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MY FELLOW DOCTORS

HERE ARE MY STEP 2CK USMLE NOTES


DERIVED MOSTLY FROM UWORLD.
PART 1 NOTESERIES

1- Turner syndrome predisposes to osteoporosis. And has no additional risk for breast cancer.
2- Warfarin could give false positive results for protein S deficiency because it inhibits protein C
and S.
3- Heparin activates Anti-thrombin 3 which in turn inactivates factor 10a, 9a, and thrombin.
Thats how Heparin works.
4- Antepartum px with RhoGam isnt required if the father is Rh-ve.
5- Massive Pulmonary Embolism presented with hypotension and/or right side heart failure which
comes as elevated JVP and RBBB. Massive PE presented as syncope which dont occur with
other types of PE. It leads to left side HF and cardiac shock then bradycardia and death.
6- Diagnosis of PSGN is low C3 levels, elevated Antistreptolysin O and anti-DNase B, biopsy will
show C3 in sub-epithelial humps.
7- Restrictive or interstitial lung diseases causes destruction of the alveolar barrier and decrease
the capacity for gas exchange, decreasing the Dlco, therefore causing V/Q mismatch and increase
the A-a gradient. Patient usually have normal or slightly below normal PaO2 but will have
hypoxemia once exertion occurs.
8- The most common cause of upper GI bleeding is peptic ulcer. The most common cause of
lower GI bleeding is diverticulosis.
9- GI bleeding with previous aortic rupture repair think of aortoenteric fistula.
10- In case of lower GI bleeding and colonoscopy reveals nothing, do angiogram if active
bleeding and small bowel studies if bleeding has stopped.
11- Diastolic rumble might be heard in isolated VSD due to increase the flow through mitral
valve.
12- Wide split of the S2 and ejection systolic murmur over the upper left sternal boarder due to
increase blood flow through pulmonary valve, its ASD.
13- TOF causes single S2 and harsh systolic ejection murmur over the left sternal boarder due to
stenosis over RV outflow.
14- Ischemic colitis versus acute mesenteric thrombosis: IC can be caused by hypotension,
vasculitis, atherosclerotic disease, fever nausea vomiting abdominal pain, and bleeding due to
ischemia of the watershed areas of the splenic flexure, acute mesenteric thrombosis also has risk
factors for atherosclerotic disease, comes with abdominal pain out of proportion and nausea and
vomiting with bleeding occur due to sloughing of the colonic mucosa.
15- Testicular mass feels like bag of worms and increase when patient do Valsalva and on
standing is varicocele when pampiniform plexus lack valves, translumination if negative.

16- Spermatocele are found high up in the testes and not over the epididymis and will
transluminate as well and they its caused by cystic dilatation of the efferent ductules. 17- Signs of
sever preeclampsia: SBP>160 or DBP> 110 on two different occasions, thrombocytopenia
<100000, Cr>1.1, new onset visual or cerebral symptoms, or pulmonary edema.
18- Trichomonas vaginals is sexually transmitted, give metronidazole for partner as well.
19- The most common cause of SAH is aneurysmal rupture, while AVM can cause both
intracerebral bleeding and SAH.
20- The cisterns are subarachnoid spaces that fill with blood in SAH.
21- CT scan without contrast, LP puncture and angiograph are all used in SAH but CT scan is first
then LP puncture will show xanthochromia if CT was equivocal, angiography is used to direct
therapy.
22- Only the patient can get a copy of their medical records, OR their representative BUT by court
order. Physician has 30 days to provide such records.
23- Olanzapine causes weight gain and sedation. Clozapine do that as well. Agranulocytosis can
occur with olanzapine but its a significant risk with clozapine.
24- Post exposure prophylaxis for rabies virus is immunoglobulin and vaccine. Hydrophobia and
Aerophobia are pathognomonic, both trigger pharyngeal spasm, if paralysis occur it would be
flaccid and ascending.
25- Central DI differ from Nephrogenic DI by the concentration of Sodium, in CDI thirst
mechanism is impaired and therefore theres hypernatremia while thirst is intact in nephrogenic
one because patient is still drinking water to compensate for urinary lost. Both situations have
diluted urine though. Polydipsia differs from both of them by the presence of hyponatremia.
26- Exertional heat stroke is mainly caused by thermoregulatory center failure, decrease intake of
fluid and salt will contribute. Temp is >104
27- Heat exhaustion due to inadequate fluids and electrolytes, CNS symptoms arent present with
exhaust, temp is <104.
28- Malignant hyperthermia occur in genetically susceptible individuals after halothane or
succinyl choline and its due to uncontrolled efflux of calcium from the sarcoplasmic reticulum.
Treat with dantrolene same as NMS.
29- NaHCO3 protect the heart in TCA toxicity due to its effect on the sodium channels while in
aspirin toxicity it causes alkalization of the urine and therefore increase the excretion of the drug.
30- 5HT3 receptor blocker, is serotonin blocker, ondansetron are the best antiemetic for
chemotherapy induced nausea and vomiting.
31- Ramsey hunt syndrome; herpes zoster that causes bells palsy, vesicles are present over the
ear.
32- Melanosis coli, factitious diarrhea, medical field personnel that takes laxatives which causes
diarrhea in about 20 times per day and nocturnal ones also occur, on biopsy of the colon we see
dark brown pigmentation with shiny pale lymph nodes. 33- Herpangina is 1 mm gray vesicles
during fall preschool age and it is associated with fever and pharyngitis and there is no lips
involvement unlike HSV.
34- Bilateral trigeminal neuralgia is one of the presentation of MS.
35- Cricopharyngeous muscle is the upper esophageal sphincter which due to its dysfunction,
zenkers diverticulum occur right above it.

36- Thyroid nodule workup; first thing to do is TSH and U/S, if high or normal TSH or suspicious
U/S send for FNA. If U/S is normal and TSH is low send for radioactive iodine uptake, if hot
nodule treat as graves, if cold nodule send for FNS. So pretty much all of them will have FNA
except hot nodule that shows high I-123 isotope uptake.
37- With normal pressure hydrocephalus remember memory loss without focal neurological signs.
38- Amoebic liver abscess could present as pleurisy if it was next to the pleura and differentials
are pyogenic liver abscess that would happen in GI infections, appendicitis and surgery.
39- Frostbite treatment is rapid rewarming with hot water (40-44) is a lot better than slow
rewarming with room temperature or dry warming like a fan.
40- Both olanzapine and clozapine causes weight gain, dyslipidemia, and new onset diabetes,
regular monitoring is mandatory.
41- Ziprasidone is associated with QT prolongation.
42- Pyromania: deliberate fire setting in more than one occasion, no second gain, not explained by
conduct or mania, fascination, arousal and tension with the act. There is also a relief after the act.
They love fire and fire station and firefighters and anything related to that.
43- Only 24-hour urinary calcium excretion can differentiate between primary
hyperparathyroidism and familial hypocalciuric hypercalcemia because both of them have high Ca
and PTH. The HP can have urine Ca >250, while the familial have urine Ca<100. HP urine
calcium/creatinine clearance is >0.02, FHH have UCCR <0.01. Because calcium sensing receptor
dont work in both kidney and parathyroid.
44- Parathyroidectomy: is recommended for patient with asymptomatic hypercalcemia with at
least one of the following: A- Serum level>1 mg above the normal at least. B- Young age<50. CT score is below 2.5. D- Reduced renal function.
45- Photosensitivity after acne treatment is common with doxycycline. It is the most
photosensitizing tetracycline.
46- McMurray sign: a popping sound or snap when slowly extending the knee from flexion
position with torsion of the tibia is highly suggestive of medial meniscal tear. Medial is more
common than lateral. Injury may take several hours to be evident.
47- Dashboard injury of the flexed knee causes posterior cruciate ligament tear.
48- Voiding cystourethrogram should be done in newborns age <1month or children <2 years with
recurrent febrile UTIs or a first UTI from an organism other than E.coli. Also should be done
when renal hydronephrosis or scarring is suspected. 49- Indications for renal and bladder
ultrasound IN KIDS:
All children age 2-24 months with a first febrile UTI.
Recurrent UTIs in children of any age.
UTI in a child with family history of renal or urologic diseases.
Children who do not respond to appropriate antibiotics treatment.
50- Patellofemoral syndrome cant be diagnosed with x-ray or MRI, only physical examination by
extending the knee and compressing the patella which elicit pain.
51- Central line placement, ideally should be placed in the superior vena cava and not the smaller
veins before SVC, and should be put proximal to the cardiac shadow. CXR should be right after
the placement to make sure its in the right place,
52- Vaginal foreign body: calcium alginate swab or irrigation with warm water can be tried first

and then approach under anesthesia is for stubborn cases.


53- If woman is admitted to the hospital after34-weeks gestation with PPROM, delivery is usually
recommended. If GBS status is unknown, antibiotics should be given.
54- Leaning on the elbow while typing causes ulnar nerve entrapment and lose of sensation over
the 4th and 5th digits.
55- Treatment of choice for scarlet fever is penicillin G.
56- Primary hyperparathyroidism could cause hypertension, significant hypertension may come
from MEN2.
57- GLP-1 receptor agonist, exanetide is added to metformin if weight loss is desired.
58- Basal insulin therapy is added to DM2 on top of the metformin if the latter fail and A1C>8.5.
59- DDP-4 inhibitors, sitagliptin are given (vs metformin) if renal failure is present.
60- Sulphonylureas and TZD both causes hypoglycemia and weight gain.
61- C.diff. has two toxins, enterotoxin A causes watery diarrhea, while cytotoxin B causes colonic
epithelial cells necrosis and fibrin deposition.
62- BW syndrome, hemi hyperplasia, overgrowth syndrome that leads to willms tumor and
hepatoblastoma. Screening for hypoglycemia is recommended due to hyperinsulinoma, then alpha
fetoprotein and ultrasound is recommended to look for tumors. Screening start at birth with alpha
fetoprotein every 3 months until age 4, then from age 4 until age 8 with abdominal ultrasound,
then from age 8 through adolescence with renal ultrasound.
63- The indications for acute therapy in hyperkalemia is when the patient has EKG changes, when
S.K level>7 without EKG changes, or when rapidly rising blood levels due to tissue breakdown.
64- Enthesitis: inflammation of the insertion of muscle with bones, occur with ankylosing
spondylitis, and most common sites are the Achilles tendon, iliac crest, and tibial tuberosity. 65Langerhans cells histiocytosis or so called histiocytosis x can cause painful solitary lytic long
bone lesions that associated with hypercalcemia and they would look like hyperparathyroidism.
66- Lochia rubra (red) turns to Lochia serosa (pale) in 3 days then turn to whitish or yellowish one
called lochia alba. If foul smell, suspect endometritis.
67- Low grade fever and leukocytosis is normal in the first 24 hours postpartum.
68- Recombinant EPO is indicated in every patient with chronic renal failure with Hb<10 and iron
deficiency was ruled out.
69- The common side effect or EPO is hypertension, which is treated by beta blockers and
vasodilators, sub cut route is less common to cause HTN, slowly rising level of hct is
recommended. Other side effects are headache, flu like syndrome, and red cell aplasia which is
rare.
70- The best indicator to follow the improvement of DKA is serum anion gap.
71- Beta 2 agonists are used in treating hyperkalemia. Beta 1 are chronotropic and inotropic and
not used.
72- Penile fracture: send for urethrogram to asses for urethral injury, then surgery. Dont rush it
with Foleys catheter.
73- Steatorrhea confirmed by Sudan stain on spot stool specimen or 72 hours stool collection.
These test can be used to observe the improvement for pancreatic replacement therapy.
74- Before starting patients on lithium, screen for renal and thyroid impairment since the major
side effects of lithium is nephrogenic DI and hypothyroidism.

75- In patient with OCP induced amenorrhea, increasing the estrogen will solve the problem.
76- Sick Euthyroid syndrome or so called low T3 syndrome, occur whenever acute patient
especially in hospital stay, due to the presence of peripheral cytokines and caloric deprivation.
There is decrease conversion of T4 into T3. T4 and TSH usually normal.
77- Abnormal uterine bleeding when presented in acute setting can be treated with high dose
estrogen I.V, second line is high dose progesterone, third line is tranexamic acid. Blood
transfusion is rarely needed for unstable anemic patient.
78- Neuroblastoma, N-myc amplification, arise from the neural crest cells anywhere in the
sympathetic track or ganglions. Mostly from kidney and retroperitoneal structures. Elevated
catecholamines metabolites usually present, no headache or palpitation like pheochromocytoma.
70% metastasized at time of diagnosis mostly to long bones.
79- Tryptophan is the precursor of serotonin (5-hydroxytryptamine) and niacin. In case of
carcinoid syndrome, patient will have too much serotonin synthesis from tryptophan and in turn
lead to niacin deficiency.
80- Bed wetting is normal before age 5, after age 5, urinalysis should be done to exclude UTI. 81Low WBC count and thrombocytopenia is present in measles and vitamin A is shown to help by
promoting the immunity and regenerating the respiratory and intestinal epithelium.
82- Supracondylar fracturebrachial artery injury.
83- Furosemide bilateral hearing loss. Thiazides orthostatic hypotension and photosensitivity.
84- Normal grief mainly have sadness and sense of emptiness that would decrease slowly over a
period of few weeks, in contrast to major depression, the anhedonia would increase gradually and
at least more than two weeks.
85- Acyclovir renal toxicity can be prevented by adequate hydration and slowing the dose rate.
86- Aspirational pneumonia and fluctuating neck mass think of Zenkers diverticulum.
87- Astigmatism is due to non-spherical cornea, presbyopia is due to loss of lenss elasticity.
88- Immobilization can lead to hypercalcemia after an average of four weeks, but it would be
faster if renal failure present.
89- Charcots triad of acute ascending cholangitis (infection of the common bile duct due to
obstruction or stone) is fever, jaundice, and RUQ pain. If confusion occur, its called Reynoldss
pentad.
90- Initial step in acute ascending cholangitis is ultrasound, then followed by supportive care and
antibiotics, in 8-% of patients that would be enough, then proceed to ERCP, if fails, T-tube.
Laparotomy is contraindicated.
91- Hypertensive urgency is defined as severe hypertension (>180/120) without end organ
damage. While hypertensive emergency is severe hypertension plus end organ damage (mainly
papilledema, retinal hemorrhages, or renal symptoms), or hypertensive encephalopathy which
occur due to cerebral edema and subsequent headache and confusion.
92- Isolated weakness of Achilles tendon reflex increase with age and doesnt mean there is spinal
cord compression.
93- Doppler can distinguish between ruptured cyst and adnexal torsion, the first one will show
small cyst with fluid collection around it, the later will show edematous enlarged ovaries with
decreased blood flow.
94- Ruptured ovarian cyst can be presented acutely after strenuous exercise or sexual intercourse,

sometimes asymptomatic and fever isnt necessarily present.


95- Doppler for Tubo-ovarian abscess will show complex multilocular fluid rather than simple
cyst.
96- Postoperative renal retention is common due to perioperative distention of the bladder, the use
of epidural anesthesia and high fluid intake after surgery. The first thing to do is bedside bladder
scan, then Foleys catheter. 97- Suspect squamous cell carcinoma of the mucosa of the head and
the neck in an alcoholic smoker who presents with a palpable cervical lymph node. The best initial
test is Panendoscopy which consists of esophageoscopy, laryngoscopy, and bronchoscopy.
98- The gold standard test for cystic fibrosis is sweat test by quantitative pilocarpine
iontropheresis, a chloride level >60 on 2 separate occasions confirms it. Median age at diagnosis
of cystic fibrosis is 6-8 months; two thirds of patients are diagnosed by 1 year of age. The age at
diagnosis varies widely, however, as do the clinical presentation, severity of symptoms, and rate
of disease progression in the organs involved. Clinical manifestations vary with the patient's age at
presentation.
99- Cystic fibrosis: Neonates may present with meconium ileus or, rarely, with other features such
as anasarca. Patients younger than 1 year may present with wheezing, coughing, and/or recurring
respiratory infections and pneumonia. GI tract presentation in early infancy may be in the form of
steatorrhea, failure to thrive, or both. Patients diagnosed later in childhood or in adulthood are
more likely to have pancreatic sufficiency and often present with chronic cough and sputum
production. Approximately 10% of patients with cystic fibrosis remain pancreatic sufficient; these
patients tend to have a milder course.
100- Atheroembolism is a common complication of cardiac catheterization and can cause blue toe
syndrome, elevated creatinine, eosinophilia, eosinophiluria, and livedo reticularis.
101- Leg Calve Perthes might look like transient synovitis especially when initial xray is negative,
but TS fades away after 1-3 weeks off the viral infection. The only difference between LCP and
slipped capital epiphysis of the femur is the later occurs in obese kids. (HY).
102- CLL symptoms if present will be due to LAP. It starts as lymphocytosis only then LAP then
splenomegaly then anemia and finally thrombocytopenia, the treatment for AIHM is steroids.
103- Opioids causes histamine release and causes miosis, bradycardia and hypotension (almost
like a shock but with bradycardia).
104- Cocaine causes mydriasis, tachycardia and hypertension.
105- MTX causes oral ulcers, elevated liver enzymes and bone marrow suppression and
cytopenias. Folate should be given when MTX chronic use, all side effects are reversible if MTX
stopped. Also causes renal induced acute kidney injury.
106- Anti-cytokines used for RA: TNF-alpha inhibitors (infliximab, etanrecept, adalimumab),
Interlukin-1 receptor blockers (anakinra, canakinumab), Interlukin-6 blockers (tocilizumab).
107- Feltys syndrome cannot be established without thrombocytopenia because RA and
splenomegaly are common in RA.
108- Reactive arthritis is a seronegative spondyloarthropathy resulting from enteric or
genitourinary infection (non-gonoccocal) infections. Findings in reactive arthritis may include
urethritis, conjunctivitis, mucocutanous lesions, enthesitis and asymmetric oligoarthritis. Not all
extra-articular manifestations need be present to suspect diagnosis. NSAIDs are the first line
therapy.

109- Parvovirus-B19 arthritis or viral arthritis: can occur in daycare or school teachers,
polyarticular and symmetrical arthritis that resolves with 3 weeks without joint destructions.
Fever, diarrhea and fatigue could occur. Presence of IgM against B19 is diagnostic.
110- Diagnosis of B19 infection in immune competent is by IgM titer for acute infection and IgG
titer for chronic or previous one, for immunocompromised, nucleic acid amplification may be
used.
111- The first responses to hemorrhage is tachycardia and peripheral vasoconstriction.
112- Any unstable patient with penetrating trauma should undergo laparotomy without imaging
delay, not even the fast U/S.
113- Malingering is to get narcotics, financial compensation or staying away from work.
Factitious to get emotional attention and living the sick role without secondary gain.
MalinGering=Gain.
114- Trichotillomania is part of OCD. Psychotherapy is the treatment.
115- Empyema caused by the same pathogens that causes the pneumonia that proceeds it, but then
a mixed aerobic and anaerobic bacteria supersedes and thats why anti-pneumonia wont work.
116- Drugs that causes acute pancreatitis: diuretics (thiazides and furosemide), IBD drugs
(sulfasalazine, 5-ASA), Immunesuppressants (azathioprine), HIV-drugs (didanosine,
pentamidine), Antibiotics (metronidazole, tetracycline).
117- Hepatic adenoma:
OCP, androgen use, DM, pregnancy, glycogen storage disease.
Liver enzymes are normal, ALP and GGT may elevate.
Benign epithelia tumor, with slight risk to develop cancer when AFP elevates.
Loss of liver architecture, high risk for rupture so biopsy in contraindicated.
Diagnosis by CT or U/A, removal is definitive no matter the size.
Focal nodular hyperplasia is non-malignant and differs from adenoma by the presence of
sinusoids and kupffer cells.
118- Prostate cancer and PSA screening: it should be discussed with the patient and counselling is
required before starting the screening usually after age 40. There is no strict recommendations.
119- Bacterial sinusitis is the most common cause of orbital cellulitis due to the close proximity,
CT is to detect any abscesses and complications include cavernous sinus thrombosis, intracranial
infection and blindness.
120- Herpes zoster opthalmicus: regular vesicular HZ over the first division of the trigeminal
nerve occur in elderly with erythema around the eye and vesicles, dendriform corneal ulcers and
conjunctivitis. 121- AIHA of the warm type can occur in malignant lymphoproliferative disorders
like CLL or NHL, and its treated with prednisone.
122- Enterotoxic E.coli is the most common cause of Travelers diarrhea.
123- Torticollis is a type of.. Dystonia.
124- Hemiballismus is a damage to contralateral sub thalamic nucleus.
125- Primary, secondary and latent syphilis treatment is penicillin G I.M (1-1-3) doses, alternative
is oral doxycycline 14-14-28 days. Tertiary syphilis treated with penicillin G I.V for 14 days,
alternative is ceftriaxone for 14 days.
126- All patient taking INH for TB should receive B6 at a low dose and if peripheral neuropathy
occurs increase the dose to 100mg.

127- Screening for osteoporosis is recommended to all women age>65 and can be considered for
younger ones with risk factors, its done by DEXA scan.
128- Esophageal rupture CXR will show widened mediastinum, or air in paraspinal muscles, or
pleural effusion or pneumomediastinum with or without pneumothorax which can occur hours to
days after. Antibiotics and surgical repair immediately. Presents as retrosternal chest pain radiates
to the back and crunching sound on auscultation may occur due to mediastinum air. Water-soluble
esophageogram is the diagnosis.
129- Niemann-Picks disease: spyngolipidosis due to deficiency of sphyngomulinase, causes
hypotonia, HSM, cervical LAP, protruding abdomen and cherry red spot.
130- Tay-Sacks disease is a deficiency of hexoaminidase A and causes hyperacusis, mental
retardation, seizures, cherry red macula but not HSM or cervical LAP.
131- Gauchers disease: deficiency of glucocerebrosidase, causes HSM, anemia, leucopenia and
thrombocytopenia but not cherry red macula.
132- Krabbes disease: deficiency of galactocerebrosidase and causes hyperacusis, irritability, and
seizures.
133- The first important thing to do after bitten by an animal suspected to have rabies is to clean
the wound and that would decrease the risk by 95%.
134- The post-exposure prophylaxis for rabies is active and passive for previously not vaccinated
patients, and only revaccination for those who have been vaccinated.
135- The most common cause of congenital hypothyroidism in USA is thyroid dysgenesis.
136- Complicated pyelonephritis may involve corticomedullary abscess, perinephric abscess,
emphysematous pyelonephritis, or papillary necrosis.
137- Tourette: the presence of motor and at least one vocal tics (not necessarily concurrent) for
more than a year and an onset before age 18. Atypical antipsychotics like risperidone is preferred,
clonidine also used. Habit reversal training also used as non-pharmacologic.
138- Acute bronchitis is the most common cause of blood tinged sputum and is usually viral in
etiology. In an afebrile patient with new-onset blood tinged sputum without significant signs of
more serious disease, observation and close clinical follow-up is the best treatment strategy. 139Suspect chronic pancreatitis when there is chronic epigastric abdominal pain with intermittent
pain free interval, malabsorption, weight loss, and type 2 DM. diagnosis is with CT scan to look
for calcifications, (dont fall for the enzymes trap) if not evident use MRCP or ERCP to visualize
the ducts. Treatment is analgesia and enzymes replacement.
140- Causes of bone vascular necrosis other than sickle cell disease is corticosteroids use,
Gauchers disease, Alcoholism, SLE.
141- Many patients with high suspicion celiac disease and villus atrophy on biopsy may show
negative serological testing due to concurrent IgA deficiency that is common with celiac disease.
In that case test for IgA quantity is required.
142- Enterobius vermicularis treatment is with albendazole or mebendazole. Scotch tape is
diagnostic.
143- The most common cause of pneumonia in children with CF is staphylococcal aureus, and the
empiric therapy is I.V vancomycin until cultures come out. While pseudomonas is the most
common cause of pneumonia in adults and Amikacin, ceftazidime, ciprofloxacin are the empirical
therapy.

144- Anterior spinal artery syndrome: may be caused by vascular surgeries especially in aortic
dissection repair, due to decrease the blood flow through the radicular arteries, or systemic
hypotension in perioperative period. Presents as flaccid paraplegia with loss of bowel and bladder
control, sexual dysfunction, loss of pain and temperature sensation, spasticity and hyperreflexia
may occur later.
145- Normally pregnant will have elevated PaO2 (100-110), decreased PaCo2 (27-29) and slightly
low bicarbonates level, this is due to increase minute ventilation by progesterone which causes
chronic respiratory alkalosis. On the contrary during the first trimester only hyperemesis
gravidarum can cause hypochloremic metabolic alkalosis (high HCO3).
146- It is normal in pregnancy to see low BUN/Cr ratio or to see increased GFR, because cardiac
output is increases and renal flow is increased.
147- Elevated BUN/Cr ratio is found in patients with upper GI bleeding due to absorption of Hb
from gut after breakdown by bacteria.
148- Emergent craniotomy is indicated in epidural hematomas whenever there is GCS<8, signs of
increased ICP, pupillary abnormalities, hemiparesis or cerebellar signs.
149- It is a common practice in the emergency to measure the BNP level to differentiate dyspnea
of heart failure from dyspnea on non-cardiac etiology.
150- Clomiphene citrate is an estrogen analogue that improves GnRH and LH release thereby
improving the chances of ovulation.
151- To differentiate acute exacerbation of CHF from acute exacerbation of COPD, look at the
arterial blood gases, in CHF the PaCO2 is usually low compared to CO2 retaining in COPD.

GOOD LUCK