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ismailalmokyad's version from 2018-01-25 17:00

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wt is kyphosis(hunchback), scolliosis, and lordosis (swayback)1-kyphosis is exaggeration of posterior thoracic curvature.
2- scoliosis is lateral S-shaped curvature of the thoracic & lumbar spine.
3-Lordosis is excessive anterior lumbar curvature
how to differentiate kyphosis for postural (normal)back curvatureA hump that is easily correctible by voluntary back extension or by lying supine is termed postural (flexible) kyphosis; in contrast, structural kyphosis does not self-correct.
what is the most common type of kyphosis ?-postural (flexible) kyphosis which is due to slouching.
-asymptomatic with no neurologic abnormalities,
-On lateral radiographs, the angle of spinal convexity is generally normal to slightly increased (20-40 degrees)
wt is structural kyphosis and how does it present-Structural kyphosis is a pathologic abnormality of the spinal column

-Presents with progressive back pain and deformity.

-Although some cases are due to congenital or acquired vertebral anomalies (eg, wedging), it is imperative to exclude potentially dangerous secondary causes (eg, spinal infection, fracture, tumor, degeneration).

-After managing any secondary source,

-treatment of structural kyphosis generally involves special exercises to strengthen and straighten the back; using a back brace or having surgical correction is considered only for chronic pain or significant spinal convexity (>60 degrees)
how to manage breast discharge in women1- if bilateral then do pregnancy test and Galactorrhea evaluation.
2-if unilateral then see age,
-age <30 do u/s with our without mammogram
-age> or equal to 30 yo then do both us and mammogram.

-(np Cytology of the breast discharge has low sensitivity and specificity for detecting malignancy, so is not used in its evaluation.)
most common cause of pathologic nipple dischargebenign papillary tumor (ie, papilloma) from the breast duct lining
what is papillomasbenign but may have associated areas of atypia, ductal carcinoma in situ, and invasive intraductal carcinoma within the lesion. Therefore, patients with pathologic nipple discharge require further evaluation with age-based imaging and if negative then do ductography
differential diagnosis for fever in a returning traveler3 categories
1-Early incubation period (<10 days)
-typhoid fever,
-dengue fever,
-chikungunya,
-influenza,
-legionellosis

2-Medium incubation period (1-3 weeks)
-malaria,
-typhoid fever,
-leptospirosis,
-schistosomiasis,
-rickettsial disease

3-Longer incubation period (>3 weeks)
-tuberculosis,
-leishmaniasis,
-enteric parasitic infections.
how does HIV alter the presentation of TB-it increase rate of infection and reactivation.
-bc advance HIV doesn't have cell medicated defenses they don't have cavitation and often present with lobar or disseminated infection.
wt is the presentation of TB effusionwith fever, cough, pleurisy, and weight loss
thoracentesis finding in TB effusion-lymphocyte-predominant, exudative effusion with elevated adenosine deaminase (not in malignancy)
-pleural biopsy is often required for diagnosis.
how does bullous pemphigoid presentprodrome of itching and urticaria, followed by an outbreak of an erythematous rash with tense bullae, 1/3 of patients will develop oral lesions (usually brief).
wt is bullous pemphigoid and wt is associated disease?-AI, common in elderly patients
-associated with a number of neurologic conditions including dementia, bipolar disorder, and multiple sclerosis.
how to dx bullous pemphigoid skin biopsy of the margin of a bullous lesion. Serum assay for basement membrane antibodies is also helpful.
how to treat bullous pemphigoid-Mild topical high-potency glucocorticoids.
-severe BP may require oral glucocorticoids.
-Steroid-sparing drugs for patients with prolonged symptoms include azathioprine, methotrexate, or a combination of antibiotics (eg, tetracycline) with nicotinamide.
who is more susibtable to hypercalcemia due to immobilization typically seen in patients with very high bone turnover (eg, adolescents, Paget disease)
wt is lab finding in pt with hyperca of immobilization1- normal 25 Vit D levels
2- low 1,25 Vit D levels (suppressed PTH)
how to manage hypercalcemia-fluid just like any other hyperCA,
-Bisphosphonates are useful in patients who are immobilized for extended periods.
wt is the three main conditions that must be ruled out before dx of dementiahypothyroidism, vitamin B12 deficiency, and depression
how to preform apnea testBaseline normal PaCO2 and PaO2 are required; apnea tests should be avoided in chronic CO2 retainers. Patients should be pre-oxygenated and then disconnected from the ventilator. Absence of a respiratory response (in a typical observation period of 8−10 minutes) with a PaCO2 >60 mm Hg (or >20 mm Hg from baseline) and a final arterial pH of <7.28 are considered a positive apnea test.
how does diaphragmatic paralysis as in ALS affect respiration-present with shortness of breath that is worse in the supine position(confused with cardio causes).
-paradoxical abdominal wall retraction during inspiration
-A sniff test using fluoroscopy can be helpful in confirming the diagnosis.
how to manage pt with DKA who has glucose of <200 but still has anion gap add dextrose to the fluid and continue insulin drip until gap normalize
in DKA Criteria for transition from intravenous (IV) to SQ insulininclude glucose <200 mg/dL along with 2 of the following: serum anion gap <12 mEq/L, serum bicarbonate >15 mEq/L, and venous pH >7.30. to do the transition one should start sc insluin for 2 hours before stopping the insulin drip.
Neonatal displaced clavicular fracture risk factors Fetal macrosomia (maternal diabetes, post-term pregnancy) Instrumental delivery (vacuum or forceps) Shoulder dystocia
Neonatal displaced clavicular fracture c/p-Crying/pain with passive motion
-Crepitus over clavicle
-Asymmetric Moro reflex
Neonatal displaced clavicular fracture dxx ray
Neonatal displaced clavicular fracture ttt1-Reassurance
2-Gentle handling
3-Analgesics
4-Place affected arm in a long-sleeved garment & pin sleeve to chest with elbow flexed at 90 degrees
anomalous aortic origin of a coronary artery (AAOCA) common types-left main coronary artery originating from the right aortic sinus
-the right coronary artery originating from the left aortic sinus.
how does pt with AAOCA present exertional angina, lightheadedness, or syncope; however, some patients experience SCD without any premonitory symptoms
how to dx AAOCA-ECG unremarkable.
-Transthoracic echocardiogram can sometimes make the diagnosis,but may miss it.
-CT coronary angiography or MR coronary angiography provide the best visualization of coronary anatomy, and are the diagnostic
wt is Brugada syndrome-genetic disorder
-symptoms are
1-pounding or fluttering in the chest.
2-SOB
3-seizure.
4-fainting spells (syncope)
5-arrhythmias that occur during sleep (possibly leading to sudden cardiac death)
-on EKG, RBBB and ST-segment elevation in leads V1-V3
wt is seborrheic keratosis (SK)benign epidermal tumor due to proliferation of immature keratinocytes.
how does seborrheic keratosis present->50 old
-common in fair-skinned individuals
-single or multiple lesions that are well-demarcated, pigmented, round or oval, and have a dull or verrucous surface with a "stuck-on" appearance.
-Typical locations include the face, upper extremities, and trunk.
-SKs can be asymptomatic or cause pruritus, pain, or bleeding (especially with friction against clothing or jewelry)
wt is the clinical amplication of Explosive onset of multiple pruritic seborrheic keratosis (Leser-Trélat sign)associated with malignancies (especially lung and gastrointestinal tumors)
how to dx seborrheic keratosis clinically but may need biopsy
how to treat seborrheic keratosis no treatment but symptomatic or cosmetically disfiguring lesions can be treated with cryotherapy or removed by curettage/shave excision or electrodessication
how long should you treat major depression with medications1-single episode at least 6 months following acute response (referred to as "continuation phase treatment").
2- Patients with a history of multiple episodes, chronic episodes (>2 years), strong family history, or severe episodes (eg, suicide attempt) should be considered for maintenance treatment for 1-3 years following remission to reduce the risk of recurrence.
3- Patients with a history of highly recurrent (eg, > 3 lifetime episodes) and very severe, chronic major depressive episodes may need to continue maintenance treatment indefinitely.
how to manage pt with elevated clacitonin after dissection for medullary thyroid cancer1-CT scan of the neck and chest with or without high-resolution ultrasound of the neck is recommended as the next step to look for metastatic disease.

2-If no lesion is identified, then an abdominal CT scan and bone scan may be required.

3- Octreotide or PET scan may be helpful if CT scans are negative despite the presence of elevated calcitonin levels.
wt is the indication of rhythm control in pt with afib-Inability control HR with rate-control agents
-Persistence of symptomatic episodes (eg, heart failure exacerbation) on rate-control agents
preferred antiarrhythmic agents in patients with AF and left ventricular (LV) systolic dysfunction with ejection fraction <35%Amiodarone or dofetilide
wt to monitor before and while on amiodarone1-pulmonary
2-thyroid,
3-hepatic toxicity
wt is benefit of combined estrogen/progesterone menopausal hormone therapy1-Menopausal symptoms (eg, hot flashes, vaginal atrophy)
2-Bone mass/fractures
3-Colon cancer
4-Type 2 diabetes mellitus
5-All-cause mortality (age <60)
wt is s/e of combined estrogen/progesterone menopausal hormone therapy1-Venous thromboembolism
2-Breast cancer
3-Coronary heart disease (age >60)
4-Stroke
5-Gall bladder disease
wt RBCs cound in LP indicate accidental damage of blood vessel-A RBC count exceeding 6,000/mm3 may indicate traumatic LP, but SAH should be ruled out.
-WBCs will be elevated but as one WBC is present per 750-1000 RBCs.
-The protein level is elevated in the presence of traumatic LP, and the glucose level is typically high.
wt is Routine prenatal laboratory tests in initial prenatal visit1-Rh(D) type, antibody screen
2-Hemoglobin/hematocrit, MCV
3-HIV, VDRL/RPR, HBsAg
4-Rubella & varicella immunity
5-Pap test (if screening indicated)
6-Chlamydia PCR Urine culture
7-Urine protein if 24-28 weeks
wt is Routine prenatal laboratory tests in 24-28 weeks1-Hemoglobin/hematocrit
2-Antibody screen if Rh(D) negative
3-50-g 1-hour GCT
wt is Routine prenatal laboratory tests in 35-37 weeksGroup B Streptococcus culture
how to dx Gestational thrombocytopenia1-Asymptomatic 2nd-3rd trimester of pregnancy
2-Platelet count 70,000-150,000/mm3
3-No history of thrombocytopenia
4-No associated fetal thrombocytopenia
5-Resolution after delivery
wt is pathophysiology of Gestational thrombocytopenia-Hemodilution
-Accelerated destruction of platelets
how to treat Gestational thrombocytopeniaSerial complete blood counts Repeat evaluation postpartum to ensure resolution
Contraindications to neuraxial analgesia (LP analgesic) in thrombocytopenic severe thrombocytopenia (platelets <70,000/mm3) or rapidly dropping platelet count (often associated with preeclampsia with severe features).
wt is the classification of pulmonary HTNWHO group: Due to left-sided heart disease
-group 2: Due to chronic lung disease (eg, COPD, ILD)
-group 3: Due to chronic thromboembolic disease
-group 4 Due to other causes (eg, sarcoidosis)
wt is c/p of pulmonary HTN-Dyspnea, fatigue/weakness
-Exertional angina, syncope
-Abdominal distension/pain
wt is sign of pulm htn1-Left parasternal lift,
2-right ventricular heave Loud P2,
3-right-sided S3
4-Pansystolic murmur of tricuspid regurgitation
5-JVD, ascites, peripheral edema, hepatomegaly
wt is characteristic chest xray finding in pulm HTNenlargement of the main pulmonary arteries with attenuation of peripheral arteries.
how to workup pt with pulm htn1-transthoracic echocardiography,
2-Definitive diagnosis with right heart catheterization (pulmonary arterial pressure >25 mm Hg)
wt is the treatment of primary pulm htn-Endothelin receptor antagonists (eg, bosentan, ambrisentan), delayed progression of disease.
-phosphodiesterase-5 inhibitors (eg, sildenafil, tadalafil)
-prostacyclin pathway agonists (eg, epoprostenol, treprostinil, iloprost).
-For patients with a positive vasoreactive test during right heart catheterization, calcium channel blockers (eg, long-acting nifedipine) are another option.
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