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ismailalmokyad's version from 2018-01-27 17:23

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Question Answer
1-colonic ischemia1-Pathophysiology
-Usually nonocclusive, “watershed” ischemia (eg, splenic flexure, rectosigmoid junction)
-Underlying atherosclerotic disease
-State of low blood flow (eg, hypovolemia)

2-Clinical features
- acute, crampy, moderate abdominal pain & tenderness (peripherally in abd vs mesenteric ischemia with usually sever and periumbilical)
-fecal urgency followed by hematochezia, or bloddy diarrhea
-Leukocytosis, lactic acidosis

3-Diagnosis
-CT scan: Colonic wall thickening, fat stranding, colonic distension or pneumatosis (gas in bowel wall)
-Endoscopy: friable, edematous mucosa; erythema; and scattered pale patches.

4-Management
-Intravenous fluids & bowel rest
-Antibiotics with enteric coverage
-Colonic resection if necrosis develops
2-what are the causes of compartment syndrome1-traumatic long bone fractures
2-trauma without fracture
-crush injuries
-thermal burns
-vascular injury in extremities
3-nontraumatic causes
-prolonged limb compression
-animal venom exposure
-nephrotic syndrome
3-pathophysiology of compartment syndrome and wt is C/Pmuscle is made of compartment, when fluid build in the intracompartmental space the pressure increase and decrease the venous outflow, increase venous pressure, decrease arteriovenous gradient and decrease perfusion to tissue.

c/p
early pain out of proportion to injury, followed by paresthesias.
early signs are tightness, muscle weakness and pain with passive stretching of muscle.
-if untreated progress to paralysis, infection and skin ulceration and necrosis, and possible will need amputation.

dx and ttt
-Compartment pressures should be measured, and pressures >20-30 mm Hg typically require fasciotomy as definitive therapy to relieve high compartment pressure
4-what is Primary nocturnal enuresis and how to manage itit is urinary incontinence age >5 without additional urinary tract symptoms (eg, dysuria, daytime incontinence)

-Management
1-Urinalysis to rule out secondary causes
2-Lifestyle changes:
-Minimize fluid intake before bedtime
-Avoid sugary/caffeinated beverages
-Void before bedtime
-Institute reward system (eg, “gold star” chart)
3-Enuresis alarm, when previous intervention fail for 3-6 months, then use the alarm which is alarm when the bed become wet, it has the best long-term outcome and a low risk of relapse.
4-Desmopressin therapy
5-expected level of TSH,T4 and T3 during pregnancyBhcg increase thyroglobylin it also stimulate secretion of T4 and T3 by bind to TSH receptor, for this reason TSH should be suppressed during pregnancy and t3 and t4 should be higher than normal
-TSH range in pregnancy
-First trimester 0.1-3.0 μU/mL
-Second trimester 0.2-3.0 μU/mL
-Third trimester 0.3-3.0 μU/mL

total T3 and total T4 are in the normal range if the levels are adjusted to 1.5 times the normal range for adults.
6-how to work up pt with confirmed syphilis and neurological symptomsany patient with syphilis who has neurologic symptoms (eg, headache, blurred vision) requires a lumbar puncture to evaluate for neurosyphilis.
7-who is the HIV pt who is at risk to develop neurosyphilis and how to confirm dx-CD4 counts are <350/mm3
-rapid plasma reagin titers are >1:128.

CSF analysis reveals an elevated leukocyte count (>5/mm3) and positive VDRL or fluorescent treponemal antibody absorption (FTA-ABS) testing.
8-how to treat syphilis by stage1-Primary, Secondary, Early latent (<12 months of infection)
-Benzathine penicillin G, 2.4 million units IM as a single dose

2-Late latent (>12 months of infection), Unknown duration, Gummatous/CV syphilis
-Benzathine penicillin G, 2.4 million units IM weekly for 3 weeks

3-Neurosyphilis or ocular syphilis
-Aqueous penicillin G, 3-4 million units IV every 4 hours for 10-14 days

4-Congenital syphilis
-Aqueous penicillin G, 50,000 units/kg/dose IV every 8-12 hours for 10 days
9-wt are symptoms of syphilis by stage-primary (eg, chancre)
-secondary (eg, diffuse rash, condylomata lata)
-tertiary (eg, neurosyphilis, aortitis)
10- how to ttt Patients with tertiary syphilis (other than neurosyphilis) who have anaphylactic reactions to penicillintreated with 2 weeks of ceftriaxone.
11-how to ttt Patients with anaphylactic penicillin allergies who have late latent syphilis or latent syphilis of unknown durationdoxycycline for 28 days.
12-Patients who develop an acute febrile syndrome within 24 hours of initial treatment for a spirochetal infection (eg, syphilis, leptospirosis, tick-borne spirochetes), wt is called, c/p, and how to prevent it,Jarisch-Herxheimer reaction. due to the rapid lysis of spirochetes, which releases bacterial proteins into the bloodstream and triggers an innate immunologic response. Manifestations commonly include fever, malaise, chills, headache, and myalgias

self-limited and resolve within 48 hours. Most patients require no treatment, but those with severe manifestations can be treated with an antipyretic medication

no way to prevent it
13-wt is associated with high mortality rate in PEelevated cardiac troponin levels are associated with a higher risk of death.

Patients with PE who are found to have a large coexisting deep venous thrombosis are at increased risk of mortality.
14-how to diffrentiate elevated trops in pe if it is mi or pein pe it present without charachteristic chest pain

resolve within 2 days, in contrast to the more prolonged elevations seen in patients with myocardial infarction.
15-when to start warfarin for PECurrent guidelines recommend early initiation of warfarin (eg, same day as parenteral therapy is started)
-DC pt after International Normalized Ratio is >2.0 for at least 24 hours.
16-how to manage hemoptysis on pt being treated with anticoagulation for PE1- if small amount in clinically stable, then continue with close observation, it is common especially if pulmonary infarction present.

2-Massive hemoptysis, defined as 600 mL over 24 hours, may occur in patients with large PE and pulmonary infarction who are receiving anticoagulation. Bronchoscopy or angiographic embolization could be considered for such extreme situations
17-Lichen planus (LP) cause, c/pit is activated T-cells directed against the basal keratinocytes of the epidermis

c/p, it can affect skin, nails, MM of mouth, and genitalia.
-classical skin lesion are shiny, discrete, intensely pruritic, polygonal-shaped violaceous plaques and papules that are most frequent on the flexural surfaces of the extremities. Wrists are a common site of skin involvement

-characteristic whitish, lacy pattern, referred to as Wickham striae, is seen often on the lesion surfaces.

**DX
-confirm with skin biopsy
-screen for liver disease especially HCV
18-Neurofibromatosis type I, cause-cause AD, due to a mutation in the NF1 tumor suppressor gene on chromosome 17q11.2.

-c/p
1- Café-au-lait macules (CALMs) are a hallmark feature
2-freckling in the inguinal and axillary skin folds
3-neurofibromas benign peripheral nerve sheath tumors (extensive nodular skin)
4-Lisch nodules, which are iris hamartomas that do not affect vision.

-screening
1- optic pathway gliomas
19-what to screen for in neurofibromatosis type 1 and type 2type 1 screen for optic pathway gliomas, Visual acuity, confrontation visual field testing, color vision testing, and extraocular motility must be assessed. if abnormal do MRI

-type 2 require audiologic evaluation for sensorineural hearing loss due to bilateral vestibular schwannomas
20-how does McCune-Albright syndrome presentclassically presents with Café-au-lait macules with irregular borders (neurofibromatosis has regular smooth borders) as well as fibrous dysplasia and precocious puberty.
21-what is melasma c/p, cause, prevention, ttt-irregularly shaped, hyperpigmented macules of varying color (light to dark brown or ash/blue in sun exposed areas
-common during pregnancy when elevated estrogen, progesterone, and melanocyte-stimulating hormone levels cause melanocyte stimulation. Sun light trigger melanocyte activation.

TTT
-regresses spontaneously within the first year after, but some may persist.
-prevent by limited by minimizing sun exposure via protective clothing and application of a broad-spectrum sunscreen
-first-line treatment options include skin-lightening agents (eg, hydroquinone, azelaic acid) or topical retinoid creams.

NBretinoids are contraindicated during pregnancy due to a high risk for spontaneous abortion and congenital defects (eg, craniofacial, cardiac, central nervous system)
22-why it is preferred to differ surgery in pregnant women to the 2nd trimester-uterus is still contained within the pelvis,
-organogenesis is complete
-progesterone production has transferred from the corpus luteum to the placenta
23-Epithelial ovarian carcinoma c/p, RF, protective factors, labs, U/S, management****Clinical presentation
-Asymptomatic: Incidental adnexal mass
-Subacute: Pelvic/abdominal pain, bloating, early satiety
-Acute: Dyspnea, obstipation/constipation, abdominal distension

****Risk factors
-Family history
-Genetic mutations (BRCA1, BRCA2)
-Age >50
-Hormone replacement therapy
-Endometriosis
-Infertility
-Early menarche/late menopause

****Protective factors
-Oral contraceptive pills
-Multiparity
-Breastfeeding

****Laboratory findings
-↑ CA-125

****Ultrasound findings
-Solid, complex mass
-Thick septations
-Ascites

****Management
-Surgical exploration(if pregnant do in beginning of 2nd trimester)
-± Chemotherapy (may be given in 2nd or 3ed trimester)
24-how to dx CML and how to treat it-it is mostly asymptomatic or present with LUQ pain(splenomegaly)
-high WBCs found incidentally
-do philadelphia T 9:22( bcr/abl fursion)
-this traslucation lead to tyrosine kinase stimulatin and this is why the best initial treatment is tyrosine kinase inhibitor ( Imatinib, gefitinib, erlotinib, sorafenib, sunitinib, and dasatinib)
-bone marrow transplant is a cure but it has high rate of mortality and BMT can be offered to patients who are young with stable disease and who have a suitable donor.
25-tinea pedis c/p and ttt?c/p slowly progressive pruritus of the feet, erythema and scaling between the toes, and extension to the soles and sides of the feet with a sharp border

ttt
-Mild topical antifungals (eg, terbinafine, miconazole, clotrimazole) in 1–4 weeks.
-More extensive or failure of topical agents may require oral therapy (eg, terbinafine, itraconazole, fluconazole).
-Patients with onychomycosis (involve nails) also require oral antifungals with a prolonged 12-week treatment course.
26-what is tinea manuum, tinea cruris, tinea pedis, onychomycosis, and intertrigo-tinea manuum in hand
-tinea cruris in groin
-tinea pedis in feets
-onychomycosis fungal infection of nails
- intertrigo is candida extend around anus (treat with topical nystatin)
27-what is the most common cause of SAH, wt is the best way to confirm dxruptured saccular aneurysm.
-ct sensitivity is 100% if done during first 6-12 hours but this decrease with time, so if CT negative and >6 hours do LP xanthochromia (pink/yellow tint due to hemoglobin degradation products)
28-how does rabies present, cause, prevention and prognosisfew days of nonspecific prodromal symptoms, including fever and malaise. Neurologic symptoms (eg, confusion, lethargy, paralysis, aphasia) develop later in the course of the disease.
-Hydrophobia is pathognomonic for rabies; water triggers pharyngeal spasms

causes
-in developing counties dogs
-in us bat and raccons (bit or inhalation of aerosolized viral particles)

manage
- Post-exposure prophylaxis with rabies immune globulin and rabies vaccine can help prevent onset of the disease; it is not helpful after the onset of clinical manifestations.

-most patients suffer from coma and death within weeks of illness onset
29-what is Premenstrual syndrome (PMS) c/p and ttt-depression, anxiety, irritability, bloating, and breast tenderness that occur in the second half of the menstrual cycle and resolve promptly with the onset of menses.
- Premenstrual dysphoric disorder (PMDD) is a severe form of PMS characterized by predominant anger and irritability.
-increase risk of depression and or anxiety disorders in future (80%)

-ttt with SSRI if failed trial of a second SSRI
-if SSRI failed twice and doesnt want to be pregnant OCP
30-premature ovarian failure1-Clinical features
-Amenorrhea at age <40
-Hypoestrogenic symptoms (eg, hot flashes)
-↑ FSH
-↓ Estrogen

2-Major causes
-Turner syndrome (45,XO)
-Fragile X syndrome (FMR1 premutation)
-Autoimmune oophoritis
-Anticancer drugs
-Pelvic radiation (MC)
-Galactosemia

3-Management
-Estrogen therapy (with progestin if intact uterus to decrease risk of cancer)
-continue ttt until normal menopause age, around age 50
-complication of ttt are DVT and CAD

4-complication
osteoprosis and fractures (this why we treat)
memorize