Neeraj s Ck Notes

8/15/2019 Neeraj s Ck Notes

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Neeraj’sUSMLE Step-2CK HY Material and NOTES

HY Notes: CK(Q-bank)

• Familial short stature: normal birth weight and length age of 2-3 years growth decelerate and drops to 5th percentile The onset and progression of puberty normal : Bone age is typically consistent with thechronologic age.

• Immunizations:Hep B vaccine- At birth, 1 month, and 6 monthsDTaP- At 2, 4, and 6 months, 15-18 months, and 4-6 years Td booster- 11-12 years, and then every 10 yearsHib- At 2, 4, and 6 months, and 12-15 months IPV- At 2 and 4 months, 6-18 months, and 4-6 yearsMMR- At 12-15 months and 4-6 yearsVaricella- 12 months

• Chemo-prophylaxis tuberculosis: The usual agent isoniazid. Indicated in the following groups:1) tuberculin skin test has converted from negative to positive within the previous 2 years;2) all small children (


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2. Symptomatic older children and adults3. Patients with abnormal mental status

Esophagoscopy should not be performed in patients with evidence of gastrointestinal perforation, significantairway edema, or necrosis and in those who are hemodynamically unstable.

• Children with sickle cell disease are at risk of serious bacterial infection and sepsis because they haveimpaired splenic function. Intravenous ceftriaxone is the most commonly used antibiotic in a febrile child

with sickle cell disease. It is effective against both S. pneumoniae and H. influenzae.

• Red urine = hematuria, hemoglobinuria, myoglobinuria, certain foods or medications (e.g., rifampin,nitrofurantoin, chloroquine, azo dyes, beets, and blackberries), and the presence of urates.

+ Strip-test for blood in a urinalysis = red blood cells, hemoglobin or myoglobin = perform microscopicanalysis to DDx

Raised serum creatinine phosphokinase = rhabdomyolysis = admit for aggressive IV hydration and treatmentwith sodium bicarbonate to alkalinize the urine to prevent precipitation of the myoglobin in the renal tubules.

• Nightmares:frightening dreams that awaken the child from REM sleep recall details of the dream. Nightterror: Stage 3 or 4 sleep,not recalled Rx simply let it go but prevent injury

• Functional abdominal pain is pain that lasts for more than 3 months and often interferes with normal activity.The pain is periumbilical and often hard to describe. The pain typically does not awaken patients from sleepor interfere with pleasant activities. The pain is real and is the result of the regulation of gastrointestinalmotility in response to either psychological or physical stress.

• Fragile X male = Adv Cytogenetic testing in female siblings = Heterozygous females frequently havedevelopmental and behavioral problems such as ADHD. They may also have borderline or mild mentalretardation.

• Rx Acne vulgaris: retinoid (tretinoin, adapalene, and the new yeast-derived agent azaleic acid).S/E skinirritation & photosensitivity. Frequent face washing with strong soap will probably cause exacerbation ofacne. Gentle face washing once or twice daily with mild soaps is recommended.

• Toxicities tricyclic antidepressant ingestion:1. A prolongation of the QRS interval is highly predictive of both cardiac and CNS toxicities

2.

Right deviation of the QRS axis (greater than 120 degrees) is very predictive of cardiac toxicityfrom tricyclics.

• Fat embolism brain = multimodal petechiae in the white matter represent the most common pathologicchange.Corpus callosum and cerebral peduncles small petechiae = Diffuse axonal injury = coma a few hours to daysafter head trauma.Multiple cortical infarcts, usually of the hemorrhagic type = Septic embolism / white matter is spared.

• Prostatic abscess:Infecting organisms include aerobic gram-negative bacilli and Staphylococcus aureus.

• Hyper IgM immunodeficiency = increased susceptibility to major gram-positive pathogens and opportunisticinfections (such as the patient's Pneumocystis infection). The biochemical basis defect in a receptor on the Tcell membrane that helps to trigger B cell switching from IgM to IgA, IgG, and IgE.

• The tidal volume for a patient on respirator is generally estimated as 10 mL/kg of weight.

• Screening every 5 years, a random cholesterol level should be checked = > 240 mg/dL =fasting lipid profile

• Scaling skin on back and extensor surfaces of the extremities/flexor surfaces are uninvolved. Cracking of theskin is prominent on the palms and soles. + atopy = ichthyosis vulgaris, Rx minimizing bathing with use ofsoaps only in the intertriginous areas. Bathing limited to 10-minute periods (to hydrate the stratum corneum),followed by immediate application of an emollient such as petrolatum, can help to control the scaling. Inaddition, 50% propylene glycol in water under occlusion by thin plastic film or bags during the night ishelpful in adults, but is not usually used in children.

KaplanQbankNotes:Neeraj 2


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• Nummular dermatitis: chronic inflammation / etiology unknown. Coin-shaped/discoid itchy patches of

vesicles and papules (ooze serum and crust over)numerous on the extensor surfaces of the extremities and onthe buttocks. Heal and then reappear at the same sites. Microscopically, localized spongiosis (correspondingto edema) of the epidermis, which may also contain minute fluid-filled holes that correspond to the tinyvesicles seen clinically in early lesions. Treatment of these patients is problematic, and numerous regimensinvolving corticosteroids or antibiotics have been recommended, each of which appears to work with some

but not all patients.

•

• Euthyroid sick syndrome: seriously ill patient with low T4 /T3, but below normal, normal, or minimallyelevated TSH and clinically do not have clinical hypothyroidism.DDx true hypothyroidism (significantlyraised TSH).

• End-stage liver disease/Cirrhosis renal vasoconstriction occurs worsening fatigue and confusion distalconvoluted tubule responds by conserving sodium diminished urine output and low urinary sodium Deranged BUN/creatinine hepatorenal syndrome Rx Liver transplantation reverse thisvasoconstriction and kidney function will return to normal.

• HIV encephalitis (AIDS dementia complex): most common CNS complication in AIDS = cognitiveimpairment, incontinence, impairment of motor skills, and confusion = sub acute inflammatory infiltration ofthe brain caused by direct spread of HIV = diagnosis of exclusion = MRI studies and CSF analysis are usefulin excluding other CNS diseases.

• Patient with respiratory distress due to pneumonia oxygen saturation is 80% on room air Hypoxia putsat significant risk for delirium, cardiac arrhythmias, and cardiopulmonary arrest Oxygen should first beadministered noninvasively starting with a non-rebreather face mask Failed go for invasive methodslike endotracheal intubation.

• Hospitalization in community-acquired pneumonia :Criteria for hospitalization: one of the following isneeded:

1. respiratory rate > 30 breaths/min,2. room air PaO2< 60 mm Hg,3. O2 saturation less than 90% on room air,4. or bilateral or multiple lobes involved

• The normal value for the anion gap is 12 ± 4 mEq/L

•

Gaucher disease: deficiency of the enzyme glucocerebrosidase (Ashkenazi Jews ) progressiveaccumulation of glucocerebroside within lysosomes of histiocytes Gaucher cells, large histiocytes withtheir cytoplasm engorged with glycolipid = "crumpled tissue paper" appearance most common adultvariant (type I) =most severely affected organs are the bone marrow, liver, and spleen Bone marrowinvolvement =progressive pancytopenia and bone fractures Glucocerebrosidase levels in circulatingleukocytes: diagnostic. In the US, the disease is Rx glucocerebrosidase named alglucerase(safe butexpensive)



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• an erythematous, slightly raised, 2-cm patch of skin on sun-exposed area (Face mostly) area has a rough, very adherent, yellow-brown scale Actinic keratosis

Rx application of 5-fluorouracil cream twice daily x 4 one-week cycles alternated with no treatment weeksheal without scarring.

• Ventilator delivering high concentrations of oxygen lead to irreversible pulmonary fibrosis Use positive-end expiratory pressure (PEEP) to prevent the development of oxygen toxicity But PEEP doesincrease the risk of both barotrauma and hypotension by impairing right-sided heart filling.

• Secondary hyperparathyroidism developed in renal failure in an attempt to correct the hypocalcaemia bone calcium deficits and pathologic bone lesions Rx Calcium supplementation in Renal failure

• Atypical nevus(Dysplastic):size from 5 to 12 mm mostcommonly on sun-exposed skin round in color, but some have subtly notched borders or are slightlyasymmetrical intermediate category between obviously benign nevi and malignant melanoma increasedrate of progression to melanoma Isolated dysplastic nevi are often excised to remove the melanomarisk cases with large numbers careful monitoring with serial photographs can identify any changinglesions which may be undergoing malignant transformation.

• Post-MI patients: Ejection fraction near or minimally subnormal Rx Beta blockers decreasing both oxygendemand and the incidence of ventricular arrhythmia Improved survivalBut if ejection fractions less than 40% Rx Angiotensin-converting enzyme (ACE) inhibitors

• Tension headache: headache often triggered or worsened by stressful situations, anxiety and fatigue Rx NSAIDs

• Eosinophilic fasciitis:Orange peel skin on the anterior aspects of the extremities= scleroderma-like disorderinvolving the arms, legs, and sometimes face and trunk, but not usually the hands and feet lead to eventualrestriction of arm and leg motion related to inflammation and fibrosis of fascia Biopsy of the skin or fasciashows cellular infiltrates with histiocytes, plasma cells, lymphocytes and (in only some cases, despite thename) eosinophils Rx high dose prednisone followed by tapering and maintenance for 2 to 5 years on lowdose prednisone.

• Pulsus paradoxus: significant fall in systolic blood pressure with inspiration = severe asthmatic attack Look for associated accessory muscles of respiration, i.e., the internal intercostal muscles and thesternocleidomastoid muscles.

• Traumatic hemolytic anemias: repeatedly compressed tiny blood vessels, causing fragmentation of some redcells (triangle and helmet shapes) e.g. forced march DDx rhabdomyolysis: high creatine kinase

• Atrial fibrillation (in CHF) causes cardiovascular embarrassment and pulmonary edema adequatemanagement of atrial fibrillation is rate control Rx Digoxin with or without a nodal agent such as a beta

blocker.However,in sinus tachycardia seen with hyperthyroidism DOC is propanolol alone.


http://skincancerguide.ca/lesions/basics/actinic_keratosis_4.html


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• Bleeding in diverticular usually due to the disruption of an often single arteriole or small artery in adiverticulum vessel can be sufficiently stretched by the diverticulum that it cannot undergo contraction.

• Sheehan syndrome: panhypopituitarism due to intrapartum necrosis of the pituitary insulin challengeMeasuring plasma levels of growth hormone and cortisol and evaluating thyroid hormones and TSH levelsRx hydrocortisone (IV not oral like prednisolone) and thyroid hormones.

• Blood supply from 1978 to 1985 was likely to be tainted with HIV positive blood patients with a history of blood transfusions during these years even if currently asymptomatic, should be screened.

• Hyperkalemia First to give: IV calcium gluconate to counteract the effect of the high potassium on theheart and muscle

• Hypercalcemia Rx IV saline and furosemide rapid and safe way to lower serum.

• hemochromatosis = total body iron load >5 g; (hemosiderosis = milder iron overload)

• cirrhosis and portal hypertension Rx Propanolol (to reduce his portal pressure) and Frusemide to relieveascites dehydration (dry mucous membranes) related to his diuretic BUN elevated may exacerbatehepatic encephalopathy but pulse does not demonstrate a reflex tachycardia because of the propranolol.

• In portal hypertension strictly restrict or entirely avoid any medications with a sedative effect, e.g., benzodiazepines as they may ppt an encephalopathy.

• Silent lymphocytic thyroiditis: common disorder of postpartum women,autoimmune reaction to the thyroidgland produce transient hyperthyroidism (related to follicle destruction) followed by hypothyroidism (thatmay be either permanent or resolve within 1 year).

• Seborrhic Keratosis: This lesion is characterized by light brown to black papules or plaques with an adherent waxy, greasy scale. The "stuck-on" appearance is verycharacteristic. It is most often found on the face and trunk.

• The findings of a coagulopathy or of an encephalopathy confer the worst prognosis in patients with acuteviral hepatitis.These findings, in fact; suggest the possibility of fulminant hepatic failure.

• IgA type heavy chain diseas:centered in the Middle East ,ages of 10-30 present with abdominal mass andmalabsorption (behaves like an abdominal lymphoma but not mailgnant) confined to the gut and mesentericlymph nodes may represent an aberrant reaction to some sort of bacterial infection Rx corticosteroids,cytotoxic drugs and broad-spectrum antibiotics.



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• Pemphigus vulgaris:uncommonautoimmune skin disorder characterized by blistering and erosions involving the mucous membranes and skin

autoimmune attack is on the junctions between epithelial cells in the epidermis blisters occur high inthe epithelium and can rupture easily(Nikolsky's sign) begin in the mouth rapid rupture of the

blisters may lead to the impression that the initial lesion is an ulcer rather than a blister IgG deposition onepithelial cell surfaces life-threatening as a result of fluid/electrolyte imbalance, secondary infection, orcomplications of the high-dose corticosteroid therapy.

• Marrow fibrosis suggests myelofibrosis. The marrow in aplastic anemia is fatty, rather than fibrotic

• Excess vitamin C supplementation can lead to uricosuria and the development of calcium oxalate stones.

• The perfusion territory of the anterior spinal artery includes the anterior horn cells and part of the pain andtemperature pathways. Thrombosis of this artery causes flaccid paralysis, loss of bowel and bladder functionand loss of pain and temperature sensation

• Infectious Mononucleosis: Ampicillin therapy leads to a maculopapular rash. An antibiotic should not begiven.

• To rapidly assess for the possibility of antifreeze ingestion, the physician can evaluate the patient's urineunder a Wood's lamp for fluorescence. Manufacturers of ethylene glycol-containing antifreezes typically addfluorescein to the mix, which will fluoresce under a Wood's lamp.

• Paroxysmal nocturnal hemoglobinuria(Marchiafava-Micheli syndrome):genetic defect in glycosyl- phosphatidyl-inositol "anchor marked sensitivity of RBC to serum complement factor C3 Hemolysistriggered by infection, iron use (prescribed to treat the anemia), vaccination, or menstruation predisposedfor thrombotic disease, including Budd-Chiari Syndrome Ham test:classic but non-specific:acid incubationcauses red cell lysis flow cytometric analysis using CD 55 and CD 59 (most definitive).Prognosis goodonly a few require allogenic bone marrow transplant.

• AMI : Thrombolytic therapy is indicated in patients up to 75 years of age .Absolute contraindications includea bleeding diathesis, major surgery or trauma within 6 months, gastrointestinal bleeding, or the presence ofaortic dissection or a known intracranial tumor.

• Whenever you see ‘Lewy’s Body’ think of relation with Parkinson’s dementia with visual hallucinationsand extrapyramidal signs dementia with Lewy bodies Like parkinsons it shows fluctuating clinicalcourse with alternating periods of improvement and deterioration DDx P ick dementia = P ersonalitychanges & disinhibition,affecting younger than 65 striking atrophy of the frontal and anterior temporallobes.

• Suspected lung carcinoma hoarseness metastatic disease to the recurrent laryngeal nerve incurability by surgical means.

• Charcoal is DOC within 4 hrs of toxic ingestion in any case also applicable to Acetominophen Givecharcoal + N-acetylcysteine within 4hrs of ingestion If >4 hrs but


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reticuloendothelial cells orange-yellow tonsillar hyperplasia (due to the cholesterol ester deposits) is adistinctive clue

• HIV patient with bloody diarrhea + tensmus + urgency/fecal incontinence Sigmoidoscopy showing proctosigmoiditis with deep ulcers suspect CMV

• Obese patient? in postop state developing respiratory distress think about PE

• Nephritic syndrome with bland urine in drug users who "skin pop" their drugs and have recurrent infections Enlarged kidneys ?Amyloidosis DDx Heroin Nephritis=Small kidneys

• Idiopathic hypertrophic subaortic stenosis (Earlier name of Hypertrphic cardiomyopathy) :frequentcause of syncope or near syncope in young patients characteristic murmur by its increase with theValsalva maneuver (Any maneuver that decreases left ventricular size will increase the murmur

because the obstructive component increases as the left ventricular cavity shrinks systolic ejectionmurmur is diminished when the patient lies down (This increases cardiac size by increasing venous returnand tends to diminish the intensity of the murmur.This increases the ventricular size and diminishes themurmur). Rx Beta-blockers, such as propanolol, help relax the left ventricular smooth muscle and reduceventricular outflow obstruction.

• Mesalamine (active ingredient 5-aminosalicylic acid) rectal suspension, suppositories, delayed release oraltablets and controlled release oral capsules not absorbed and acts topically modulation of arachidonicacid metabolites, including prostaglandins, leukotrienes, and hydroxyeicosatetraenoic acids well toleratedexcept sulfite sensitivity.

• Hypertensive emergency (Raised both systolic & diastolic BP)may lead to increased Intracranialtension(Blurry vision/Papilledema) subarachnoid hemorrhage and end-organ failure (Like renal manifestingas ‘cola’ colored urine) Rx Control BP but the blood pressure should not be lowered too far systolic

pressure in the range of 160-170 mm Hg because some of the elevated pressure may represent acompensatory mechanism to maintain cerebral perfusion pressure in the face of increased intracranial

pressure or cerebral arterial narrowing (May lead to watershed infarcts) IV nitroprusside is a good agent because it can be titrated with the blood pressure. If the pressure drops too low, the IV can be turned off.

• IgG subclass deficiency: minor forms of immunodeficiency disease deficiency may involve either or bothIgG2 and IgG3 with or without IgG4 deficiency (IgG1 is the major form, and its deficiency leads to adeficiency of total IgG (by definition not considered a "subclass" deficiency) potentially clinically

important point that patients with IgG2 deficiency may also have IgA deficiency and may developanaphylaxis if given IgA-containing blood products.

• Chronic "autoimmune" hepatitis young age & hypergammaglobulinemia biopsy demonstrating portalinflammation with lobular damage resulting in bridging necrosis

1. Type I(classic type: most frequent):associated with antinuclear and anti-smooth muscleautoantibodies

2. Type II(more common in women of Western European descent):associated with autoantibodies tocirculating liver-kidney microsomes. insidious + amenorrhea.

• Chronic hepatitis C positive enzyme immunoassay test for HCV-antibodies(this test may be falsely positive in situations with hypergammaglobulinemia like seen in chronic autoimmune hepatitis) positivityshould be confirmed by a more specific RIBA.

• Ganglion cyst: degenerative nontumourous/cystic swellings with gelatinous material having high hyaluronicacid content the center over dorsal aspect of the wrists, usually near or attached to tendon sheaths and jointcapsules Common sites:65%scapholunate joint,volar aspect of the radius and the flexor tendon sheath.

regress spontaneously or after needle aspiration of the contents. Recurrent ganglia or ganglia that arecosmetically unacceptable to the patient can be surgically excised, but may recur after excision.

• Strenuous exercise like swimming development of headache, dizziness, One sided arm clumsiness and legweakness + loss of pain and temperature sensation on same side face and contra lateral body areas No

prior illness ? lateral medullary syndrome investigate vertebral artery dissection.



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• Diagnosis of Myocardial infarction requires either characteristic ST segment elevations on the ECG ORelevations in serum markers for cardiac injury. ‘Myocardial ischemia’ may or may not always manifest asMI( Angina). Diabetics often have silent ischemia.

• Propranolol is considered to be relatively contraindicated in patients with peripheral claudication & asthma.

• HIV/ lymphomas/organ transplants. Evidence of destruction of myelin at multiple sites in the CNS

PML JC virus(papovavirus) involves Oligodendrocytes in active lesions contain characteristicintranuclear inclusions.

• In constrictive pericarditis (calcification of the anterior pericardium) a pericardial knock is heard 0. 06-0. 12seconds after the aortic valve closes. This corresponds to the sudden cessation of ventricular filling.

• Hypertrophic heart disease is the best recognized cause of diastolic dysfunction

• ECG P waves preceding the QRS complex but no two P waves have the same morphology ‘Multifocalatrial tachycardia’ Variable P wave morphology and PR and RR intervals associated with severe

pulmonary disease control of this tachycardia comes with improved ventilation and oxygenation.

• HSV is thought to cause encephalitis following transport to the brain along the trigeminal nerve.

• HIV with pneumocystis showing respiratory distress oxygen saturation on room air is 71% Rx intravenoustrimethoprim-sulfamethoxazole and prednisone given in any patient showing significant respiratorydistress or room air oxygen saturation of less than 75 % otherwise in HIV Steroids are only given if thequestion of adrenal insufficiency, a common complication of HIV, is suspected.

• HIV patient with watery diarrhea typical small bowel-type diarrhea(weakness & weight loss) mostcommon etiology cryptosporidiosis spores can be seen on the tips of the villi on biopsy.

• Hypotension always accompanied with Tachycardia but when it is associated with Bradycardia It is vagalresponse Rx Atropine.E.g: post AMI

• Amyotrophic lateral sclerosis is a progressive motor neuron disease that affects both upper and lower motorneurons. Patients present with a gradual onset of asymmetric weakness of the distal limb. Even in advanceddisease, sensory and bladder function are preserved. On exam, there is hyperactivity of muscle stretchreflexes.

• If autonomic dysfunction is suspected in a diabetic patient, a useful maneuver on physical examination is tolook for a decrease in heart rate in response to the Valsalva maneuver (forced expiratory effort against aclosed airway).

• Meniere disease = tinnitus, vertigo, and progressive hearing loss thought to be related to a degeneration ofthe vestibular and cochlear hair cells Rx includes bed rest, a low-salt diet, dimenhydrinate, cyclizine ormeclizine.

• Heparin-induced thrombocytopenia (HIT) is the result of platelet aggregation (platelet count falls below50,000/mm3) caused by heparin-induced antibodies lead to limb-threatening thromboses and constitutesa medical emergency (Arterial thrombosis is a manifestation of the HIT syndrome) Rx discontinue heparinand use lepirudin.

• An atypical gastric upset, heartburn, indigestion may turn out to be a myocardial ischemia ++> Look forobjective signs of sympathetic activation including sweating, anxiety, tachypnea, and tachycardia or light-headedness, dyspnea, orthopnea, cough, nausea and syncope. An ECG examination is imperative in any

patient presenting with this symptomatology. A normal tracing is rare with acute MI.

• Cerebellar bleed Cerebral bleedabrupt onset develops slowlylucid patient early loss of consciousnesscerebellar tonsillar herniation No herniationshould be evacuated as soon as possible before coma ensues No such need



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• The most common cause of chronic AF is valvular disease, followed by congestive heart failure (CHF).The most common anatomic correlate seen in patients with AF (Framingham Heart Study) is an enlarged leftatrium.

• Otosclerosis may progress more rapidly in pregnancy Rx hearing aids; severe cases may respond toremoval of the stapes with implantation of a prosthesis

• Amylodosis: echocardiogram reveals ventricular walls with a "speckled pattern restrictive

cardiomyopathy ventricular filling is impaired and the cardiac silhouette may be mildly enlarged ECGnonspecific arrhythmias Like all restrictive ds develops into diastolic dysfunction.

• The pulmonary artery catheter/Swan-Ganz catheter allows direct, simultaneous measurement of pressures inthe right atrium, right ventricle, pulmonary artery, and the filling pressure ("wedge" pressure) of the leftatrium elevated right-sided pressure and low wedge pressure Rt ventricular infarct? Causing backing upof venous blood and decreased forward flow, producing a decrease in left ventricular filling, Rx aggressivefluid administration.

• A communication between an arteriole and venule in the cecum is a description of a vascular ectasia, alsoknown as an arteriovenous (AV) malformation. This a common cause of painless colonic bleeding in theelderly and may present with acute gastrointestinal bleeding,chronic gastrointestinal bleeding, or iron-deficiency anemia. These lesions may be difficult to demonstrate, as the bleeding may be intermittent or thecolon may be so full of blood that the site of origin is obscured. Techniques used to demonstrate bleeding AVmalformations include colonoscopy, intraoperative endoscopy, and visceral angiography. Treatment of theselesions is problematic because many patients will subsequently develop new or recurrent bleeding vessels.

• Having difficulty holding and using a writing instrument due to hand and forearm spasms no medications,dizziness or loss of consciousness or any history suggestive of a seizure focal dystonia of unknown cause.

• Cardioversion Synchronized electrical cardioversion is the process by which an abnormally fast heart rate or cardiac arrhythmia is terminated by the delivery of therapeutic dose of electrical current to the heart at aspecific moment in the cardiac cycle as determined by a compute0r (Pharmacologic cardioversion usesmedication) Synchronized electrical cardioversion is used to treat hemodynamically significantsupraventricular (or narrow complex) tachycardias , including atrial fibrillation and atrial flutter . It is alsoused in the emergent treatment of wide complex tachycardias, including ventricular tachycardia , when apulse is present. Pulseless ventricular tachycardia and ventricular fibrillation are treated withunsynchronized shocks referred to as defibrillation .So,hemodynamically unstable(loss of consciousness)vetricular tachcardia treat with asynchronous

cardioversion.• Hypertension eye tries to protect itself from the hypertension arteriolar constriction thickening of the

arteriolar walls (producing the broad light reflex) arterioles squeeze down too hard superficial foci ofretinal ischemia(cotton wool spots) hemorrhage and deposits occur because of vessel damage with leakageof contents.Hypertensive retinopathy seen in chronic essential hypertension, malignant hypertension, andtoxemia of pregnancy. Rx control of the hypertension. (Practically, progression can be stopped and thehemorrhages will resolve, but the vessel changes remain.)

• Nonproliferative diabetic retinopathy= hemorrhage and exudates in the retina + microaneurysms (visible asred dots).

• Proliferative diabetic retinopathy = nonproliferative diabetic retinopathy +neovascularization with vesselgrowth into the vitreous.

• Brain-death no electrical activity and no clinical evidence of brain function on physical examination (noresponse to pain , absent cranial nerve reflexes , pupillary response :fixed pupils, oculocephalic reflex , cornealreflexes ), absent response to the caloric reflex test and no spontaneous respirations. But patient without suchcriteria but with no purposeful activity one week after an anoxic brain injury bodes poorly for a meaningfulneurological recovery!(Not a brain death but recovery not meaningful).

• Whenever you see a case with a link to water reservoir/source like cruise/hospital/air-conditioner system and patient developed mental changes + diarrhea + Pneumonia = DDx Legionnaires pneumonia Rx Erythromycin


http://en.wikipedia.org/wiki/Heart_ratehttp://en.wikipedia.org/wiki/Cardiac_arrhythmiahttp://en.wikipedia.org/wiki/Electrical_currenthttp://en.wikipedia.org/wiki/Hearthttp://en.wikipedia.org/wiki/Cardiac_cyclehttp://en.wikipedia.org/wiki/Computerhttp://en.wikipedia.org/wiki/Tachycardiahttp://en.wikipedia.org/wiki/Atrial_fibrillationhttp://en.wikipedia.org/wiki/Atrial_flutterhttp://en.wikipedia.org/wiki/Ventricular_tachycardiahttp://en.wikipedia.org/wiki/Ventricular_tachycardiahttp://en.wikipedia.org/wiki/Ventricular_fibrillationhttp://en.wikipedia.org/wiki/Defibrillationhttp://en.wikipedia.org/wiki/Electroencephalographyhttp://en.wikipedia.org/wiki/Physical_examinationhttp://en.wikipedia.org/wiki/Pain_and_nociceptionhttp://en.wikipedia.org/wiki/Cranial_nervehttp://en.wikipedia.org/wiki/Reflexhttp://en.wikipedia.org/wiki/Pupil_constrictionhttp://en.wikipedia.org/wiki/Oculocephalic_reflexhttp://en.wikipedia.org/wiki/Corneal_reflexhttp://en.wikipedia.org/wiki/Corneal_reflexhttp://en.wikipedia.org/wiki/Caloric_reflex_testhttp://en.wikipedia.org/wiki/Caloric_reflex_testhttp://en.wikipedia.org/wiki/Corneal_reflexhttp://en.wikipedia.org/wiki/Corneal_reflexhttp://en.wikipedia.org/wiki/Oculocephalic_reflexhttp://en.wikipedia.org/wiki/Pupil_constrictionhttp://en.wikipedia.org/wiki/Reflexhttp://en.wikipedia.org/wiki/Cranial_nervehttp://en.wikipedia.org/wiki/Pain_and_nociceptionhttp://en.wikipedia.org/wiki/Physical_examinationhttp://en.wikipedia.org/wiki/Electroencephalographyhttp://en.wikipedia.org/wiki/Defibrillationhttp://en.wikipedia.org/wiki/Ventricular_fibrillationhttp://en.wikipedia.org/wiki/Ventricular_tachycardiahttp://en.wikipedia.org/wiki/Ventricular_tachycardiahttp://en.wikipedia.org/wiki/Atrial_flutterhttp://en.wikipedia.org/wiki/Atrial_fibrillationhttp://en.wikipedia.org/wiki/Tachycardiahttp://en.wikipedia.org/wiki/Computerhttp://en.wikipedia.org/wiki/Cardiac_cyclehttp://en.wikipedia.org/wiki/Hearthttp://en.wikipedia.org/wiki/Electrical_currenthttp://en.wikipedia.org/wiki/Cardiac_arrhythmiahttp://en.wikipedia.org/wiki/Heart_rate


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• Yersinia enterocolitica: Right lower quadrant pain mimicking appendicitis with symptoms of an acute ileitis

and diarrhea (In appendicitis patient typically have difficulty moving their bowels). Acquired through thefecal-oral route and diagnosis is based on clinical suspicion and the finding of the organism in stool cultures.

• Campylobacter jejuni: acute onset of either watery or bloody diarrhea consistent with colitis , severe fecal urgency , nocturnal bloody diarrhea sigmoidoscopy reveals continuous, symmetric inflammation from the

anal verge to the proximal sigmoid colon diarrhea in all age groups/peak of incidence is in youngchildren Fecoral spread

• Intentional inhalation of volatile hydrocarbons(model glue, correction fluid, spray paint and gasoline) in alarge quantity = "quick drunk": resembles alcoholic intoxication very high dose ataxia, hallucinations, andnystagmus Encephalopathy is the major chronic morbidity (Hydrocarbons are highly lipophilic leading toCNS damage) high level of suspicion is needed no drug screen test that can detect inhalanthydrocarbons.

• Rubella vaccine Gap of 3 months to be pregnant(theoretical risk of exposure to the rubella virus throughvaccination) But if pregnancy occurs within 3 months after vaccination not an indication or a reason toterminate the pregnancy(Simply woman should be counseled about the theoretical risk).

• Neonatal especially preterm steatorrhea due to smaller bile acid pool substitute medium-chaintriglycerides (MCTs) in the formula for long-chain triglycerides (LCTs) MCTs do not require bile acids forabsorption.

• Milestones:1. 4-years draw a four-sided figure (i.e., a square), count to 4, identify four colors, say a four-to

five-word sentence, and draw a picture of a person with at least four parts. (Easily remembered as4-year-olds do things in 4's.)

2. 5 yrs Drawing a triangle,count to 10, repeat a 10-syllable sentence, and draw a picture of a person with 8-10 parts

3. 6 yrs Building a staircase with cubes,can perform simple addition and draw a person with 12-15 parts.

4. 7- yrs ability to repeat five digits,can repeat three digits backward, draw a diamond shape, anddraw a person with 18-22 parts.

• Mitral valve prolapse =An apical click followed by a late systolic murmur Rx antibiotic before Dental

procedureMitral and tricuspid regurgitation = produce holosystolic murmurs with relatively uniform intensity. Mitralregurgitation is heard at the apex while tricuspid regurgitation is best heard along the lower left sternal

border.Mitral stenosis= mid-diastolic murmur heard after an opening snap.

• nasal foreign body: frequent sneezing and obstruction(Often misinterpreted as a common cold or allergy)infection develops resulting in a purulent and malodorous discharge unilateral involvement

• A saturation of 90% corresponds to an oxygen partial pressure of around 60 mm Hg =Hypoxia needs oxygen

• hepatitis A diagnosis is best made by determination of IgM levels against hepatitis A virus acuteinfection(antibody peaks at 4-6 weeks and does not persist beyond 6 months )while IgG is produced in the

primary infection, but for most viral infections, including hepatitis A, it persists for a life time .

• Attention deficit/hyperactivity disorder (ADHD) is characterized by impulsivity, hyperactivity, andinattention lasting at least 6 months and disorder must have started before age 7.

• Cardiac defects:1. Hypoplastic Lt heart syndrome: underdevelopment of the left cardiac chambers(left atrium and

ventricle often exhibit endocardial fibroelastosis ), atresia or stenosis of the aortic and/or the mitralorifices, and hypoplasia of the aorta No murmur , precordial hyperactivity (enlarged rightventricle is contracting against systemic pressure), loud second heart sound (because the

pulmonary artery acts as the aorta by pumping blood to the systemic circulation through the ductusarteriosus). When the ductus closes, or when the pulmonary vasculature resistance falls, the flow to



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the systemic circulation will decrease, causing greatly diminished peripheral pulses. Managementincludes infusion of prostaglandin E1 and administration of room air while on a ventilator.Prostaglandin E1 may open the ductus arteriosus and restore systemic blood flow.

2. Total anomalous pulmonary venous return:pulmonary veins forming a confluence behind the leftatrium, and draining into the right atrium Complete mixing takes place in the right atrium right-to-left shunt through the foramen ovale to the left side of the heart Often, no murmur isheard chest roentgenogram often shows a normal heart size with pulmonary edema. If there is

obstruction to pulmonary venous return, as is almost always present with veins draining inferior tothe diaphragm, cyanosis can be very prominent.3. Neonate becomes cyanotic then lost consciousness following feeding or when crying vigorously

baby picked her up and held infant regained hypercyanotic spells or "Tet spells" TOFDDx Frequent cyanosis and difficult breathing following birth but improves whilecrying Choanal atresia Rx intubation via oropharynx

• Post infectious Bells palsy:Mostly EBV

• CHF in infant: respiratory distress, tachycardia and/or hyperdynamic precordium, and cardiac enlargementevidenced by echocardiogram. DDx left-to-right shunt (ASD, VSD, PDA, atrioventricular canal, or AVfistula), left-sided obstruction leading to myocardial dysfunction (severe coarctation or AS), or intrinsicmyocardial dysfunction (myocarditis, cardiomyopathy, or infarct due to anomalous coronary artery). Rx IVfurosemide provide quick symptomatic relief and improve respiratory distress.

• Rx streptococcal pharyngitis is oral penicillin V for 10 days. However, Benzathine penicillin G can be givenas a single dose intramuscularly. It is a long-acting antibiotic and can complete the treatment:Prevention ofRheumatic heart Ds in a noncompliant patient

• Patients with sickle cell disease are at risk for infection by Salmonella and other gram-negative bacteriaincreased risk for acute recurrent Salmonella osteomyelitis. However, even in patients with sickle celldisease, Staphylococcus aureus is still the most common pathogen for osteomyelitis.

• Children


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• Breast-feeding jaundice decreased intake and increased enterohepatic circulation.

• Any ingested toxic substance/overdose presented within 60 mints Gastric lavage+ Add charcoal if possible

• Hypernatremic dehydration: hypotonic fluid loss (history of diarrhea or vomiting),inadequate supply ofmother's milk or high concentration of sodium in mothers milk irritable,lethargic infant and have a high-

pitched cry Complication like intracranial hemorrhage

• Intussusception usually occurs within the 6 to 12-month-old age group

• Conscious Sedation minor procedures like suturing laceration able to maintain airway patency, protective airway reflexes and responses to physical stimuli Use short-acting or long-acting benzodiazepine(midazolam or diazepam, respectively) by the oral or rectal route for (Intravenous midazolam or diazepamcan be used for procedures that produce more intense pain or discomfort, such as repair of complexlacerations, bone marrow aspiration, and reduction of fractures)

• "Do's" and "Don't's." during the seizure episode don't Put any object into the patient's mouth,do Place the patient on the side,Put a pillow or other soft object under the patient's head,Loosen tight clothing around theneck,Remove sharp objects from the surroundings.After the seizures, caretakers or parents should remainwith the patient until he/she is fully alert and allow him/her to go back to the usual activities.

• Child with ecchymoses Eliminate bleeding abnormalities by coagulation studies Normal study Thinkabout Abuse!

• Triad of thrombocytopenia (hemorrhage may be the presenting complaint), eczema, and recurrent infections(often respiratory) Wiskott-Aldrich syndrome(X-linked recessive) defects in both T and B cellfunction vulnerable to pyogenic bacteria, viruses, fungi and Pneumocystis carinii often died by age 15and survivors have increased incidence of cancer (lymphoma /ALL ) Rx splenectomy, continuousantibiotic therapy, IV immunoglobulin, and bone marrow transplantation.

• Severe combined immunodeficiency (Autosomal recessive) "bubble boy" disease because its victims areextremely vulnerable to infectious diseases adenosine deaminase deficiency (purine salvage enzyme anddeficiency leading to turn off DNA synthesis) Low T/B cells counts.

• X linked SCID mutations in gene encoding the common gamma chain (γ c),shared by the receptors for

multiple interleukins affects development and differentiation of T and B cells All males with thedefective gene will have SCID Females are carriers.

• Bruton agammaglobulinemia Cellular immunity is intact mature B-lymphocytes do notform germinal centers are absent in lymph nodes infections after about six months (maternal antibodieshave decreased) recurrent pyogenic infections, particularly of the lungs, sinuses, and bones.

• Common variable immunodeficiency syndrome Clinically same as Bruton’s but onset in lateadolescence/young adulthood hypogammaglobulinemia with markedly decreased IgM failure of B-lymphocytes to differentiate into plasma cells patients have an increased risk for B-cell lymphomas, gastriccarcinoma, and skin cancer

• Meconium =fetal stool(desquamated cells from the gastrointestinal tract admixed with enough bile to give thesoft stool a greenish color) distressed fetus will pass meconium into the amniotic fluid and then mayaspirate it In maternal preeclampsia, hypertension, or postmaturity aspirated meconium is very irritatingto the lungs and causes a chemical pneumonitis Rx prompt suction of the nasopharynx and mouth

• Kawasaki disease:systemic vasculitis of unknown origin mucocutaneous lymph node syndrome Clinicaland echocardiographic features remain the basis for diagnosis An (unidentified) infectious origin and a T-cell immune activation Fever, bilateral non-exudative conjunctivitis, mucous membrane changes (injected

pharynx, cracked lips, or strawberry tongue), extremity changes (edema, desquamation, erythema, or rash),and cervical adenopathy myocarditis, valvular insufficiency, arrhythmias, pericardial effusion, andcongestive heart failure Leukocytosis and an elevated C-reactive protein are associated with thedevelopment of coronary artery aneurysms Rx aspirin ,IV immune globulin &Corticosteroids(Controversial:Reduces coronary artery aneurysm?).


http://en.wikipedia.org/wiki/Mutationhttp://en.wikipedia.org/wiki/Common_gamma_chainhttp://en.wikipedia.org/wiki/Interleukinhttp://en.wikipedia.org/wiki/Interleukinhttp://en.wikipedia.org/wiki/Common_gamma_chainhttp://en.wikipedia.org/wiki/Mutation


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• The most commonly abused drug by pregnant mothers is cocaine Infants small for gestational age ( SGA )and sometimes, microcephaly and neurodevelopmental abnormalities irritable and cries in high-pitch .increased risk of sudden infant death syndrome & Periventricular leukomalacia.

• Interesting facts that pancreatitis may show normal amylase(Rely more on lipase)

• Interesting facts that Gullain Barre synd may rarely have sensory involvement

• Listeriosis acquired by mothers exposed to unpasteurized dairy products or raw vegetables exposed to cattleor sheep manure amnionitis abortion, stillbirth or neonatal sepsis brown, murky amniotic fluid orDisseminated disease in the fetus can cause granuloma formation (with associated tissue destruction) in manytissues, including liver, adrenal glands, lymphatic tissue, lungs, and brain(granulomatosis infantiseptica)

• Prenatal toxoplasmosis Rx Treatment is with combination antibiotic therapy, including pyrimethamine,sulfadiazine, and leucovorin.

• Bupropion antidepressant with both dopaminergic and noradrenergic properties improve depressionand cognitive functioning (term cognition is used in several loosely related ways to refer to a faculty for thehuman-like processing of information , applying knowledge and changing preferences) also used to reduceNicotine craving/dependence Any drug with anticholinergic properties might impair cognitivefunction(even SSRI)

• Propranolol known to occasionally lead to depressive symptoms

• Loosening of associations ideas are disconnected and seem to jump from one topic to an unconnected topic.Clang associations Words that rhyme are frequently associated.Concrete thinking poor ability to think in abstract terms despite normal intelligence.Tangential thoughts thoughts that go off on a tangent, interviewer is commonly left with the sense that aquestion to the patient elicited a long string of thoughts that ended up having nothing to do with the originalquestion.Thought blocking occurs when thoughts and speech halt, often in mid-sentence, as if forgotten. Thethought may be picked up later, after a period of apparent confusion.

• Cimetidine known to cause psychiatric effects like delusions and psychosis related to the effects ofcimetidine on the H-2 histamine receptor in the brain.

•

Electroconvulsive therapy (ECT) has been safely used in pregnancy. In case of psychotic depression withincreased risk for suicide, the situation requires expeditious treatment to protect the mother and fetus, andECT is the treatment of choice.

• Post-traumatic stress disorder Rx Sertaline

• Maternity blues is a normal state of sadness, dysphoria, frequent tearfulness, and dependence that about 20%to 40% of women experience in the postpartum period. It is thought to be derived from rapid changes inwomen's hormonal levels and the stress of childbirth associated with maternity

• Behavioral therapy is the most frequently used treatment in children with enuresis. Dry nights are recordedon a calendar and rewarded with a star as a gift.

• Agoraphobia(fear of open spaces or of the marketplace)is a fear of panic attacks in situations from which itwould be difficult to gracefully remove oneself. Behavioral therapy is used to encourage patients to modifytheir activities.

• Generally conventional antipsychotic + prophylactic anticholinergic agent (benztropine, diphenhydramine, ortrihexyphenidyl).is given together sudden ceassation of anticholinergic Ppt Extrapyramidal signs likedystonic reaction/torticollis Rx IM administration of an anticholinergic agent

• Although risperidone is an atypical antipsychotic, it is like conventional antipsychotics in its ability to causesignificant elevations in plasma prolactin levels.


http://en.wikipedia.org/wiki/Informationhttp://en.wikipedia.org/wiki/Information


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• Psychomotor agitation is a series of unintentional and purposeless motions that stem from mental tension ofan individual. This includes pacing around a room, wringing one's hands, pulling off clothing and putting it

back on and other similar actions. In more severe cases, the motions may become harmful to the individual,such as ripping, tearing or chewing at the skin around one's fingernails to the point of bleeding DDxPsychomotor agitation in major depressive disorder > bipolar depression

• Catatonia include stupor, negativism(motiveless resistance to all attempts to be moved or to all instructions),

rigidity, posturing, mutism, stereotypies, mannerisms, waxy flexibility, and catatonic excitement. Catatoniamay be associated with schizophrenia (catatonic type), mood disorders (with catatonic features), or generalmedical condition or Extrapyramidal side effect of drug .

• Nihilistic delusions are false feelings that the self or others do not exist or are destroyed. It is typical fordepression with psychotic features. At its extreme, it is called Cotard's syndrome.

• Prescribing antidepressants in bipolar depression may un-mask underlying mania Start mood stabilizer before beginning treatment with an antidepressant

• Panic disorder Rx benzodiazepine like clonazepam or use of cognitive behavior therapy, which incorporatesexposing the patient to disturbing stimuli in an attempt to develop coping mechanisms in response to thestimuli.

• Adjustment disorder is exemplified by a set of behavioral or emotional symptoms developing as a response toan identifiable stressor within 3 months after exposure to the stressor. The symptoms are excessive comparedwith what one would expect from the exposure, and they cause marked impairment in social functioning.

• Any event that affects the vasculature, such as a myocardial infarction or a cerebrovascular accident (CVA),has been shown to increase the risk of major depressive disorder in the months following such an event.Post-stroke mania is a rare phenomenon usually seen in infarctions of right frontal lobe and sometimesother parts of the right hemisphere.

• Pemoline is a sympathomimetic agent approved for the treatment of attention deficit/hyperactivity disorder.Given the rate of reported cases of hepatic failure. Dextroamphetamine is approved for the treatment ofattention deficit/hyperactivity disorder. Its main adverse reactions involve the cardiovascular system, theCNS, the gastrointestinal system, and the endocrine system.

• Prevalence of ADHD is estimated to decline by 50 % every 5 years until the mid-20's i.e. older the children

get without symptoms of ADHD, the less likely they have the disorder. (Generally manifest before 6-7yrs)• Mini-Mental Status Examination (MMSE) is a brief instrument designed to grossly assess cognitive

functioning. It assesses orientation, memory, calculation, reading and writing capacity, visuospatial ability,and language. The maximum score is 30. can be re-administered periodically to follow progression ofdementia.

• prochlorperazine and haloperidol administration feeling of restlessness & agitation(akathisia) Rxlorazepam given IV during administration of the neuroleptic drug.

• The most serious side effect of lamotrigine(adjunct in the treatment of refractory seizures and bipolardisorder) is rash (skin changes that looked like burns.) Stevens-Johnson syndrome

• Clozapine is an atypical agent more effective in resistant schizophrenia. It exerts an antagonistic effect on D1and D4 receptors S/E agranulocytosis requires regular blood count monitoring



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(a)Solid Masses in Women Less Than 40 Years of Age

1. Physical Examination No evidence of mass reassured and instructed in breast self-examination.2. Physical Examination physical finding is uncertain directed ultrasound examination not demonstrate

a mass Repeat physical examination ?mammogram (35 to 40 years not in younger)3. Physical Examination dominant mass (? suspicious mass is solitary, discrete, hard and often, adherent to

adjacent tissue) mammography pathologic diagnosis. 4. Physical Examination dominant mass (? Not a suspicious mass or clinically benign) discus options of

surgical excision or follow-up with the patient patient desires surgical excision no additional testing isdone patient opts for further work-up an ultrasound examination and fine-needle aspiration are performedto confirm that the mass is benign. "Triple test" (clinical examination, ultrasonography [or mammography]and fine-needle aspiration).

• The size of the lesion must be measured with a ruler at presentation and on subsequent visits to allow anaccurate assessment of size over time.

• patient is examined every three or four months for one year to ensure stability of the mass.

(B) Solid Masses in Women More Than 40 Years of Age.

1. Abnormalities detected on physical examination in older women should be regarded as possible cancers

until they are documented to be benign.2. mammography is a standard part of the evaluation of a solid breast mass.3. In the presence of a dominant breast mass, a normal mammogram should never be considered proof of

the absence of breast cancer.

• Premenstrual dysphoric disorder : constellation of physical and emotional symptoms occurring during thelate luteal phase of the menstrual cycle symptoms must be present during most cycles in the past year andduring at least two subsequent cycles at least five of the following symptoms: depressed mood, markedanxiety, affective lability, decreased interest, decreased energy, sleep disturbance, craving food, feelingoverwhelmed, and difficulties concentrating interfere with social or occupational functioning and are notdue to other psychiatric or medical disorders.

• Exposure therapy a type of behavior therapy most commonly used treatment of specific phobia desensitizes the patient by a gradual exposure to the phobic stimulus Relaxation and breathing control areimportant parts of the treatment.

• Alprazolam belongs to the group of short-acting benzodiazepines. Even though it has a short half-life, it can produce confusion, disinhibition, and amnestic problems like blackouts in the elderly population. The risk isincreased if it is combined with CYP3A inhibitors.

• In pseudodementia of depression, the patient often tends to emphasize disability related to memory loss muchmore than patients experiencing true dementia.

• Olanzapine is an atypical antipsychotic indicated for the management of psychotic disorders. It is said to beassociated with weight gain.

• HIV dementia is characterized by affective, cognitive, behavioral, and motor symptoms and signs. It presents

as a subcortical process and is most likely to occur in patients with a CD4 count below 200/mm3. It usuallyhas a slow onset, and, after a period of stability, there can be a precipitous decline. The diagnosis is madewhen other causes of delirium are excluded; the disease may present with psychosis within HIV dementia.The symptoms are controlled with low doses of neuroleptics.

• Circumstantiality refers to speech that is delayed from reaching the point, characterized by overinclusion ofdetails.DDxTangentiality : patient never gets to the desired goal from the starting point of discussion.

• Patients with disorganized type schizophrenia are likely to exhibit disorganized speech, disorganized behavior, and flat or inappropriate affect. Examples of disorganized thoughts and speech include: loosening



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of associations or derailment, flight of ideas, tangentiality, circumstantiality, word salad, neologisms, andclang associations.

• The newer atypical antipsychotics have minimal, if any effect on plasma prolactin concentrations, except forrisperidone, which is associated with elevated prolactin.

• A Papanicolaou smear should ideally be a sampling of the transformation zone(adequate sample should show

endocervical cells) endocervical cells not present?whether the transformation zone was fullysampled Repeat the sample if high risk individual or after 1 yr if with no high risk and had all earlier papnormal Every woman should have yearly pap smear after first intercourse or 18yrs whatever comes earlier

• Rarely struma ovarii is a cause of hyperthyroidism and patients with this manifestation may have symptomsof hyperthyroidism, as well as elevated levels of thyroid hormones and decreased levels of thyroidstimulating hormone (TSH).

• There is no evidence that breast-feeding increases HCV transmission to the baby.

• Postpartum endometritis Cesarean section is the major risk factor Organisms ascending from the vaginaand causing a polymicrobial infection of the endometrium fever and chills, lower abdominal pain, a foul-smelling vaginal discharge and malaise abdominal tenderness, and uterine tenderness Rx clindamycinand gentamicin ( prophylactic antibiotics are recommended in all cases of nonscheduled cesarean deliveryi.e. a cesarean delivery that is not anticipated like with membranes broke but non-progressing/Breech etc andare given before or after the umbilical cord is clamped)

• Discharge criteria patient should be alert, able to ambulate (if this was her preoperative level of function),able to tolerate adequate oral intake(Patient on IV intake should not be discharged) , have stable vitalsigns, and have satisfactory bowel and urinary tract function.

• Chorioamnionitis (can develop at any time before and during delivery) fever and uterine tenderness Rxampicillin or penicillin with gentamicin.

• Asymptomatic bacteriuria in pregnant women association with preterm delivery/low birth weight Rxtrimethoprim-sulfamethoxazole, nitrofurantoin, and cephalexin follow-up urine culture after 10 days ofcompleting the medication test-of-cure.

• Gestational diabetes usually diagnosed by means of oral glucose tolerance testing Patients with

gestational diabetes and normal fasting glucose two major risks fetal macrosomia & eventualdevelopment of overt diabetes(within the next 20 years) with gestational diabetes and abnormal fastingglucose increased risk of stillbirth.

• Significant mitral stenosis during pregnancy should be monitored invasively using a Swan-Ganz catheter second stage of labor be shortened using forceps or vacuum to prevent excess maternal Valsalva efforts andmaternal tachycardia.

• HIV Positive mother combination of ZDV therapy + cesarean delivery decreases the risk of transmissionto approximately 2% Amniocentesis should be avoided, if possible, in the HIV-positive woman.

1. 2% vertical transmission with ZDV + Scheduled CS prior to the onset of labor or ruptureof membranes

2. 8% antiretroviral therapy in mother + Infant3. 25% when none used

• Constitutional delay is normal pubertal progression at a delayed rate or onset. The average age at menarche is12 1/2 years, but it may be delayed until 16 or may begin as early as age 10.

• Current recommendations are that pregnant women who will be in the second or third trimester during the fluepidemic season should be given the influenza vaccination.

• "once a cesarean, always a cesarean." This is no longer the case. Some women are allowed to approximately 70% of all women attempt vaginal birth after a prior cesarean delivery will be successful.



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• Face presentation Causes: anencephalic fetus, pelvic contraction, and high parity vaginal delivery is possible when the fetus is in a mentum anterior position (i.e., the fetal chin is oriented toward the maternal pubic symphysis.) Fetus can flex its head, thereby allowing delivery Vacuum delivery /Forceps deliverywith a non-vertex presentation would be contraindicated.

• The presence of a classic uterine scar (vertical incision into the uterus that extends from the lower uterinesegment up into the active myometrial portion toward the fundus of the uterus) mandates elective repeat

cesarean delivery when the fetus is mature as patients with a previous classic cesarean delivery have roughlya 10% risk of uterine rupture.

• Oxytocin or Prostaglandin (PGE2) gel is an effective agent to use for labor induction shown to improve theBishop's score, to shorten the length of labor and delivery, to decrease the amount of oxytocin needed, and todecrease the cesarean delivery rate main complication from its use is uterinehyperstimulation increased frequency of contractions (greater than 5 every 10 minutes) or an increasedlength of each contraction (greater than 2 minutes) or contractions of normal duration occurring within 1minute of each other and a non-reassuring fetal heart rate tracing Rx IV or subcutaneous terbutaline or IVmagnesium sulfate(MgSo4 also most effective medication for seizure prophylaxis in women with

preeclampsia) in case of PGE2 or discontinuing the oxytocin (bradycardia to the 80s) or reducing its dosage(where the fetal heart rate tracing is not as non-reassuring)

• Home uterine activity monitoring (HUAM) women are monitored at home with a tocodynamometer (away to measure uterine contractions) will allow for preterm labor to be recognized and treated in its earlieststages to prevent preterm births In practice not been proven to prevent preterm birth possible benefitearly recognition of preterm labor would allow for the administration of corticosteroids to bring about fetal

pulmonary maturity (Steroid administration in a Diabetic mother may lead to increased dosage of Insulin).

• Fetal scalp sampling (FSS):method of fetal assessment with fetal blood pH When the fetal heart ratetracing is not reassuring, FSS can be used to determine the acid-base status of the fetus, which will help withmanagement of the labor pH is > 7.25 then the patient may be managed expectantly pH is between 7.20and 7.25:repeat in 15 to 30 minutes pH is < 7.20, steps should be taken to bring about delivery(Acidemialikely to cause damage to the fetus appears to occur at values < 7.00, by using a cutoff of 7.20, there is amargin for error to protect the fetus)

• Forceps and the vacuum extractor To expedite the delivery indications:1. non-reassuring fetal heart rate tracing,2. maternal exhaustion

3.

maternal contraindications to pushing (such as maternal cardiac disease.Choice of forceps or vacuum ? Forceps may be used in face presentation with a mentum anterior presentation(vacuum is contraindicated) Vaccum extractor does not occupy space next to the fetal head;this should lead to less trauma to maternal tissues Both the vacuum and forceps should preferably be usedonly in low- or outlet- situations (i.e., with the fetal vertex at +2 station or lower.)

• A major advantage of chorionic villus sampling is that it can be performed at 10-12 weeks, as opposed toamniocentesis, which is performed in the second trimester. CVS thus allows a woman to undergo an earliertermination than amniocentesis allows for. However, there is some evidence that one subtype of limb defect,called transverse digital deficiency, is more common with CVS.

• The Bartholin's glands are bilateral structures that are present near the posterior fourchette of the vagina at the5 and 7 o'clock positions. They secrete mucus, particularly during sexual stimulation, which drains into the

posterior vagina.They undergo rapid growth during the process of puberty and they shrink after themenopause. When the duct of the Bartholin's gland becomes obstructed, a Bartholin's cyst results cyst

becomes infected Bartholin's abscess polymicrobial /gonococcus implicated in 25% Rx placement of aWord catheter .( This is a small balloon-tipped catheter)allows drainage of the cyst and the formation of anepithelialized tract that will allow continued drainage once the catheter is removed tract should prevent thecyst from reforming If Bartholin's cysts continue to form in spite of the use of the Word catheter, amarsupialization procedure may be tried. In this procedure, the cyst walls are sutured open to the surroundingskin to prevent re-closure and re-formation of the cyst interestingly; one cannot make this assumption in apostmenopausal patient cystic mass on the vulva in a postmenopausal woman must be biopsied(as there isa higher likelihood that this lesion represents a Bartholin's gland carcinoma)

• High-grade squamous intraepithelial lesion (HGSIL) will progress to invasive cervicalcancer colposcopically directed biopsy diagnosis of HGSIL is confirmed the distribution of the lesion



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is known, removal or destruction of the entire transformation zone should be performed done with a loopelectrode excision procedure (LEEP a thin-wire loop electrode is used to excise the entire transformationzone LEEP can thus be used as both a diagnostic and therapeutic procedure immediate risks of LEEP are

bleeding and infection. The possible long-term risks include cervical incompetence and cervical stenosis.

• The American Heart Association guidelines for the prevention of bacterial endocarditis antibiotic prophylaxis is not necessary for cesarean delivery or normal vaginal delivery Except patient with "high

risk" cardiac conditions, which include women with a history of endocarditis, or who have prosthetic heartvalves, complex cyanotic congenital heart disease, or surgically corrected systemic pulmonary shunts Mitral valve prolapse if associated with mitral regurgitation (demonstrated by Doppler or a murmur) isconsidered a moderate risk condition and therefore antibiotic prophylaxis is not necessary.

• Physiologic leukorrhea can be seen during 2 different periods of childhood. Some female neonates develop a physiologic leukorrhea shortly after birth as maternal circulating estrogens stimulate the newborn'sendocervical glands and vaginal epithelium. Physiologic leukorrhea can also be seen during the months

preceding menarche. During this time, rising estrogen levels lead to a whitish discharge not associated withany symptoms of irritation or infection.

• With each uterine contraction, blood flow to the placenta decreases, and the fetus is exposed to transienthypoxia. As the labor progresses and more and more contractions occur, this hypoxia can eventually lead to achange from aerobic to anaerobic metabolis fetal academia most fetuses tolerate the stress protectivemechanisms including a blood buffering system and the diving reflex (a lowering of the heart rate in timesof hypoxic stress) Electronic fetal monitoring is used to determine whether the fetus is becomingdangerously acidemic or "stressed"? But many fetuses with a non-reassuring fetal heart rate tracing do nothave academia Thus, the delivery of many fetuses is expedited because of the concern for fetal acidemiawhen, in fact, the fetus is not acidemic at all!

• Group B Streptococcus part of the normal bacterial colonization of many women which women willreceive antibiotics during labor? likelihood of infection is increased if following risk factors are present:

1. The five risk factors are: 1. History of a GBS-affected neonate . 2. Urine culture with GBS (GBSbacteriuria) 3. Preterm labor (HIV during operative procedures etc

• BRCA1 is associated with high risk for breast and ovarian cancer.BRCA2 is associated with a high risk of female and male breast cancer.But total number of breast cancer cases associated with BRCA1 and BRCA2 mutations is a small percentageof the total number Therefore, screening of the general population is not recommended.

• RhoGAM (anti-D immune globulin) is given at 28 weeks' gestation, within 72 hours after the birth of an Rh- positive infant, after a spontaneous abortion, or after invasive procedures such as amniocentesis, threatenedabortion, antenatal bleeding, external cephalic version, or abdominal trauma The amount is 300 µg (coversa fetal to maternal hemorrhage of 30 mL or 15 mL of fetal cells) when fetal to maternal hemorrhage inexcess of this 30 mL like with manual removal of the placenta (like this patient had) or placental abruption.

To determine the amount of fetal to maternal hemorrhage that occurred, it is necessary to perform aKleihauer-Betke test This acid-dilution procedure allows fetal red blood cells to be identified and

counted.

• Aspiration pneumonitis is a major cause of anesthesia-related death in obstetrics Rx treatment positive- pressure ventilation with 100% oxygen administered through an endotracheal tube when an epidural isgoing to be placed, the patient should be given an antacid

• Two of the major risk factors for uncomplicated UTI are sexual intercourse and hypoestrogenism.Hypoestrogenism is believed to be a risk factor for UTI because it is known that postmenopausal women notreceiving estrogen replacement therapy (ERT) are at greater risk for developing a UTI compared with thosewomen who do use ERT.



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• There is no effective screening test for endometrial cancer .It is not cost-effective to screen asymptomaticwomen for endometrial cancer.

• Cancer screening should be an essential part of an annual examination. Colorectal cancer screening should begin at age 50 with no significant family history. Screening consists of a digital rectal examination withfecal occult blood testing. This can be performed at the same time that pelvic examination is performed.Sigmoidoscopy should be performed every 3-5 years.

• Various studies have also shown that rates of preeclampsia, placental abruption, and heart failure may beincreased in pregnant patients with hypothyroidism. Pregnancy often leads to an increased requirement forthyroid hormone replacement (thyroxine) as the pregnancy progresses.

• Coumadin is contraindicated during the first trimester because of the risk of birth defects. Coumadinembryopathy is a syndrome consisting of nasal hypoplasia and stippled vertebral and femoral epiphyses.Second- and third-trimester exposure to Coumadin can lead to hydrocephaly, microcephaly, ophthalmologicabnormalities, fetal growth retardation, and developmental delay. Low-molecular-weight heparin has beenshown to be an excellent anticoagulant because it has a longer half-life and a more predictable dose-response relationship ,also less likely to cause thrombocytopenia and hemorrhagic complications thanunfractionated heparin.

• Tubal ligation failure may result from many factors including recannalization of the tube and poor surgicaltechnique. The most commonly quoted failure rate is about 1 in 100, although a more accurate figure may becloser to 1 in 300.

• Raloxifene is selective estrogen receptor modulators (SERMs) have pro-estrogenic effects in some tissuesand anti-estrogenic effects in other tissues approved for prevention of osteoporosis no effect on hotflashes.

• Patient post-hysterectomy for Endometrial CA asking for HRT? if any neoplasm is remaining in body itwill grow and recur earlier! +Standard risk of venous thrombosis

• Hot flashes can respond to estrogen or progestin both When both are contraindicated(like H/o pulmonaryembolus for estrogen or depression for progestin) Rx alternative treatment Clonidine in low doses.

• Vitamin A supplementation during pregnancy is not needed or recommended for most women. In fact,vitamin A supplementation has been associated with birth defects, including cranial neural crest

malformations. Most commonly used prenatal vitamins contain 5000 IU or less, and this is consideredacceptable.

• Ovarian hyperstimulation syndrome (OHSS) in patients undergoing ovulation induction mild OHSS(ovaries 10 cm) with ascites, hydrothorax, hemoconcentration,and oliguria Rx mild cases: conservatively, more severe cases: paracentesis, thoracentesis, or surgery.

Pelvic or abdominal examinations can lead to rupture of the ovarian capsule hence ultrasound examinationis preferred.

• During pregnancy: gastric acid secretion & motility is reduced and mucus secretion increased Reduced peptic ulcer disease Similarly 70% of women with migraines will have improvement(Rx acetaminophenand antiemetics or Codeine or meperidine may be given for severe headaches Ergotamine preparationsshould be avoided in pregnancy) safety of sumatriptan during pregnancy has not been established?

• Mode of delivery with twin gestations:1. Vertex-vertex twins are generally allowed to have a vaginal delivery.2. presenting twin that is non-vertex are generally advised to have a cesarean delivery3. Presenting twin vertex and the non-presenting twin non-vertex may decide which mode of

delivery they would prefer Once the presenting (vertex) twin has delivered first option is anexternal cephalic version, in which the head of the second twin is guided into the pelvis so that it

becomes a vertex presentation second option is a breech extraction of the second twin(Breechextraction may be performed so long as there is an adequate pelvis, a fetal weight greater than2,000g, an experienced physician, a flexed fetal head, and available general anesthesia)



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• DNA-based molecular analysis can be used to diagnose fragile X syndrome. This can be performed oncultured amniocytes obtained at amniocentesis. Chorionic villus sampling is not considered to be reliablefor the diagnosis of fragile X syndrome because of different methylation patterns in the trophoblastcompared with the fetus.

• Kallmann syndrome (i.e., isolated gonadotropin deficiency or familial hypogonadotropic hypogonadism) can present with primary amenorrhea ,anosmia or hyposmia, color blindness, and cleft lip or cleft palate(during

embryogenesis the GnRH neurons originally develop in the epithelium of the olfactory placode and normallymigrate into the hypothalamus Thus exists the link between the midline defects and the amenorrhea) Rxexogenous estrogen and progestin replacement therapy If pregnancy is desired, ovulation induction can be

brought about with the pulsatile administration of exogenous GnRH.

• In case of PID: The partner of the patient must be treated as well as the patient herself in order to preventreinfection. A test of cure (TOC) should be performed 4 to 6 weeks after treatment is given to ensure that theorganism has been completely eradicated from the patient and her partner or partners.

• PID in preganacy Rx Clindamycin + gentamycin

• Meperidine can be used as a systemic analgesic during labor. It is an opioid and readily crosses the placenta;therefore, the fetus is exposed to the medication. As an opioid, it causes respiratory depression. Neonates areat greatest risk for respiratory depression when delivery occurs approximately 2 to 3 hours after meperidine isadministered to the mother.Rx nalaxone

• Compound presentation:when an extremity prolapses alongside the fetal presenting part brought aboutwhen the pelvic inlet is not completely occluded by the fetal head(Most often with premature fetuses) compound presentation can be allowed to undergo a normal labor and delivery.

• Women of child-bearing age should consume 0.4 mg/day of folic acid starting preconceptionally andcontinuing for the first 3 months of pregnancy.

• Molar preganancy: Once there is pathologic confirmation of the diagnosis, it is essential that the patientcontinued to be followed weekly until the beta-hCG value returns to 0. The patient should then be followedmonthly for an additional year to ensure that the values stay at 0 and that there is no evidence of persistent ormetastatic disease.

• Syphillis in preganancy :Only Rx is penicillin as no other drug permits safe and effective treatment of the

fetus as well as the mother In a patient who is allergic to penicillin, oral desensitization must be performedfirst in a hospital setting with appropriate facilities.

• Genital herpes: no "cure" for herpes genitalis. Acyclovir can be used to shorten the duration of symptoms. In patients who have more than 6 outbreaks per year, daily oral acyclovir is recommended to prevent thesefrequent outbreaks.

• In all other solid organ transplants, deterioration of function 10 days out would suggest an acute rejectionepisode, and appropriate biopsies would be done to confirm the diagnosis. In the case of the liver, however,antigenic reactions are less common, whereas technical problems with the biliary and vascular anastomosisare the most common cause of early functional deterioration. They are, therefore, the first anomalies to besought.

• Fluid replacement in a case of burns the Parkland calculations made by standard formulas are only aneducated guess. Once fluid administration begins, we judge its adequacy by the information provided byurinary output and central venous pressure, aiming for an output of 1-2 mL/kg/hr, while not exceeding avenous pressure of 10 or 15.

• Parkland formula: 4 mL of Ringer's lactate x body weight in Kg x percentage of the body surface burned +2000 mL of dextrose 5% in water

• The treatment of breast cancer in a pregnant woman should be the same as that in a nonpregnant woman,except for two restrictions: no chemotherapy during the first trimester, and no radiation therapy during the

pregnancy. It is not necessary to terminate the pregnancy. The surgical option could be mastectomy orlumpectomyas per the size.Should axillary nodes be positive, systemic therapy should be done later.



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• 2nd postoperative day after an operative procedure urinary output in the past 2 hours has been zero (ARF

ruled out as s ome urine is still produced in ARF, although it is a small volume) Rule out catheter block?

• Lumpectomy alone has an unacceptably high incidence of local recurrence Always add local radiationtherapy If metastatic disease found in axillary nodes Add systemic therapy. As a rule, chemotherapy is

preferred for premenopausal women & receptor positive.

• Never operate a patient under GA if liver function marginal would be tipped into overt liver failure by ananesthetic and an operation

• Any gunshot wound below the nipples involves the abdomen, and the management of all gunshot woundsof the abdomen requires exploratory laparotomy.

• Compartment syndrome triggered by prolonged ischemia followed by reperfusion (the arm pressed againstthe park bench until he woke up and changed position), and located in one of the two most common sites(forearm and lower leg) reliable physical finding pain on passive extension and the diagnosis is not ruledout by normal pulses. Only a fasciotomy will solve his problem.

• Amputed finger under transport must be kept from drying out must not be injured with any directchemical agents must not be placed in direct contact with ice or allowed to freeze.

• There is some evidence that high-dose corticosteroids administered as soon as possible after the injury willresult in a better ultimate outcome

• A rough guideline to quantify water loss every 3 mEq/L that the serum sodium concentration is abovenormal, represents about 1 L of water deficit E.g Na+ 155 = excess of 15 = water deficit of about 5 L.While correcting hypernatremia the tonicity correction should not happen with the same speed with which thevolume is going to be corrected (Brain should adapt with osmolality changes) That delay is achieved bychoosing a fluid that is not pure water, but one that has some sodium in it to dampen the effect ontonicity E.g Dextrose with half NS

• Severe head trauma sufficient to produce coma + facial injuries always evaluate with CT to R/o bleed andinclude Neck also

• All failed regimen in anal fissure Opt for Forceful dilatation under anesthesia, lateral sphincterotomy, or

botulinum toxin injections

• Abdominal compartment syndrome the life-saving massive fluid infusions produce severe edema in thesurgical field Forced closure would compromise ventilation and venous return A temporary plasticcoverage, or a mesh, allows the bowel to be protected without undue pressure.

• Pelvic bone fracture Falling BP but no free fluid within abdomen Pelvic fractures can bleed massively,and often the source is torn veins that are not easily controlled Minimizing the motion of the bonefragments by external fixation can be helpful Comminuted fractures of the femurs are also known to beone of the few places in the body where enough occult blood loss may occur to lead to hypovolemic shock.

• Hyperthyroid state But the thyroid gland normal Radioactive iodine uptake should be high if her glandis indeed hyperfunctioning but it will be near zero if it is suppressed by the exogenous hormone.

• Breast mass found after trauma not regressing after week might not be a hematoma or fat necrosis trivialtrauma sometimes brings to the attention of the patient an area of the body that had not been examined

before A breast mass in a >40-year-old woman requires a mammogram and biopsy.

• Gunshot wounds to the base of the neck may injure major vessels, the tracheobronchial tree, and theesophagus diagnostic studies should precede surgical intervention if time allows

• Several months after sustaining a crushing injury to arm constant, burning, agonizing pain in thatarm Not responding to usual analgesic medications aggravated by the slightest stimulation of the area,such as rubbing from the shirt sleeves arm not swollen and pulses normal neurologic function of major



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nerves intact causalgia (reflex sympathetic dystrophy) If sympathetic block relieves the symptoms, permanent cure will be obtained with surgical sympathectomy.

• Small umbilical hernias can close spontaneously up to the age of 2 years.

• Enucleation of Eye Often done for two malignant tumors retinoblastoma and melanoma melanoma may present as metastatic tumour after even 20-some years A patient with a glass eye or missing toe and a liver

full of tumor is classic examples to illustrate the unpredictable behavior of melanoma.

• Suspected Skin CA Always perform biopsy edge of the lesion offers the best information for the pathologist An excision before pathologic diagnosis risks doing too much (a basal cell cancer needs only 1or 2 mm of margins) or too little (a melanoma should have at least 2 cm).

• most important thing that can be done for caustic chemical burns is to wash away the caustic agent as soon as possible

• When coagulopathy develops during operative procedure provide fresh frozen plasma and platelet packs.when hypothermia complicates the picture Close the abdomen immediately bleeding surfaces have to

be packed, waiting for a more propitious time in which to attempt hemostasis, once coagulation function and body temperature have improved

• Diffuse esophageal spasm v/s Nutcracker esophagus on manometry there is a mean distal esophageal peristaltic amplitude of more than 180 mm Hg, including an elevated baseline pressure in the lower sphincterin Nutcracker (Normal pressure and relaxation in diffuse esophageal spasm).

• De Quervain's tenosynovitis: Tenosynovitis of the abductor or extensor tendons of the thumb positiveFinkelstein sign (the pain produced by ulnar deviation to stretch the affected tendons).

• Advanced breast CA Rad/chemo to make it operable

• A high spinal anesthetic can produce vasomotor shock by inducing widespread vasodilation. Vasoconstrictorsare the appropriate therapy, but since the capacity of the vascular tree is also increased under thesecircumstances, filling it up with additional volume is also helpful.

• Follicular thyroid cancers can metastasize by way of the blood stream to the liver, lung, brain, or bones.Because the tumor has rudimentary functional capability, it can be traced with and ablated by radioactive

iodine; however, the tumor cannot compete successfully with normal thyroid tissue for the capture of iodine.After removal of the entire gland, the tumor becomes the most effective iodine trapper in the body.

• Very tender spot in the third interspace foot(between the third and fourth toes) no redness, limitation ofmotion, or signs of inflammation classic for Morton's neuroma, a benign neuroma of the third plantarinterdigital nerve.

• A fracture from such trivial strain signifies a very weakened bone. In this age and gender, the most likelycause would be a lytic lesion from metastatic breast cancer.

• Post-traumatic hemothorax criteria to perform thoracotomy if the initial blood recovery exceeds 1000mL, or if subsequent drainage adds up to 600 mL or more, over the ensuing 6 hours.

• wound dehiscence after abdominal surgery draining copious amounts of clear pink fluid from his midlinelaparotomy wound could have been handled by taping the wound securely Immediate surgical repair ismandatory Not allowed to strain abdomen or move around Once the bowel came out, the problem

became an evisceration

• Acute ‘Senility’ within short periods of weeks Suspect chronic SDH.

• In case of Pheochromocytoma presence of catabolites from epinephrine indicates that the tumor is in theadrenal glands, and not at an extra-adrenal site.



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• When hitting the knees against the dashboard, the femurs can be driven backward and out of the acetabulum,resulting in posterior dislocation of the hips. Because of the tenuous blood supply of the femoral heads, suchinjury must be promptly recognized and treated.

• Postoperative complications:1. Atelectasis : seen on day 12. Fever day 3 is usually from the urinary tract infection.

3. Deep thrombophlebitis 5-7 days after surgery4. Intra-abdominal abscess 7-10 days

• Intraoperative myocardial infarction is mostly seen in elderly men, and the most common triggering event is prolonged hypotension. Furthermore, the mortality greatly surpasses that of a myocardial infarction de novo(ie, unrelated to surgery), reaching upto 50-90%

• heel pain every time foot strikes the ground worse in the mornings, preventing him from putting any weighton the heel when the ankle is dorsiflexed, the entire inner border of the fascia is tender to palpation

plantar fasciitis.

• central cord syndrome:mechanism of injury (hyperextension) relative sparing of the lower extremities inthe presence of upper extremity deficits are classic

• Anterior cord syndrome all functions are lost, except for positional and vibratory sense. Those injuries occurwith blowout of the vertebral bodies.

• Posterior cord syndrome is quite rare, and it would show loss of positional and vibratory sense.

• Anorectal signs and mass with Inguinal nodes has to be anal SCC AdenoCa of rectum will nevermetastasize to inguinal nodes.

• Ogilvie syndrome is the acute pseudoobstruction and dilation of the colon in the absence of any mechanicalobstruction in severely ill patients

• Brain tumor with increased intracranial pressure development of hypertension and bradycardia (Cushing'sreflex) signifies that the brain has run out of compensatory mechanisms to minimize the intracranial pressureelevation generated by increased intracranial volume. When that point is reached, brain perfusion suffers anddeath is imminent.

• Posterior dislocation of the shoulder: Can be missed in AP view mechanism of injury (massive contractionof all muscles in the area) Axillary view x-ray films are needed to make the diagnosis.
http://en.wikipedia.org/wiki/Intestinal_pseudoobstructionhttp://en.wikipedia.org/wiki/Intestinal_pseudoobstruction

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