risk of colorectal ca in those who consume saturated fat
(RR=4). What percentage of colon ca can be attributed to fat consumption? ARP=41/4=75%. Attributable risk percent indicates the excess risk in exposed population that is
explained by the risk factor.
3. Tighter the confidence interval, more precise is the study. Increasing the sample size
increases the precision of the study, but it doesnt affect the accuracy. Accuracy and

validity represent the measure of systematic bias. Accuracy is when test-retest reliability
is good. Wider the CI, more accurate and less precise is the test.
4. Sampling bias- sample is not representative of the population. Eg predicting
population prevalence by hospital studies (Berkesonian bias), people included in the
study are significantly different from those not in the study( Non-respondent bias). How
to prevent it? Randomisation
5. Respondent bias- when the outcome is obtained by the patients response and not by
objective msmt.
6. Measurement bias- asking leading questions( you dont like your doctor, do you?),
Hawthorne effect (subjects behavior changes bcoz they are being studied). Preventioncontrol group/placebo
7. Pygmalion effect- experimenters expectations are communicated to subjects. Can
be avoided by double blind studies.
8. Lead time bias: false estimate of increased survival when the disease is uncovered
by a screening test at an early stage. Prevent by measuring back end survival.
9. Recall bias- patients fail to accurately recall the events in the past.
10.
Late look bias- severe pts die and are not included in the study, for eg
one study showed that pts with AIDS only have mild symptoms. Prevent by stratifying
by severity.
11.
Confounding
12.
Unacceptability bias- medical students may not uncover their smoking
status in a study, coz they know that smoking is harmful.
13.
Effect modification: effect of estrogen on the risk of DVT is modified
by smoking.
14.
Loss to follow up will cause selection or sampling bias.
15.
Likelihood ratio is TP/FP rate, or sensitivity/(1-specificity). If a test
has sensitivity of 0.9 and specificity of 0.9, then its likelihood ration is 9, ie a positive
result is 9 times more likely in a patient with disease than in patient without it.
16.
Likelihood ratio for a negative test is given by (1-sensitivity)/specificity.
Smaller the likelihood ratio, better the test performs at ruling out the disease.
17.
A distribution with 10,10,10,20,20,40,50 is positively skewed, as most
of the entries are clustered on the left (low end), and the tail is on the right end, and hence
mode>mean.??

ACID BASE DISORDERS:

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

clues in the question stem.

G) Osmolar gap and using this concept to identify the etiology in metabolic
acidosis and in toxicology.
Memorize the following formulas:
1) Anion gap = (Na+)-{(Cl-)+(Hco3-)}
Normal gap is 4 to 12.
Anion gap greater than 12 indicates increased anion gap metabolic acidosis. This
indicates the presence of a foreign substance causing acid-base imbalance.
If there is acidosis ( low bicarb <>It is important to know the distinction because
the causes of increased gap metabolic acidosis are different from non-gap
acidosis. So, once you know whether the gap is increased or not, you can further
focus only on the relevant causes.
Causes of Increased Gap Acidosis ( MUDPILES)
- Methanol (M)
- Uremia (U)
- Diabetic Ketoacidosis ( D)
- Paraldehyde, Propylene glycol ( P)
- Isoniazid ( I)
- Lactic acid (L)
- Ethylene Glycol (E)
- Salicylic acid ( S)
Causes of Non-Gap acidosis : The gap here is normal because when the hco3drops, there is a compensatory increase in the chloride there by, keeping the gap
normal. This indicates no foreign substance but it is because of the loss of
bicarbonate either through the GI tract ( Diarrhea) or Renal system ( RTA). These
causes are:
- Gastrointestinal loss of Bicarbonate : Diarrhea, small bowel fistulas, urinary
diversion
- Renal causes : Renal tubular acidosis, renal insufficiency, hypoladosteronism.
- Recovery phase of DKA
Concept of Urine Anion Gap
Now, let us say you have a metabolic acidosis and the gap is normal --> you
know that this is normal anion gap acidosis. But there are two important causes
of normal gap acidosis as you have already seen earlier - GI vs. Renal . How do
you differentiate between the two?
For this, you will need to know URINE ANION GAP
Urine Anion Gap (UAG) = {(urineNa)+(urineK+)}-(urine Cl-)
Normal values for UAG is -10 to +10.

A logical approach here is to look at the urine Na+. If urine Na+ is low ( which
you would expect in dehydration, diarrhea etc), urine anion gap tends to be more
negative and points towards GI losses ( such as diarrhea)
So, a UAG < -10 ( more negative gap) indicates a GI cause for Non Gap
Acidosis where as a UAG > +10 indicates a Renal Tubular Acidosis.
If you have difficulty remembering this, remember neGUTive - negative
UAG in bowel (GUT) causes.
Renal Tubular Acidosis ( RTA)
A normal gap metabolic acidosis with positive urine anion gap ( UAG) could be
due to RTA. There are different types of RTA.
Type 1 ( distal)
Type 2 (proximal)
Type 4 (hyporeninemic hypoaldosteronism)
On the exam, once you identify a metabolic acidosis and then identify an RTA,
you will be tested on the etiology of that RTA. So, it is important to know how to
differentiate between different RTAs and their causes.
To differentiate between various RTAs, first look at the serum potassium. If
K+ is high in an RTA , this is most likely Type 4 ( because low aldosterone
causes decreased renal excretion of acid and potsssium) If the potassium is
normal or low, then the RTA could be Type 1 (Distal) or Type II (Proximal).
You will need to look at the urine pH to differentiate between Distal and
Proximal RTA. Remember that Distal RTA can never acidify the urine so,
the Urine pH is never less than 5.5. So, if a MCQ gives a urine pH of less
than 5,5, you are most likely dealing with Proximal RTA.
Type 1 RTA - Distal RTA :
- Causes: autoimmune diseases ( scleroderma), hyperglobinemia states and
hereditary
- Present with normal anion gap acidosis, urine pH >5.5, hypokalemia,
hypercalciuria, nephrocalcinosis and stones
- Treatment: alkali i.e. K citrate
Type II RTA - Proximal RTA :
- Failure to reabsorb filtered bicarbonate in the proximal tubule
- Presents with Hypokalemia and normal gap acidosis
- Urine pH > 5.5, but it will be less than 5.5 once serum HCO3 is less than 16
- Causes: Multiple myeloma, Acetozolamide, Ifosfamide Lead, cadmium, copper
Type IV RTA - Hyporeninemic Hypoaldosteronism
- Causes: diabetes mellitus, HIV and tubulo-interstitial disease
- Present with hyperkalemia, normal anion gap acidosis and normal urine pH

Identifying Mixed Acid-Base Disorder in Metabolic acidosis

A) To understand if a patient has both increased anion gap acidosis and non-gap
acidosis at the same time or metabolic acidosis + metabolic alkalosis at the same
time, you will need to know the concept of "Delta Gap" . Delta gap is logically
explained in the video clip below. Logically, if the serum bicarbonate (Hco3-)
falls more than the change in the anion gap, then a patient has both nongap+increased gap acidosis. If the serum bicarbonate falls less than the
change in the anion gap, then the patient has mixed disorder - metabolic
acidosis + metabolic alkalosis.
For example, if the anion gap is 20 --> you can say the change in the anion gap is
8 ( because normal anion gap is 12. ) In this scenario let us say if the MCQ gave
serum hco3- as 10, drop in the serum bicarb here is 14 ( remember, for
calculation normal serum bicarb is taken as 24. so, if it is 10 now, the drop in
bicarb is obviously, 14). --> this means when your anion gap has increased by 8
your bicarb has fallen more than 8 i.e; by 14....that means some other factor apart
from the factor responsible for increased gap acidosis is also contributing to
acidosis here! - this suggests co-existing increased anion-gap+normal-gap
acidosis . A classic example is diarrhea with shock - where diarrhea causes non
gap acidosis but shock can lead to lactic acidosis which increases the gap - so,
things can co-exist!
B) To understand if your patient has a mixed disorder of metabolic acidosis +
respiratory acidosis or metabolic acidosis + respiratory alkalosis, you will need
to be familiar with Winter's formula.
Winter;s formula :
Expected pCo2 = {1.5(Hco3-) +8} +/-2
If your patient has metabolic acidosis, you expect him to breathe fast and wash
out the Co2 so as to maintain the pH in normal limits ...this is called
"Compensation". Compensation brings the serum pH towards the normal but
never makes it completely normal - so, if you are seeing a normal pH in a
metabolic acidosis , you can right away say that you are dealing with a Mixed
disorder rather than a compensation alone.
The expected Pco2 in the above formula is the one that is expected as a
comprnsation if your patient has low bicarbonate or metabolic acidosis. You need
to compare this expected Pco2 with the real value of Pco2 obtained on the
arterial blood gases ( measured Pco2).
Pearls for answering questions on Mixed Disorders:
A) If measured Pco2 is lower than the expected Pco2, that means your
patient is washing out more C02 than expected ---meaning, he has

respiratory alkalosis co-existent with metabolic acidosis ( one example of

such mixed disorder is Salicylate toxicity) .
B) If measured Pco2 is higher than expected Pco2, that means your patient
is retaining Co2 which means he has a co-existent Respiratory acidosis along
with metabolic acidosis ( eg: Cardiac arrest can cause such mixed acidosis
because reduced respiratory drive causes CO2 retention leading to respiratory
acidosis where as shock because of cardiac arrest causes lactic acidosis which is
metabolic acidosis).
eg: If Hc03 - is 16, the expected PCo2 as per Winter;s formula should range
between 30 to 34 ( see the above formula). However, let us say your patients
Pco2 on the arterial blood gas is 20 --> you can call this metabolic acidosis +
respiratory alkalosis. eg : Salicylate Toxicity
If Hc03 - is 16, the expected PCo2 as per Winter;s formula should range between
30 to 34 ( see the above formula). However, let us say your patients Pco2 on the
arterial blood gas is 44 --> you can call this metabolic acidosis + respiratory
acidosis. eg : Cardiac arrest
NOTE, normal anion gap is 12, and normal bicarb is 24. Normal ph is 7.35 to
7.45
A. Identifying benign hematuria and its approach
B. Correct interpretation of "Dipstick" Hematuria
C. Evaluation of Asymptomatic Microscopic Hematuria in normal patient
population vs. those at high risk for urological malignancy.
D. Test of choice for symptomatic hematuria ( Urolithiasis, Cystitis etc)
E. Evaluation of Asymptomatic Hematuria
F. If upper tract imaging for Asymptomatic Hematuria is chosen, what is the
initial test of choice? - Many get confused about the initial test for upper tract
imaging becauses several sources state several different things. Students are
stuck between the choices CT urogram vs. Traditional Intravenos
Pyelogram. The guidelines have been updated recently and there is an
increasing trend towards CT Urogram even in asymptomatic hematuria
( please check the explaination below).
Here is a summary on how to approach Hematuria on your exam as well as in
your office. All the recommendations are taken from AUA, American college of
radiology guidelines on appropriate imaging choice.
Hematuria: The following Q and A aaproach will help you understand the
principal concepts of Hematuria.
How do you test for Hematuria?

The initial office test that we use to detect hematuria is "Dipstick". Dipstick is
highly sensitive but not specific. False negatives are very rare but false positives
are common. Dipstick detects "BLOOD" but it does not say whether this "blood"
is an RBC or a Pigment. Remember that pigments such as myoglobin ( as in
rhabdomyolysis) or Hemoglobin ( as in hemoglobinuria, Black water fever) can
stain as "Blood" on dipstick. So, please do not automatically assume that
everything that stains as "blood" on a dipstick is an RBC. In order to know if
there is true hematuria, the next step is to do urine microscopy. If the urine
reveals RBCs then there is true hematuria. However, if the dipstick reads "blood"
and if the urine did not reveal RBCs on microscopy then you are dealing with a
pigment - either myoglobinuria ( rhabdomyolysis) or hemoglobinuria. At this
point, if the CPK is also elevated it suggests that the etiology of blood on the
dipstick is Rhabdomyolysis.
So, a dipstick hematuria should always be confirmed with urine microscopy!
If dipstick is negative for blood, it excludes abnormal hematuria ( false-negative
results are unusual with dipstick testing).
Benign causes of "Red" urine but negative dipstick test - In some conditions,
you may see a red urine resembling "Gross hematuria" but dipstick is negative
for blood. This should not be called hematuria. This is just reddish
discoloration of urine.
Occurs in :
a) Ingestion of red pigmented foods ( eg: beets, berries, rhubarbs, paprika)
b) Drugs like Rifampin or Phenazopyridine derivatives ( remember these drugs
only cause reddish urine but NOT a positive dipstick).
c) Diseases such as "Porphyria"
Causes of a Positive Dipstick but no true Hematuria: Here Dipstick stains
positive for blood but no RBCs in the urine
a) Myoglobinuria ( Rhabdomyolysis, vigorous exercise)
b) Hemoglobinuria ( Intravascular hemolysis)
Is the Hematuria associated with pain? - Understand the causes of painless
hematuria are different from painful hematuria. Painless hematuria is often from
tumors of the urinary tract, bladder cancer or glomerulonephritis. Painful
hematuria is often associated with urolithiasis ( renal calculi) or inflammation/
infection of the bladder ( Cystitis).
What will be the approach to identify the source of Hematuria? - The work up for
hematuria may involve invasive and expensive approaches. So, it is important to
determine the nature of hematuria so that you can limit investigations to the real
and pathological hematurias.
Gross Hematuria: Reddish or Tea colored urine, dipstick positive for blood and
urine microscopy shows RBCs. Any patient with gross hematuria should

always be referred for urological evaluation unless this is secondary to an

infection. If a woman has gross hematuria but the urine dipstick also reveals
leucoesterase or nitrite or if the woman has symptoms of UTI ( dysuria etc) or if
the cultures are growing bacteria, this can be treated as UTI ( cystitis) with
antibiotics with out referring for further evaluation. Even in this setting of
infection, if there are risk factors for urological malignancy the patient should
still be referred for further evaluation ( since hematuria from cancer can also be
intermittent).
Runner's hematuria or March hematuria is another benign condition that presents
as gross hematuria after a severe physical activity. In such cases, patients may be
observed for resolution however, if the hematuria is persistent or if the patient
has any risk factors for having a urological malignancy, must be referred to a
urologist
Microscopic Hematuria: Grossly, urine looks normal. Dipstick positive for
blood and urine microscopy reveals RBCs.
Microscopic Hematuria is often intermittent and most causes are usually benign.
So, it is important to define a significant microscopic hematuria that requires
further investigations.
Microhematuria is defined as three or more red blood cells per high-power
microscopic field (RBCs/HPF) in two out of three properly collected and
prepared specimens. Repeat urinalyses to establish whether significant
hematuria is present must be done within 3 to 6 months of the initial test.
Minimal microhematuria ( i.e; one or 2 rbcs per HPF ) in asymptomatic
young adults does not require any evaluation. ( many studies have indicated
that small amounts of blood may be released into the urine of persons with
no detectable pathology in the urinary tracts)
In patients with risk factors for having a urological malignancy, a
microhematuria even in one or more samples must be considered significant and
be evaluated.
Some benign causes of Microhematuria :
A) Exercise
B) Sexual activity
C) Menstruation
D) UTI
If UTI is present ( symptoms and dipstick for leucoesterase are clues that point
towards infection) - treat it with antibiotics and repeat urinalysis after the
infection has cleared.
E) Benign Prostatic Hypertrophy
F) Prostatitis

Now, carefully look for other charecterestics of urinalysis - Presence of other

findings on the microscopic urinalysis such as RBC casts or Dysmorphic
RBCs or proteinuria or the labs revealing elevated serum creatinine suggests
a the hematuria is originating from the kidney/ glomerulus itself ( eg:
Glomerulonephritis, IgA nephropathy). In such cases, the next step in
evaluating hematuria is referral to a nephrologist ( not urologist) and a renal
biopsy.
Further Approach to Microscopic Hematuria
Symptomatic Hematuria: In painful hematuria --> first rule out infection and
renal colic. If infection is absent or if there is a pain similar to renal colic
( classic flank pain) - consider renal stones as the cause of Hematuria. The best
initial step in evaluating the cause of painful hematuria that is not explained by
UTI is Non-Contrast CT scan (Spiral CT) ( test of choice for imaging renal
calculi).
In pregnant women, ultrasound can be performed to avoid radiation exposure.
Asymptomatic MicroHematuria : Patients without the classic flank pain of
urolithiasis should be evaluated extensively. Once benign causes such as
infection and the kidney ( glomerular) origin are ruled out, further
approach should be defined based on the patient's risk profile.
A) For patients with low risk of urological disease, a less extensive work-up
may be appropriate ( First do upper tract imaging and if this is negative, add
urine cytology+cystoscopy).
B) If the patient is a high risk of having a urological malignancy, extensive
work-up is needed ( see the risk factors below) --> Upper tract imaging +
cystoscopy+ urine cytology all are needed. Urine cytology should be obtained
in all patients with asymptomatic hematuria since it is an easy and non
invasive step. Sensitivity of urine cytology is only 48% but remember that if
it is positive it is highly specific for urological cancer ( 94% specificity)
Risk factors for urological cancer ( bladder ca):
1. Heavy somkers
2. Occupational exposure to aniline dyes
3. History of Gross hematuria
4. History of pelvic irradiation
5. Age > 40 years
6. Analgesic abuse
7. Presence of irritative voiding symptoms
8. Previous use of Cyclophosphamide ( increases the risk of bladder cancer
where as ongoing use often causes hemorrhagic cystitis as a adverse effect)
What imaging studies should be done as initial step in evaluating

Asymptomatic Hematuria?
For both high risk and low risk patients, upper tract imaging must be performed
as an initial step. For upper tract imaging, CT urography ( i.e; non-contrast CT
followed by contrast CT imaging from kidney to bladder) is best recommended
initial test now to evaluate asymptomatic hematuria. CT urography is less
affected by overlying bowel gas and is more sensitive for detecting small tumors
and calculi than the IVP. Students often confuse this with other choices such as
ultrasound and Intravenos pyelogram. IVP used to be the best preferred test for
upper tract imaging in hematuria evaluation but now CT urogram is becoming
the preferred method. IVP and ultrasound are good to image the urinary tract but
they do not completely assess the renal parenchyma. If you order an IVP, you
may eventually need to order a CT urogram again to image the parenchyma
better - so, in order to avoid ordering multiple studies, CT urogram is
recommended as the best initial test.