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Be overly suspicious for an intraocular foreign body in patients with high-velocity injuries (drilling, grinding, etc). If the initial pen light (after local anesthetic application) examination does not reveal any conjunctival and corneal abrasions or foreign bodies, proceed with fluorescein examination. If a foreign body is not demonstrated and a strong suspicion remains, CT or ultrasonography can be considered. MRI is never performed for the diagnosis of a foreign body; in fact, it is contraindicated, since it can dislodge the foreign body because of the strong magnetic field. **Weight loss is the most effective nonpharmacologic measure to decrease blood pressure in overweight individuals. Weight loss with other nonpharmacologic measures can prevent or delay the onset of hypertension and reduce the overall risk of cardiovascular events in such patients. In some patients with established hypertension, lifestyle changes alone may control their blood pressure. These changes can also allow for fewer drugs and lower doses of antihypertensive medication when needed. Sodium restriction is recommended for most patients with hypertension, but its effect on blood pressure Is inconsistent in some individuals. Sodium restriction Is more effective in older (especially postmenopausal women), African American, and overweight individuals.

*** Smoking cessation is an important component of lifestyle modification that reduces the risk of future cardiovascular events. Although smoking cessation may directly lower blood pressure, its impact is not as significant as that for weight reduction. Treatment of hypertension: Modification 1-Weight loss, Reduce BMI <25 kg/m2 Approximate decrease in systolic BP (mm Hg)5-20 per 10 kg loss 2-DASH diet: Diet high in fruits and vegetables 8-14 and low in saturated fat and total fat; Approximate decrease in systolic BP (mm Hg) is 8-14 3-Exercise: 30 minutes/day for 5-6 days/week; Approximate decrease in systolic BP (mm Hg) is 4-9 4- Dietary sodium <3 g/day Approximate decrease in systolic BP (mm Hg) is 2-8 5- Alcohol intake: 2 drinks/day in men and 1 drink/day in women Approximate decrease in systolic BP (mm Hg) is 2-4

Clinical presentation of whooping cough 1. Catarrhal phase (2 weeks)-cold like symptoms(rhinorrhea, conjunctival injection, cough) 2. Paroxysmal phase(2-5 weeks)-increasing to severe coughing paroxysms, inspiratory "whoop" and facial petechiae, post tussive emesis. 3. Convalescent phase>2 weeks of gradual resolution of cough Since the introduction of pertussis vaccines, the epidemiology of reported pertussis infections has changed; in the United States in the 1990s, more than one-half of cases occurred in adolescents and adults **for caustic esophageal injury do endoscopy in 24 hours post injury and base on grading consider surgery. ●Grade 0 - Normal ●Grade 1 - Mucosal edema and hyperemia ●Grade 2A - Superficial ulcers, bleeding, exudates ●Grade 2B - Deep focal or circumferential ulcers ●Grade 3A - Focal necrosis ●Grade 3B - Extensive necrosis Patients with grades 2B and 3A develop strictures in 70 to 100 percent of cases. ●Grade 3B carries a 65 percent early mortality and the need for esophageal resection with colonic or jejunal interposition in most cases. For patients in respiratory distress, laryngoscopy should be performed in order to evaluate the need for tracheostomy.

*** Evaluation of dyspnea of possible cardiac origin is one of the indications for stress echocardiography. Iatrogenic esophageal perforation: Initial management — Once the diagnosis is suspected, treatment is started immediately: ●Patient is made NPO (nothing by mouth, nil per os). ●A large bore intravenous line is started and fluid resuscitation is performed with isotonic saline solution or lactated ringers solution. ●Broad spectrum intravenous antibiotics that provide coverage for aerobes and anaerobes are administered intravenously, such as ampicillin/sulbactam (3 grams every six hours), piperacillin/tazobactam (3.375 grams every six hours), or a carbapenem. In the setting of beta lactam hypersensitivity, use of clindamycin (900 mg every eight hours) plus a fluoroquinolone, such as ciprofloxacin (400 mg every 12 hours) is acceptable. ●Antifungal coverage (eg, fluconazole 400 mg once a day) is warranted in selected cases. These include patients who have been hospitalized or received broad-spectrum antimicrobial agents prior to perforation, patients on long-term antacid therapy, patients who have received steroids or other immunosuppressive therapy prior to perforation, patients with HIV infection, and/or patients who fail to improve after several days of appropriate antibacterial therapy. ●The patient can be transferred to an intensive care unit for hemodynamic monitoring, stabilization, and volume resuscitation. Insertion of a central venous catheter, arterial catheter, and urinary catheter should be considered. These preparations should not delay surgical evaluation and management. ●****The patient should be prepared for operative management.

***In TIA: If symptoms resolves or ongoing but not disabling then do MRA (not MRI), CTA or carotid doppler ultrasonography. If symptoms are ongoing or disabling then: Patients who present within the appropriate time window after ischemic symptom onset and have a persistent neurologic deficit that is potentially disabling, despite improvement of any degree, should be treated with intravenous thrombolysis and/or mechanical thrombectomy in the absence of other contraindications. Further management of these patients is similar to that of other patients with a potentially disabling stroke.

***Malignancies associated with the greatest absolute number of episodes of VTE were cancers of the lung, colon, and prostate, due to the relatively high frequency of these cancers in the population. Due to location in periphery, adenocarcinoma can present with pleural effusion or severe pain due to infiltration of the pleura. **Normal CVP <= 8 cm H2O Using a centimeter ruler, measure the vertical distance between the angle of Louis (manubrio sternal joint) and the highest level of jugular vein pulsation. A straight edge intersecting the ruler at a right angle may be helpful. Add 5 cm to measurement since right atrium is 5 cm below the sternal angle.

CVID:Defect in B-cell differentiation into plasma cells Sinopulmonary infections, including pneumonia, bronchitis, and sinusitis, as well as otitis and conjunctivitis, are observed in the majority of patients with CVID. Patients are particularly susceptible to infection with the encapsulated bacteria, Streptococcus pneumonia and Hemophilus influenzae, and with atypical bacteria from the Mycoplasma species. Pneumonia - Over three-quarters of patients have at least one episode of bacterial pneumonia prior to diagnosis. Rhinosinusitis/otitis media - Both acute and chronic rhinosinusitis and otitis media are common, particularly in untreated CVID patients. Patients with longstanding disease may develop hearing loss. Obstructive disease - An obstructive pattern on spirometry in patients with CVID can accompany asthma, bronchiectasis, or other lung processes.

***Very low glucose levels in pleural effusion (<25 mg/100 mL), although not pathognomonic, are seen in a few diseases. Rheumatoid arthritis, tuberculosis, empyema, and tumors or malignancy with extensive involvement of the pleura are most commonly associated with very low glucose levels.

Arthrocentesis with synovial fluid analysis, should be attempted in all patients with joint pain of unknown cause who have an effusion or have signs suggestive of inflammation within the joint, the main purpose of synovial fluid analysis is to narrow the differential diagnosis by categorizing the effusion as noninflammatory, inflammatory, hemorrhagic or septic.

**All HIV-infected individuals, regardless of CD4 count, should be screened for latent tuberculosis using either tuberculin skin testing or an interferon gamma release assay. Therapy for latent infection should be administered to those who test positive and without evidence of active disease.

Treatment of Chronic (preexisting) hypertension in pregnancy: Chronic hypertension is defined as systolic pressure ≥140 mmHg and/or diastolic pressure ≥90 mmHg that antedates pregnancy, is present before the 20th week of pregnancy, or persists longer than 12 weeks postpartum. At present, there is no convincing evidence that decreasing maternal blood pressure during pregnancy improves perinatal outcome or has beneficial effects on the mother. Treatment of uncomplicated mild hypertension (140/90) is not necessary and does not decrease the risk of intrauterine growth restriction, preterm delivery and superimposed pre-eclamsia. We advise only close monitoring of these cases. **Although the drug of choice for emergent hypertension is usually IV sodium nitroprusside, patients presenting with comorbid signs of ischemic heart disease should be treated with IV nitroglycerin instead. Blood pressure in emergent hypertension should be initially be reduced by 25% of initial presentation over the first 2 hours.

**CEA or carcinoembryonic protein rises in colon cancer and ovary cancer and alpha-fitoprotein rises in HCC. **The most common autoantibodies that affect clotting factor activity and lead to a bleeding disorder are directed against, and interfere with, the activity of factor VIII, a condition also called acquired hemophilia A. Although there are no large series describing the immunoglobulin class of the factor VIII autoantibodies, most have been IgG antibodies that do not bind complement. The reasons for the production of factor VIII autoantibodies in a particular individual are not clear, but may involve the presence of certain gene polymorphisms (eg, HLA, CTLA4) and/or autoreactive CD4+ T lymphocytes. An individual patient, either nonhemophilic or hemophilic, can produce antibodies of different IgG subclasses directed against different epitopes on the factor VIII molecule. However, the production of multiple antibodies is much more common in patients with hemophilia . aPTT in prolonged and platelet number is usually normal.

1-Diagnosis ( Tamponade ) elevated diastolic pressures equal end-diastolic pressures in RV or LV ( or PCWP ) absence of ventricular filling early in diastole absence of Y descent in atrial tracings This increased pressure in the right ventricle will cause the interventricular septum to bulge towards the left ventricle, leading to decreased filling of the left ventricle. At the same time, right ventricle volume is markedly diminished and sometimes it can collapse. 2-Diagnosis ( Constrictive Pericarditis ) elevated diastolic pressures equalization of diastolic pressures in the RV and LV completion of diastolic filling in early diastole ( dip and plateau in ventricular trace ) rapid x and y descents Kussmal's **in both constrictive pericarditis and cardiac tamponade the, pulmonary artery catheterization shows the same pressure during diastole in all 4 chambers. PCWP represents the pressure in left atrium and will be equal too .

**Characteristics of patients with cardiogenic shock include the following: Patients in shock usually appear ashen or cyanotic and have cool skin and mottled extremities Peripheral pulses are rapid and faint and may be irregular if arrhythmias are present Jugular venous distention and crackles in the lungs are usually (but not always) present; peripheral edema also may be present. Heart sounds are usually distant, and third and fourth heart sounds may be present The pulse pressure may be low, and patients are usually tachycardic Patients show signs of hypoperfusion, such as altered mental status and decreased urine output

Mucinous Adenocarcinoma of Ovary is a common malignant ovarian tumor that generally affects middle-aged women. The causal factors for Mucinous Adenocarcinoma of Ovary are unknown, but genetic mutations such as mutations in KRAS gene have been reported in some cases. **Diffuse thickening of the omentum from chronic (omental cake) seen in Ovarian carcinoma. **In radiology, omental cake is sign indicative of an abnormally thickened greater omentum. It refers to infiltration of the omental fat by material of soft-tissue density. Typically, it is caused by infiltration of metastatic tumours arising from the stomach, ovary, or colon. **It has been proposed that 24,25-dihydroxyvitamin D3 is a metabolite of 25-hydroxyvitamin D3 which is destined for excretion. like increased hypercalcemia.

**Epithelial carcinoma of the ovary clinical manifestation: 1-Pleural effusion — The initial presentation for some women with EOC is shortness of breath due to a malignant pleural effusion. 2-Bowel obstruction — Some women with EOC present with bowel obstruction, and may come to medical attention due to severe nausea and vomiting. 3-Diffuse thickening of the omentum from chronic (omental cake) seen in Ovarian carcinoma. 4-symptoms that may be present in women with EOC include: ●Bloating ●Urinary urgency or frequency ●Difficulty eating or feeling full quickly ●Pelvic or abdominal pain

Multiple myeloma: Can only present with anemia, hypercalcemia, and back pain. At the time of diagnosis, approximately 25% of patients with MM have hypercalcemia. Typically, this is a result of osteolytic bone destruction by the neoplastic plasma cells. Although hypercalcemia may be asymptomatic with a calcium level <12 mg/dL, fatigue, constipation, and depression are common. *Renal complications of sickle cell trait include hematuria, renal medullary carcinoma, and urinary tract infections. Painless hematuria is likely due to renal papillary ischemia or necrosis. The relatively low local partial pressure of oxygen in the vasa rectae predisposes the affected red blood cells to sickling. Papillary necrosis can occur with massive hematuria, but the episodes are usually mild and resolve spontaneously. The urinalysis usually shows normal-appearing RBCs. Other renal complications include inability to concentrate the urine (vasa rectae damage with inability to maintain concentrated medullary gradient) and distal renal tubular acidosis (tubular damage with impaired H+ secretion).

**Gross hematuria can be from bladder (eg, cystitis, cancer), renal (eg, glomerulonephritis), ureteral (eg, nephrolithiasis), or prostate (eg, benign prostatic hyperplasia) pathology. Sickle cell trait is a benign condition associated with hemoglobin AS that is more common in Africa, the Middle East, and Mediterranean countries, and in African American and Hispanic individuals. Patients with sickle cell trait have no clinical symptoms of sickle cell disease and no change in overall life expectancy. The diagnosis is confirmed by hemoglobin electrophoresis showing hemoglobin AS. However, patients have normal hemoglobin concentration, reticulocyte count, and RBC indices and morphology.

Chylous ascites is an uncommon clinical condition that occurs as a result of disruption of the abdominal lymphatics. Multiple causes have been described, including the following: Abdominal surgery Blunt abdominal trauma Malignant neoplasms - Hepatoma, small bowel **lymphoma, small bowel angiosarcoma, and retroperitoneal **lymphoma Spontaneous bacterial peritonitis Cirrhosis - Up to 0.5% of patients with ascites from cirrhosis may have chylous ascites. Pelvic irradiation Peritoneal dialysis **Abdominal tuberculosis **Carcinoid syndrome Congenital defects of lacteal formation

**IV replacement is recommended in symptomatic or severe hypocalcemia with cardiac arrhythmias or tetany. Doses of 100-300 mg of elemental calcium (10 mL of calcium gluconate contains 90 mg elemental calcium; 10 mL of calcium chloride contains 272 mg elemental calcium) in 50-100 mL of 5% dextrose in water (D5W) should be given over 5-10 minutes. This dosage raises the ionized level to 0.5-1.5 mmol and should last 1-2 hours. Caution should be used when giving calcium chloride intravenously. Calcium chloride 10% solution delivers higher amounts of calcium and is advantageous when rapid correction is needed, but it should be administered via central venous access.

Second-trimester sonography is more than 95% sensitive for abdominal wall defects, and maternal serum a-fetoprotein is elevated. Gastroschisis results In the bowel being exposed to amniotic fluid, which causes inflammation and edema of the bowel wall. This inflammation increases the risk of complications (eg, necrotizing enterocolitis, short bowel syndrome). Oysmotllity (ileus, delayed gastric emptying, intolerance of feeds) occurs in over 50% of cases and may lead to prolonged reliance on total parenteral nutrition. Gastroschisis is an Isolated defect >90% of the time. After delivery, the exposed bowel should be covered with sterile saline dressings and plastic wrap to minimize Insensible heat and fluid losses. The infant should have a nasogastric tube placed to decompress the bowel and should be started on antibiotic therapy. Prompt surgical repair Is necessary and can usually be accomplished In a single-stage closure.

**Intermittent fever, slight LFT increase, uveitis are seen in both sarcoidosis and brucellosis. In brucellosis In the first stage of the disease, septicaemia occurs and leads to the classic triad of undulant fevers, sweating (often with characteristic smell, likened to wet hay), and migratory arthralgia and myalgia (joint and muscle pain). Blood tests characteristically reveal leukopenia and anemia, show some elevation of AST and ALT, and demonstrate positive Bengal Rose and Huddleston reactions. **Viral keratitis is infection of the cornea due to herpes simplex or varicella zoster virus. Patients have corneal vesicles, opacification, and/or dendritic ulcers. Treatment includes topical ganciclovir or trifluridine.

Erythrasma: 1-Pruritic, erythematous, scaly, and mildly hyperpigmented rash of 2 weeks' duration that involved the scrotum and both inguinal creases. 2-Ultraviolet A light from a Wood's lamp, the rash exhibited coral-red fluorescence. 3-This common disorder results from overgrowth of Corynebacterium minutissimum in the superficial stratum corneum of moist intertriginous and interdigital regions. The coral-red fluorescence is a result of the production of coproporphyrin III by C. minutissimum, and it helps to distinguish this disorder from dermatophytoses, candidal intertrigo, and psoriasis. Skin scrapings show gram-positive filamentous rods, which may be helpful in assessing for concurrent dermatophytic and candidal infection. 4- The most common site of involvement is between fourth and fifth toes.

**Intertrigo is any infectious or noninfectious inflammatory condition of two closely opposed skin surfaces (intertriginous area). While it may result from the overgrowth of microorganisms including bacteria, the term often refers to a process that is due to a superficial infection with Candida species. Candidal intertrigo is the most common cutaneous candidal infection of hair-bearing skin. It can be manifestation of contact dermatitis. Any intertigo may cause: Red or reddish-brown rash Raw, itchy, or oozing skin Foul odor Cracked or crusty skin

The majority of DUs are caused by either Helicobacter pylori infection or nonsteroidal anti-Inflammatory drugs (NSAJDs). Malignant ulceration should be considered with gastric ulcers but would be very unlikely in this young patient with DU. As this patient has no history of NSAJD use, H pylori infection is the most likely etiology and can be confirmed with endoscopic biopsy or urea breath test. Management of DU due to H pylori requires the following: • Antisecretory therapy, preferably a proton pump inhibitor (PPI) (eg. omeprazole. pantoprazole ), and • Antibiotic eradication (eg, amoxlcillin plus clarithromycin) Heavy alcohol Intake can contribute to hemorrhagic gastritis, but light alcohol Intake likely does not affect the course of DU. Smoking appears to Increase the risk of peptic ulcer In patients infected with H pylori but does not increase relapse following H pylori eradication.

**Methemoglobinemia presents with many similarities to carbon monoxide poisoning. It can be induced by certain drugs and environmental exposures. Unlike carbon monoxide (Pinkish-red skin hue) and cyanide poisoning, it presents with cyanosis and bluish discoloration of skin and mucous membranes. **OCPs decrease the risk of benign breast disease, particularly fibroadenoma and fibrocystic breast disease. A history of benign breast disease or family history of breast cancer is not a contraindication to OCP use. OCPs reduce the risk of endometrial and ovarian cancer. The decreased risk of endometrial cancer Is due to progestin, which counteracts estrogen's effect on endometrial proliferation. OCP use has been associated with glucose intolerance and increased insulin resistance In some studies, but it has not been directly linked to the development of type 2 diabetes mellitus.

The first-line treatments for cognitive symptoms of Alzheimer's dementia are cholinesterase inhibitors. The cholinesterase inhibitors donepezil (Aricept), galantamine (Razadyne), galantamine ER (Razadyne ER), and rivastigmine (Exelon) have been shown to be effective in patients with mild-to-moderate dementia. Cholinesterase inhibitors may improve quality of life and cognitive functions, including memory, language, thought, and reasoning. Donepezil is approved for all stages of Alzheimer's dementia. Memantine, an N-methyi-D-aspartate receptor antagonist, is approved for moderate-to-severe dementia. Plantar Fascitis: The deep plantar fascia (plantar aponeurosis) is a thick, pearly-white tissue with longitudinal fibers intimately attached to the skin. The deep plantar fascia (plantar aponeurosis) is a thick, pearly-white tissue with longitudinal fibers intimately attached to the skin. The etiology is poorly understood and is probably multifactorial. Possible risk factors for the development of plantar fasciitis include obesity, prolonged standing or jumping, flat feet, and reduced ankle dorsiflexion. ●Tenderness is best elicited by the examiner dorsiflexing the patient's toes with one hand in order to pull the plantar fascia taut, and then palpating with the thumb or index finger of the other hand along the fascia from the heel to the forefoot. Treatment: ●Performing of stretching exercises for the plantar fascia and calf muscles, which the patient can do at home. ●Avoiding the use of flat shoes and barefoot walking. ●Using prefabricated, over-the-counter, silicone heel shoe inserts (arch supports and/or heel cups). ●Decreasing physical activities that are suggested by the medical history to be causative or aggravating (eg, excessive running, dancing, or jumping). ●Prescribing or recommending a short-term trial (two to three weeks) of nonsteroidal antiinflammatory drugs (NSAIDs). Use of NSAIDs is reasonable, but their long-term use should be reserved for patients with known systemic rheumatic disease. ●Injecting the tender areas of the plantar region with glucocorticoids and a local anesthetic.

**Morton neuroma is associated with pain between the third and fourth toes on the plantar surface and with a clicking sensation (Mulder sign) that occurs when simultaneously palpating this space and squeezing the metatarsal joints. The etiology of Morton neuroma is not fully understood but is thought to be similar to metatarsalgia, involving collapse of the transverse arch that places traction and increased pressure on the interdigital nerve, ultimately leading to injury. Overpronation and tight shoes are often associated with the condition. Morton neuroma is a common problem in athletic and non-athletic populations. The patient with a neuroma most commonly complains of a burning pain in the third intermetatarsal space (between the third and fourth distal metatarsals) that may radiate towards the toes. *Tarsal tunnel syndrome is due to compression of the tibial nerve as it passes through the ankle. It is usually caused by a fracture of the ankle bones. Patients develop burning, numbness, and aching of the distal plantar (not dorsal) surface of the foot/toes that sometimes radiate up to the calf. Rotator cuff tendinopathy & tear: Rotator cuff impingement or tendinopathy: • Pain with abduction, external rotation • Subacromial tenderness • Normal range of motion with positive tendinopathy impingement tests (eg, Neer, Hawkins) Rotator cuff tear • Similar to rotator cuff tendinopathy User • Weakness with abduction & external rotation • Age >40

**Diverticulitis can be classified as uncomplicated (75%) or complicated (25%). 1-Uncomplicated diverticulitis in stable patients can be managed In the outpatient setting with bowel rest, oral antibiotics, and observation. However, hospitalization and Intravenous antibiotics are recommended for patients who are elderly, Immunosuppressed, have high fever or significant leukocytosis, or have significant comorbidities. 2-Complicated diverticulitis refers to diverticulitis associated with an abscess (e.g.rim-enhancing peri sigmoid fluid collection) , perforation, obstruction, or fistula formation. A fluid collection <3 cm can be treated with intravenous antibiotics and observation, with surgery reserved for patients with worsening symptoms. However, a fluid collection >3 cm should have CT-guided percutaneous drainage. If the symptoms are not controlled by the fifth day, surgical drainage and debridement are recommended. Sigmoid resection is generally reserved for patients with fistulas, perforation with peritonitis, obstruction, or recurrent attacks of diverticulitis. **The chi-square test is used to compare proportions. A 2 x 2 table may be used to compare the observed values with the expected values. The two-sample z-test and two-sample t-test are used to compare two means. not proportions.

**Ovarian torsion: 1- Risk factors • Ovarian mass • Women of reproductive age • Infertility treatment with ovulation induction 2- Clinical presentation: • Sudden-onset unilateral pelvic pain • Nausea and vomiting • +/_ palpable adnexal mass 3-Ultrasound • Adnexal mass(can be complex) with absent Doppler flow to ovary 4-Treatment • Laparoscopy with detorsion • Ovarian cystectomy • Oophorectomy if necrosis or malignancy Ultrasound differentiates ovarian torsion from other acute gynecologic conditions (eg, ruptured cyst) by the presence of an adnexal mass and lack of Doppler flow, the latter of which is the pathognomonic finding. Patients require prompt surgery- laparoscoplc cystectomy and detorsion - with goals of restoring normal anatomy and saving the ovary from irreversible necrosis. Salpingo-oophorectomy with torsion is reserved for obvious adnexal necrosis or suspected ovarian malignancy. Untreated torsion may lead to chronic pelvic pain, infertility, hemorrhage, or peritonitis and sepsis.

Postpartum psychosis: 0.1%-0.2% Variable: Days to weeks Delusions, Hallucinations, thought disorganization, bizarre behavior Treatment: Anti psychotics, antidepressants, mood stabilizers Hospitalization; do psychotherapy not leave mother alone with infant (risk of infanticide)

**Pseudocyesis: This is an uncommon condition in which a woman presents with many signs and symptoms of pregnancy such as amenorrhea, enlargement of the breasts and abdomen, morning sickness, weight gain, sensation of fetal movement and reported positive urine pregnancy test per the patient. Ultrasound, however, will reveal a normal endometrial stripe and the pregnancy test in office will be negative. Pseudocyesis is usually seen in women who have a strong desire to become pregnant. It has been suggested that the depression caused by this need is behind the occurrence of some hormonal changes mimicking those of pregnancy. This is a form of conversion disorder, and management requires psychiatric evaluation and treatment. DDX:In a missed abortion ultrasonogram usually reveal an intrauterine collapsed gestational sac and absent fetal cardiac activity. An in office pregnancy test is positive.

An arrested second stage occurs when there is no fetal descent after pushing for >=3 hours in nulliparous patients or >=2 hours in multiparous patients. The most common cause of a prolonged or arrested second stage is fetal malposition. The fetal position is the relationship of the fetal presenting part to the maternal pelvis. The optimal fetal position is occiput anterior as it facilitates the cardinal movements of labor. Deviations from this position (eg, occiput transverse, occiput posterior) can cause cephalopelvic disproportion and arrest of the second stage. **Breast-palpation-guided FNA has been used for years to evaluate a palpable breast mass. When a lesion is palpable, especially one that is large and obvious, fine needle aspiration can be rapidly performed as a non-image-guided procedure. On the other hand stippled microcalcification or an occult lesion in breast stereotactic needle localization and biopsy (needle-localized open biopsy also called core needle biopsy with incision in skin) under mammographic guideline can be used.

**Slightly higher systolic blood pressure measurement in the left compared to the right arm may be due to subclavian stenosis. Aortic dissection always present with pain. **Acute graft rejection is mediated by T cell and it is due to failure to suppress class 2 antigen recognition in the host. Therefore, it is an example of Type IV hypersensitivity. This process results in leukocyte infiltration of the graft vessel. **Failure to suppress non-circulating preformed reactive antibodies is hyperacute rejection.It is caused by accidental ABO Blood type mismatching of the donor and recipient which almost never happens anymore. This means the host has preformed antibodies against the donated tissue. For example, a recipient with Type B blood would have pre-made antibodies targeted at the carbohydrates on the blood of a Type A donor. The presence of preformed antibodies is why the reaction takes places so quickly. This is an example of Type II Hypersensitivity and results in thrombosis and occlusion of the graft vessel.

SCFE, also called slipped upper femoral epiphysis (SUFE) and physiolysis of the hip, is characterized by a displacement of the capital femoral epiphysis from the femoral neck through the physeal plate. It is one of the most common hip disorders of adolescence. The mean age of presentation is 12 years in girls and 13.5 years in boys, near the time of peak linear growth. The male-to-female ratio is approximately 1.5:1.he two most common features of the presentation of SCFE are pain and altered gait. The classic presentation is that of an obese adolescent with a complaint of nonradiating, dull, aching pain in the hip, groin, thigh, or knee, and no history of preceding trauma. The pain is increased by physical activity and may be acute, chronic, or intermittent. The treatment of SCFE is operative stabilization. Children with SCFE should be referred promptly to an orthopedic surgeon. The operative goals are stabilization of the diseased physis to prevent further slippage and avoidance of complications. The gold standard for stabilization of chronic/stable slips, regardless of severity, is the use of a single cannulated screw placed in the center of the epiphysis. The complications of SCFE include osteonecrosis of the femoral head and chondrolysis, and femoroacetabular impingement, both of which increase the risk of subsequent development of osteoarthritis. *Patients with AS can develop limitations in lung expansion due to diminished chest wall and spinal mobility. Pulmonary function tests (PFT) may reveal a mildly restrictive pattern with reduced vital capacity (VC) and total lung capacity (TLC) but normal FEV1/FVC ratio. Functional residual capacity (FRC) and residual volume (RV) are normal or increased due to fixation of the rib cage in an inspiratory position.

**Systemic arteriovenous shunts including •Large arteriovenous fistula (eg, hemodialysis fistula) •Multiple small arteriovenous shunts (such as with hereditary hemorrhagic telangiectasia, Paget's disease, or renal cell carcinoma) is one of the main causes of High-output heart failure. Acquired fistulas are usually post-traumatic or iatrogenic. Traumatic causes include bullet or knife wounds, especially in the thigh. Iatrogenic fistulas include surgically constructed arteriovenous fistulas used for access to the circulation in patients undergoing chronic hemodialysis. **High-output heart failure may manifest with S3, S4, distended jugular vein, bilateral crackles in lung and no edema. The heart rate is typically between 85 and 105 beats per minute, but it may be higher with some causes, eg, thyrotoxicosis. Examination of the systemic veins may reveal a cervical venous hum, heard best over the deep internal jugular veins, particularly on the right side. Less often, a venous hum may be appreciated over the femoral veins. Examination of the arteries may display signs related to increased left ventricular stroke volume. The pulse is usually bounding with a quick upstroke, and the pulse pressure is typically wide. Cardiac examination may reveal an enlarged heart with a midsystolic murmur in the second and third left intercostal spaces, and a third heart sound, which is due to the increased rate of ventricular filling.

** Age 19-64 1-PPSV23 alone in • Chronic heart, lung, or liver disease • Diabetes, current smokers, alcoholics Sequential PCV13 + PPSV23 (very high risk patients) • CSF leaks, cochlear implants • Sickle cell disease, asplenia • lmmunocompromised (eg, HIV, malignancy) • Chronic kidney disease Age >=65 Sequential PCV13 + PPSV23 • 1 dose of PCV13 followed by PPSV23 at a later time

**The 13-valent pneumococcal conjugate vaccine (PCV1 3) is recommended for all adults age >=65 followed by the 2.3-valent pneumococcal polysaccharide vaccine (PPSV23) at least 6-12 months later. Sequential PCV1 3 and PPSV23 are also recommended for adults age <65 with certain very high risk comorbidities (eg, cerebrospinal fluid leaks, sickle cell disease, cochlear implants, congenital or acquired asplenia, immunocompromised patients). PPSV23 alone is recommended as a one-time vaccine for adults age <65 who are current smokers or have other chronic medical conditions, including heart or lung disease, diabetes, and chronic liver disease. They should then receive sequential PCV13 and PPSV23 at age 65.

Pelvic inflammatory disease (PIC) typically presents with fever, lower abdominal tenderness, mucopurulent cervical discharge, and cervical motion and uterine tenderness. Infection can extend from the upper genital tract to spread throughout the abdomen and cause liver capsule inflammation (eg, perihepatitis or Fitz-Hugh- Curtis disease), resulting in vomiting and slightly elevated transaminase levels. Patients with hepatic involvement present with symptoms of acute PID (fever, lower abdominal pain) as well as pleuritic right upper quadrant pain (eg, increased pain during inspiration). **Treatment of acute PID with perihepatitis includes hospitalization and intravenous antibiotics. Symptoms • Lower abdominal pain **• Abnormal bleeding Treatment • Third-generation cephalosporin plus • Azithromycin or doxycycline Physical examination • Cervical motion tenderness • Fever >38.3 C (>100.9 F) • Mucopurulent cervical discharge

**The greatest risk factor for suicide is a history of suicide attempt(s). **Breast engorgement refers to swelling of the breast and can occur early or late in the postpartum period. The breast becomes firm, enlarged, tender, and may be warm to the touch. Early engorgement is secondary to edema, tissue swelling, and accumulated milk, while late engorgement is due solely to accumulated milk. Early engorgement typically occurs between 24 and 72 hours postpartum, with a normal range of one to seven days. May give rise to a mild temperature elevation for a short period of time. 1-Inferior Ml: RCA or LCX: • ST elevation in leads II, Ill & aVF 2-Posterior Ml: LCX or RCA • ST depression in leads V1-V3 • ST elevation in leads I & aVL (LCX) • ST depression in leads I & aVL (RCA) 3- LCX, diagonal • ST elevation in leads I, aVL, V5 & V6 • ST depression in leads II, Ill & aVF 4-Right ventricle Ml: RCA (occurs in 1/2 of inferior Ml) • ST elevation in leads V4-V6R

Mild cognitive impairment (MCI) is an intermediate state between normal cognition and dementia. While specific changes in cognition are frequently observed in normal aging, there is increasing evidence that some forms of cognitive impairment are recognizable as an early manifestation of dementia. MCI refers to cognitive impairment that does not meet the criteria for dementia. Patients with MCI, particularly the amnestic subtype, complain primarily of impaired memory. It is important to ascertain that this represents a change over baseline. ●Cognitive concern reflecting a change in cognition reported by patient or informant or observed by clinician ●Objective evidence of impairment in one or more cognitive domains, typically including memory ●Preservation of independence in functional abilities ●Not demented

**Unstable angina chest pain of cardiac origin that is variable, usually increasing in frequency and intensity and with irregular timing. You should admit the patient to the hospital repeat ECG and cardiac biomarkers 6-12 hours later.

Interstitial cystitis/bladder pain syndrome (IC/BPS) is defined as an unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection or other identifiable causes (exclusional diagnosis, more in women) -increase in discomfort with bladder filling and a relief with voiding. Normal UA.

**Virilization + ovarian mass (unilateral) possible ovarian tumor that secretion testosterone (sertoli-Ledig tumor) or PCOS (also testosterone); ddx with adrenal cause of virilization (by test DHEA-S)

P450 Inducers: CRAP GPS induce me to madness!! Carbemazepines Rifampicin Alcohol (chronic) Phenytoin Griseofulvin Phenobarbitone Sulphonylureas Ginseng/ St. John's wart Oral contraceptives. **SIADH after head trauma, for asymptomatic hyponatremic patients is water restriction which is usually enough.Among patients with severe symptomatic hyponatremia who present with seizures or other severe neurologic abnormalities or with symptomatic hyponatremia in patients with intracerebral diseases, we recommend urgent intervention with hypertonic saline rather than other therapies (Grade 1C). An effective initial regimen is 100 mL of 3 percent saline given as an intravenous bolus, which should raise the serum sodium concentration by approximately 1.5 meq/L in men and 2 meq/L in women, thereby reducing the degree of cerebral edema.

1. Central DI is usually partial, and therefore both ADH release and the urine osmolality may increase as the plasma osmolality rises, but submaximally (during water deprivation test). Desmopressin will lead to a rise in urine osmolality (and an equivalent fall in urine output) of more than 100 percent in complete central DI and 15 to 50 percent in partial central DI 2. nephrogenic, urine osmolality wll not rise above 300 even with water restriction300 3.Primary polydipsia will be associated with a rise in urine osmolality, usually to above 500 mosmol/kg, and no response to desmopressin, since endogenous release is intact. Maximum concentrating ability is frequently impaired in this disorder, resulting in a maximum urine osmolality that may reach 500 to 600 mosmol/kg, as compared to 800 mosmol/kg or more in

Decrease CUT OFF--> increaseD SENSITIVITY, INCREASED NEGATIVE PREDICTIVE VALUE, DECREASED POSITIVE PREDICTIVE VALUE, DECREASED SPECIFICITY.

A low upper limit of normal will increase sensitivity and increase specificity.

Factors associated with poor outcome after witnessed out-of-hospital sudden cardiac arrest • Time elapsed prior to effective resuscitation (delayed bystander CPR, delayed defibrillation) • Initial rhythm of pulseless electrical activity or asystole • Prolonged CPR (>5 minutes) • Absence of vital signs • Advanced age • Prior history of cardiac disease • >=2 Chronic illnesses • Persistent coma after CPR • Need for intubation or vasopressors • Pneumonia or renal failure after CPR • Sepsis, cerebrovascular accident, or class Ill or IV heart failure

A right upper quadrant ultrasound distinguishes intrahepatic (no biliary tract dilation) from extrahepatic (biliary tract dilation; eg, due to gallstones) cholestasis. If ultrasound suggests intrahepatic cholestasis . the next step Is to obtain serum anti-mitochondrial antibody titers, which have high sensitivity and specificity for primary biliary cholangitis (PBC, previously termed primary biliary cirrhosis). **PBC is a chronic liver disease characterized by autoimmune destruction of the intrahepatic bile ducts with resulting cholestasis. It presents most commonly in middle-aged w om en and Is Insidious In onset. As the disease progresses, jaundice, hepatomegaly, steatorrtlea, and portal hypertension may develop. Additional complications can include severe hy perlipidemia (w ith xanthelasma) and metabolic bone disease. PBC Is often associated with other autoimmune disorders (eg, autoimmune thyroid disease).

Treatment of post-surgical hypocalcemia due to parathyroid removal:: Patients with acute symptomatic hypocalcemia (calcium level lower than 7.0 mg/dL, ionized calcium level lower than 0.8 mmol/L) should be treated promptly with IV calcium. Calcium gluconate is preferred over calcium chloride because it causes less tissue necrosis if extravasated. The first 100 to 200 mg of elemental calcium (1 to 2 g calcium gluconate) should be given over 10 to 20 minutes. Faster administration may result in cardiac dysfunction, even arrest. This should be followed by a slow calcium infusion, at 0.5 to 1.5 mg/kg/hr. Calcium infusion should continue until the patient is receiving effective doses of oral calcium and vitamin D. Calcium for infusion should be diluted in saline or dextrose solution to avoid vein irritation. The infusion should not contain bicarbonate or phosphate because this can form an insoluble calcium salt. If bicarbonate or phosphate administration is necessary, a separate IV line should be used.

A transthoracic echocardiogram should be obtained in all patients with syncope due to suspected structural heart disease (aortic stenosis, hypertrophic cardiomyopathy, left ventricular dysfunction, or cardiac tamponade) to confirm diagnosis and plan definitive management. Echocardiogram is recommended prior to exercise testing to assess for organic heart disease (cardiomyopathy or valvular heart disease). Exercise stress testing is contraindicated in patients with symptomatic severe AS. Upright tilt table testing is occasionally used to establish the diagnosis of vasovagal syncope in patients with recurrent unexplained syncope in the absence of organic heart disease.

hereditary hemochromatosis: ●Unexplained abnormalities in liver function, chronic liver disease, cirrhosis ●Cardiac enlargement with or without heart failure or conduction defects ●Diabetes mellitus ●Hypogonadism, with decreased libido and impotence in men ●Skin hyperpigmentation ●Unexplained fatigue ●Arthropathy, especially involving the second and third metacarpophalangeal joints ●Positive family history of iron overload Screening for the presence of HH — A transferrin saturation ≥60 percent in men or ≥50 percent in women has been accurate in detecting over 90 percent of patients with homozygous HH who have clinical symptoms and/or documented iron overload. the 2011 guidelines from the AASLD regarding the appropriate cutoff levels for transferrin saturation (greater than 45 percent) and serum ferritin (greater than 200 ng/mL in men and greater than 150 ng/mL in women) for screening patients with iron overload are in general agreement with the above-noted values

Abnormal prostate histology leading to neoplasia: Atypical small acinar proliferation — Atypical small acinar proliferation (ASAP) is defined as highly suspicious glandular architecture that is insufficient for the diagnosis of prostate cancer Prostatic intraepithelial neoplasia — Prostatic intraepithelial neoplasia (PIN) is defined pathologically as abnormal cellular change within the prostatic ductal cells consistent with prostate cancer, but without invasion of the basement membrane. PIN is divided into low-grade and high-grade subtypes. **Clostridium difficile spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item. **Although it is a self-limited illness, oral or intravenous antiviral treatments, particularly acyclovir, have been used in the management of immunocompromised or severely infected patients. Topical acyclovir has not been shown to be effective in management of herpetic whitlow. Lancing or surgically debriding the lesion may make it worse by causing a superinfection or encephalitis.

Social anxiety disorder (social phobia): Diagnosis • Marked anxiety about >=1 social situations for >6 months • Fear of scrutiny by others, humiliation, embarrassment • Social situations avoided or endured with intense distress Treatment • Marked impairment (social, academic, occupational) • Subtype specifier: Performance only • SSRI/SNRI • Cognitive-behavioral therapy • Beta blocker or benzodiazepine for performance-only subtype Individuals with performance-only social anxiety disorder do not fear non-performance social situations (e.g. enjoy socializing and is able to relax during the interview). The pharmacologic treatment of performance-only social anxiety disorder includes beta blockers or benzodiazepines. Beta blockers (propranolol) on an as-needed basis help control the associated autonomic response (tremors, tachycardia, and diaphoresis). Benzodiazepines can also be used but are not preferred when performance could be impaired by sedation and cognitive side effects. They should also be avoided in patients with substance abuse.

Acetaminophen intoxication: IF Single dose >=7.5 g (pediatric >=150 mg/kg) and <= 4 hours since ingestion then administer activated charcoal and then Check acetaminophen levels, if after checking the level • Levels above treatment line in nomogram • > 1 0 micro g/ml if timing of ingestion unclear • Any evidence of liver injury Then administer N-acetylcysteine & monitor for liver injury if Chronic ingestion, then directly go to check acetaminophen level For patients who present soon after a single, potentially toxic ingestion (> 7. 5 g) of acetaminophen, the first step in management is gastric decontamination and measurement of acetaminophen levels. Patients can be asymptomatic during the first 24 hours after ingestion. Patients at risk for fulminant hepatic failure should be evaluated for potential liver transplantation.

Research most strongly supports that, in addition to PTSD, sexual assault victims are at increased lifetime risk for major depression and contemplation of suicide or actual attempts. Patients with Borderline personality disorder often have a history of childhood abuse; **Intravascular hemolysis refers to the breaking down of RBCs in the blood vessels. Schistocytes are seen on the peripheral blood smear. Common causes include shearing secondary to prosthetic valves, disseminated intravascular coagulation (DIC), thrombotic thrombocytopenic purpura (TTP), hemolytic uremic syndrome (HUS), and paroxysmal nocturnal hemoglobinuria (PNH). Of note, the spleen and reticuloendothelial system are considered extravascular. Therefore, autoimmune hemolytic anemia in patients with chronic lymphocytic leukemia (CLL) is extravascular! **Colorectal cancer is the most common source of liver metastases (as blood from the colon moves through the portal circulation directly to the liver) and should be excluded In this patient, even in the absence of specific symptoms (eg, alteration in bowel habits, gastrointestinal bleeding). Abdominal CT Is a useful screening test but can often miss primary intraluminal tumors. Colonoscopy Is the most appropriate next diagnostic step as It both localizes the tumor and provides a tissue diagnosis.

Acute Gout Attack: 1- NSAIDS: Commonly used NSAIDs during an acute gout attack include ibuprofen 800 mg three to four times daily or indomethacin 25 to 50 mg four times daily. Treatment should be discontinued when symptoms resolve. 2- Colchicine: Intravenous colchicine is associated with serious toxicities and side effects, so it should be used as an oral formulation only. High dose oral colchicine (1.2 mg followed by 0.6 mg every hour for 6 doses) is generally poorly tolerated because of GI side effects. Lower doses are much better received and may be used in combination with NSAIDs. 3- Corticosteroids: In patients with contraindications to NSAID use, corticosteroids are the next choice. Corticosteroids can be administered as an injection into the effected joint (intra-articular steroids) or given systemically (orally, such as prednisone or medrol). Intra-articular steriods are useful if only one or two joints are affected and the treating physician is proficient in injecting those joints. Oral corticosteroids can be used starting at 30-40 mg daily tapering over 10-14 days.

Clinical features of thyroid storm: Precipitating factors • Thyroid or non-thyroid surgery • Acute illness (eg, trauma, infection), childbirth • Acute iodine load (eg, iodine contrast) Clinical presentation • Fever as high as 40-41 .1 C (104-106 F) • Tachycardia, hypertension, congestive heart failure, cardiac arrhythmias (eg, atrial fibrillation) • Agitation, delirium, seizure, coma • Goiter, lid lag, tremor, warm & moist skin • Nausea, vomiting, diarrhea, jaundice Treatment • Beta blocker (eg, propranolol) to decreased adrenergic manifestations • PTU followed by iodine solution (SSKI = potassium iodide) to decrease hormone synthesis & release • Glucocorticoids (eg, hydrocortisone) to decreased peripheral T4 to T3 conversion & improve vasomotor stability • Identify trigger & treat, supportive care

Acute adrenal insufficiency (adrenal crisis): Risk factors: Adrenal hemorrhage/infarction Acute illness, injury, or surgery in patients with: • Chronic adrenal insufficiency • Chronic glucocorticoid use • Congenital adrenal hyperplasia Clinical features: • Hypotension/shock • Nausea/vomiting, abdominal pain • Weakness • Fever • Acute kidney injury Diagnostic testings: • Cortisol • Electrolytes, BUN, creatinine, glucose • ACTH • Renin • ACTH stimulation test when stable Treatment: • Hydrocortisone or dexamethasone • High-flow intravenous fluids • Monitor serum electrolytes

Acute cholangitis is a clinical syndrome characterized by fever, jaundice, and abdominal pain that develops as a result of stasis and infection in the biliary tract. It is also referred to as ascending cholangitis. Cholangitis was first described by Charcot as a serious and life-threatening illness; however, it is now recognized that the severity can range from mild to life-threatening. The most important predisposing factor for acute cholangitis is biliary obstruction and stasis. The most common causes of biliary obstruction in patients with acute cholangitis without bile duct stents are biliary calculi (28 to 70 percent), benign stenosis (5 to 28 percent), and malignancy (10 to 57 percent). Acute cholangitis is caused primarily by bacterial infection in a patient with biliary obstruction. The organisms typically ascend from the duodenum; hematogenous spread from the portal vein is a rare source of infection. Biliary obstruction raises intrabiliary pressure and leads to increased permeability of bile ductules, permitting translocation of bacteria and toxins from the portal circulation into the biliary tract. most common symptoms of acute cholangitis are fever and abdominal pain, which are seen in approximately 80 percent of patients. Jaundice is less common and is seen in 60 to 70 percent of patients. Patients with severe (suppurative) cholangitis may present with fever, abdominal pain, jaundice, hypotension, and mental status changes (Reynolds pentad). Older adults and patients receiving glucocorticoids may have atypical presentations (such as hypotension alone), which may lead to a delay in diagnosis and treatment.

Acute cholangitis is a clinical syndrome characterized by fever, jaundice, and abdominal pain that develops as a result of stasis and infection in the biliary tract. It is also referred to as ascending cholangitis. Routine laboratory tests typically reveal an elevated white blood cell count with neutrophil predominance, and a cholestatic pattern of liver test abnormalities, with elevations in the serum alkaline phosphatase, gamma-glutamyl transpeptidase (GGT), and bilirubin (predominantly conjugated) concentration . However, a pattern of acute hepatocyte necrosis can be seen in which the aminotransferases may be as high as 2000 int. unit/L. ●Fever and/or shaking chills ●Laboratory evidence of an inflammatory response (abnormal white blood cell count, increased serum C-reactive protein, or other changes suggestive of inflammation) and one of the following: ●Jaundice ●Abnormal liver chemistries (elevated alkaline phosphatase, gamma-glutamyl transpeptidase, alanine aminotransferase, aspartate aminotransferase) The diagnosis is considered definite if, in addition to meeting the criteria for a suspected diagnosis, the patient also has: ●Biliary dilation on imaging ●Evidence of an etiology on imaging (eg, a stricture, stone, or stent)

Pulmonary nodule: Higher chance of being malignant: Stippled or eccentric calcification. ill-defined or spiculated margin. Doubling time should be more than 30 days and less than 465 days. High uptake of PET-scan tracer. ** less than 30 days of doubling time is more suggestive of infection. Benign calcifications: Popcorn (in hamartomas) and bull's eyes in (granulomas) IF no CXR and low risk do follow-up with CT in 3-6 months. **The current standard of treatment for alcoholic patients is to give them thiamine 100 mg intravenously (IV) before administering glucose containing IV fluids and then to continue this dose for several days.

Acute pyelonephritis: Acute pyelonephritis is a common bacterial infection of the renal pelvis and kidney ... microscopic pyuria or hematuria, or white blood cell casts. Women with pyelonephritis requiring hospitalization should be treated initially with an intravenous antimicrobial regimen such as a fluoroquinolone, an aminoglycoside (with or without ampicillin), an extended-spectrum cephalosporin (e.g IV ceftriaxone), an extended-spectrum penicillin, or a carbapenem. Indications for pyelonephritis hospitalization: Those with **vomiting, older age, sepsis, and certain medical conditions (eg, **diabetes mellitus, urinary obstruction) require hospitalization and intravenous antibiotics due to a higher risk of treatment failure with outpatient oral antibiotics. Even in uncomplicated give Intravenous antibiotics if vomiting, elderly, septic. After 48 hours of symptomatic improvement, most hospitalized patients can be transitioned to culture-guided oral antimicrobials.

Organizing pneumonia — Organizing pneumonia, previously called bronchiolitis obliterans organizing pneumonia (BOOP), is a rare type of pediatric lung disease characterized by patchy areas of inflammation and organizing pneumonia with obstruction of airways by intraluminal polyps of fibrous tissue. The characteristic histopathologic lesions include excessive proliferation of granulation tissue within small airways (proliferative bronchiolitis) and alveolar ducts, associated with chronic inflammation in the surrounding alveoli. It can be idiopathic, in which case it is called cryptogenic organizing pneumonitis (COP). **ABPA on radiograph:ntral bronchiectasis is a frequent feature of ABPA and affects airways in the central one-half to two-thirds of the chest on imaging studies. Evidence of mucus plugging may be present on chest imaging as well. "Tram line" shadows due to thickened walls of nondilated bronchi •"Parallel lines" due to the presence of ectatic bronchi •"Ring shadows" due to bronchial wall thickening or saccular bronchiectasis •"Toothpaste shadows" due to mucoid impacted second- to fourth-order bronchi •"Gloved finger shadows" due to intrabronchial exudates with bronchial wall thickening; these appear as branched tubular radiodensities 2 to 3 cm long and 5 to 8 mm wide that extend from the hilus. •Perihilar opacities due to mucus plugging may mimic hilar adenopathy

Allergic bronchopulmonary aspergillosis (ABPA) is a complex hypersensitivity reaction in response to colonization of the airways with Aspergillus fumigatus that occurs almost exclusively in patients with asthma or cystic fibrosis (CF). Allergic bronchopulmonary aspergillosis (ABPA) is characterized pathologically by mucoid impaction of the bronchi, eosinophilic pneumonia, and bronchocentric granulomatosis in addition to the histologic features of asthma. T cells also play an important role in ABPA. There are increases in Th2 CD4+ cell responses to Aspergillus antigens both in the bronchoalveolar lymphoid tissue and systemically. The clinical picture of ABPA is dominated by asthma and recurrent exacerbations. In severe cases, episodes of bronchial obstruction, fever, malaise, expectoration of brownish mucus plugs, and, at times, hemoptysis may occur. Wheezing is not always evident, and some patients present with asymptomatic pulmonary consolidation. A minority of patients with ABPA have concomitant allergic aspergillus rhinosinusitis with symptoms of nasal congestion/obstruction, sinus pressure, and thick, dark-colored nasal discharge. ●Obligatory criteria (both must be present) for diagnosis: •Aspergillus skin test positivity or detectable IgE levels against Aspergillus fumigatus •Elevated total serum IgE concentration (typically >1000 IU/mL, but if the patient meets all other criteria, an IgE value <1000 IU/mL may be acceptable)

Doppler ultrasound can evaluate for vasa previa (fetal blood vessels covering the cervical os), which is often associated with resolved placenta previa. Doppler ultrasound of the umbilical artery is also used in the surveillance of fetal growth restriction (estimated fetal weight <10th percentile). Fetal growth restriction is not a common complication of placenta previa. ** When pancreatitis is very severe, such as when there is >30% percent necrosis visible on the CT scan, the risk of infected and hemorrhagic pancreatitis markedly increases. For this reason, necrosis on a CT scan is an indication for starting antibiotics, such as imipenem or meropenem, which will diminish both the risk and severity of hemorrhagic and infected pancreatitis. Severe necrosis, particularly when there is a persistent fever, is also an indication to perform a percutaneous needle biopsy of the pancreas. If there is infection of the pancreas in addition to the necrosis, urgent surgical debridement is indicated. (this is before the development of an abscess which does not begin 4 to 6 weeks after the onset of pancreatitis.

Although placenta previa may resolve spontaneously by the third trimester due to growth of the lower uterine segment and/or placental growth toward the fundus, pelvic rest and abstinence from intercourse (due to potential penile contact with the cervix) are recommended for all patients once the diagnosis of placenta previa is made. Clinicians should refrain from digital cervical examination as cervical penetration can potentially disrupt the placenta. Labor and vaginal delivery are also contraindicated. Cesarean delivery is scheduled for 36-37 weeks gestation as cervical changes and uterine contractions can cause partial placental detachment from the cervix. Should a follow-up ultrasound show resolution of the placenta previa, the plan of care can be modified accordingly and the pelvic rest restriction can be lifted.

Communitu acquired pneumoia: Admit if : CURB65=admission Confusion Uremia **Respiratory distress **BP low Age >65 For hospitalized inpatients give new fluroquinlons such as levofloxacin, moxifloxacin or gemifloxacin or second or third generation cephalosporin (ceftriaxone or cefuroxime) combine with macrolide or doxycycline. or β-Lactam Antibiotic and β-Lactamase Inhibitor Combinations such as Ampicilin-sulbactam, Ticarcillin-clavulanate and piperacillin-tazobactam combined with doxycycline or a macrolid

Anti-U1 RNP antibodies in mixed connective tissue disease. Anti- La/SSB and anti-RO/SSA sen sjogren syndrome. Anti-RO/SSA beside sjogren is seen in SLE and neonatal SLE and RA.

Hyperosmolar hyperglycemic state: According to the consensus statement published by the American Diabetes Association, diagnostic features of HHS may include the following: ( usually precipitated by an infection, myocardial infarction, stroke or another acute illness) Plasma glucose level >600 mg/dL (>30 mmol/L) Serum osmolality >320 mOsm/kg Profound dehydration, up to an average of 9L (and therefore substantial thirst (polydipsia)) Serum pH >7.30 Bicarbonate >15 mEq/L Small ketonuria (~+ on dipstick) and absent-to-low ketonemia (<3 mmol/L) Some alteration in consciousness Additionally it may also lead to: Neurologic signs including focal signs such as sensory or motor impairments or focal seizures or motor abnormalities, including flaccidity, depressed reflexes, tremors or fasciculations. Hyperviscosity and increased risk of blood clot formation

Aortic aneurysms are well-known complications of giant cell or temporal arteritis due to the involvement of the branches of the aorta. For this reason, patients should be followed with serial chest x-rays. ***Atopic dermatitis (eczema): Risk factors • Low humidity • Relatives with eczema, allergies, or asthma Clinical features: • Infant: Itchy, red, scaly, crusted lesions on extensor surfaces, trunk, cheeks & scalp • Child/adult: Lichenified plaques in flexural creases Treatment Topical emollients +/- steroid ointment Complications • Eczema herpeticum • Cellulitis/abscess • Discomfort interfering with daily activities & sleep

Diagnosis of Chorioamnionitis (intra-amniotic infection) Maternal fever >38 C (100.4 F) PLUS >=1 of the following: • Maternal o Tachycardia >=100/min o Uterine tenderness o Malodorous/purulent amniotic fluid or vaginal discharge o White blood cells >15,000/IJL • Fetal tachycardia >160/min Management of patients with acute aortic dissection • Pain relief with morphine • Intravenous beta blockers for a target systolic blood pressure of 100-120 mm Hg • Transfer to intensive care unit • Initiate additional vasodilator (eg, sodium nitroprusside) if systolic blood pressure remains elevated • Surgery for acute ascending aortic dissections & complicated descending aortic dissections

Aortic dissection involving the ascending aorta (type A) is considered a surgical emergency with m ortality rates of 1%-2% per hour following symptom onset, and rapid diagnosis and treatment are critical. The goals of initial therapy of aortic dissection include: • Adequate pain control • Reduction of systolic blood pressure (SSP) to a goal of 1 00-120 mm Hg • Decrease in left ventricular (LV) contractility to reduce aortic wall stress Intravenous beta blockers (eg, labetalol, propranolol, esmolol) are preferred for initial therapy to reduce heart rate, SSP, and LV contractility. These effects lead to a decrease in the rate of rise in SSP (dP/dt) and in aortic wall stress. **for pediatric hypertension give labetalol, nefidipine, nitroprusside and in the end hydralazine.

Atopic dermatitis (eczema) is a very common condition characterized by pruritus, erythema, and scaly lesions on the skin. Pathogenesis involves epidermal dysfunction due to improper synthesis of stratum corneum components. Allergens can enter the disrupted skin barrier and generate an inflammatory response. Excessive bathing, dry environments, stress, overheating, and irritating detergents can trigger flares. Eczematous lesions usually begin with pruritus alone and evolve to erythematous papules and scaly plaques. Severe lesions may have serous exudates and crusting. Infants typically have lesions in the distribution of the face, scalp, and extensor surfaces of the extremities. The lesions can also be seen in flexural creases in older children and adults. **Patients who have decision-making capacity have the right to refuse procedures and treatment. The physician should address any modifiable obstacles to treatment. If the patient still refuses, services should be offered if the patient reconsiders.

Autopsy studies have suggested evidence of cardiac noncaseating granulomas in at least 25% of patients with sarcoidosis. However, only 5% of patients demonstrate signs or symptoms of cardiac involvement, suggesting that cardiac sarcoidosis is underdiagnosed or often remains subclinical. Infiltration of noncaseating granulomas leads to surrounding inflammation and can result in conduction defects (complete AV block is most common), restrictive cardiomyopathy (early manifestation), dilated cardiomyopathy (late manifestation), valvular dysfunction, and heart failure. Sudden cardiac death can occur due to complete AV block or ventricular arrhythmia. Cardiac sarcoidosis should be suspected in any young patient (age <55) with unexplained second- or third-degree heart block or when ECG changes occur in a patient with known or suspected systemic sarcoidosis. Definitive diagnosis can be challenging due to poor sensitivity of endomyocardial biopsy, but a combination of imaging findings, ECG findings, and history often strongly suggests the diagnosis.

Contact lens-associated keratitis: Most cases are due to Gram-negative organisms such as Pseudomonas and Serratia, but can also be due to Gram-positive organisms as well as certain fungi and amoebas. Contact lens-associated keratitis is a medical emergency and can lead to corneal perforation, scarring, and permanent vision loss if not addressed promptly. In addition to removal and discarding of the contact lens, most patients require topical broad-spectrum antibiotics. thick, globular yellow discharge is present at the medial eye corner and on the lid margins. The cornea is edematous, hazy, and ulcerated and there is extensive scleral injection. Thus. radiographic imaging is required. If x-ray reveals that the battery is lodged in the esophagus, immediate endoscopic removal is necessary In order to prevent mucosal damage and esophageal ulceration . Batteries located distal to the esophagus on x-ray pass uneventfully in 90% of cases. Such patients are observed to confirm excretion of the battery by stool examination and/or radiographic follow-up.

Avascular necrosis: Etiology • Steroid use • Alcohol abuse • Systemic lupus erythematosus • Antfphospholipid syndrome • Hemoglobinopathies (eg, sickle cell) • Infections (eg, osteomyelitis, HIV) • Renal transplantation • Decompression sickness Clinical manifestations • Pain on hip abduction & internal rotation • No erythema, swelling, or point tenderness Laboratory findings: • Normal white blood cell count • Normal ESR & CRP/no fever Radiologic imaging • Crescent sign seen in advanced stage • MRI is most sensitive modality

Acute bronchitis: Patients with acute bronchitis present with a cough lasting more than five days (typically one to three weeks), which may be associated with sputum production. The usual causes of acute bronchitis are viral infections of the upper airways including influenza A and B, parainfluenza, coronavirus (types 1-3), rhinovirus, respiratory syncytial virus, and human metapneumovirus. Other pathogens that can cause acute bronchitis, although less commonly than viruses, include: ●Mycoplasma pneumonia ●Chlamydia pneumonia ●Bordetella pertussis Physical examination of the chest may reveal wheezing or rhonchi, but signs of consolidation or rales should not be present. Abnormal vital signs (fever, tachypnea, or tachycardia) and signs of consolidation or rales on physical examination suggest the possibility of pneumonia and the need for a confirmatory chest radiograph to distinguish acute bronchitis from pneumonia. We have normal CXR or may see hyperinflation if patient has concomitant COPD. Treatment: Most patients with acute bronchitis require only reassurance and symptomatic treatment. **Although morphologically normal, the neutrophils in CML are cytochemically abnormal. The cytochemical reaction called leukocyte (or neutrophil) alkaline phosphatase (LAP, or NAP) when scored is low. The low LAP score is useful in excluding a reactive leukocytosis or "leukemoid reaction," typically due to infection, in which the score is typically elevated or normal. Absolute basophilia is a universal finding in the blood smears from CML patients, and absolute eosinophilia is seen in about 90 percent of cases.

Basophils: The least common of the circulating white blood cells, comprise less than 1 percent of the total white blood cell count, and are recognized by their prominent dark blue-black granulesThese cells differ from a neutrophil by the presence of coarse, dark blue-black granules (Wright-Giemsa stain). Chronic myelogenous leukemia (CML), a myeloproliferative disorder characterized by increased proliferation of the granulocytic cell line without the loss of their capacity to differentiate. So, from the peripheral smear, early myeloid cells such as myeloblasts, myelocytes, metamyelocytes, and nucleated red blood cells are commonly present in the blood smear, mimicking the findings in the bone marrow. The presence of the different midstage progenitor cells differentiates CML from the acute myelogenous leukemias. Basophilia is a constant finding in CML, The clinical manifestations of CML are insidious, like fatigue, low-grade fever.The median age at presentation is approximately 50 years for patients enrolled on clinical studies, but the actual median age from cancer registry data may be 10 years older. Exposure to ionizing radiation is the only known risk factor.Abdominal pain and discomfort may include left upper quadrant pain (sometimes referred to the left shoulder) and early satiety, due to the enlarged spleen with or without perisplenitis and/or splenic infarction. Tenderness over the lower sternum, due to an expanding bone marrow, is sometimes seen. Acute gouty arthritis may also present at this time, due to overproduction of uric acid.

Type of androgen abused: • Exogenous (eg, testosterone replacement therapy) • Synthetic (eg, stanozolol, nandrolone) androgens • Androgen precursors (eg, DHEA) Chorioamnionitis should be treated with intravenous broad-spectrum antibiotics (eg, ampicillin, gentamicin, clindamycin) and delivery. These interventions can reduce the risk of life-threatening neonatal infection and other complications. Therefore should receive oxytocin to accelerate labor. Cesarean delivery is reserved for standard obstetric indications (eg, fetal distress, breech presentation, multiple prior cesarean deliveries) and not for chorioamnionitis exclusively. This patient's fetal heart tracing showed that fetal tachycardia is likely related to maternal fever rather than fetal distress due to the absence of decelerations. Antipyretics are typically administered to reduce maternal fever, which in turn should improve fetal tachycardia.

Carotid endarterectomy (CEA) is recommended for men and women with symptomatic carotid stenosis of 70%-99% and is also beneficial for men with asymptomatic carotid stenosis of 60%-99%. Some experts recommend CEA for asymptomatic women with high-grade stenosis (70%-99% ), but the data are less convincing. CEA can be considered in men with symptomatic carotid lesions of 50%-69%. Patients are selected for surgery based on their individual surgical risk and predicted survival, the presence of a surgically accessible carotid lesion, and the experience of the surgeon/center.

Can be causes of Torsade de Pointe: Fluconazole and moxifloxacin), which along with a history of alcoholism (electrolyte imbalances). Women with an acute placental abruption classically present with the **abrupt onset of vaginal bleeding, mild to moderate abdominal and/or back pain, and uterine contractions. Back pain is prominent when the placenta is on the posterior wall of the uterus. The uterus is often firm, and may be **rigid and tender. Contractions are usually **high frequency and low amplitude, but a contraction pattern typical of labor is also possible and labor may proceed rapidly. Vaginal bleeding ranges from mild and clinically insignificant to severe and life-threatening. Blood loss may be underestimated because bleeding may be retained behind the placenta and thus difficult to quantify. The amount of vaginal bleeding correlates poorly with the degree of placental separation and does not serve as a useful marker of impending fetal or maternal risk. Abdominal pain is a better predictor of poor outcome . Maternal hypotension and fetal heart rate (FHR) abnormalities suggest clinically significant separation that could result in fetal death and severe maternal morbidity. When placental separation exceeds 50 percent, acute disseminated intravascular coagulation and fetal death are common . In 10 to 20 percent of placental abruptions, patients present with only preterm labor, and no or scant vaginal bleeding. In these cases, termed "concealed abruption," all or most of the blood is trapped between the fetal membranes and decidua, rather than escaping through the cervix and vagina. In phase 1 labour: The cervix dilates to 3-4 cm in this stage. The frequency of the uterine contractions at this stage is from 1-3 per 10 minutes in normal labour and each contraction lasts for less than a minute. The uterus may become firm and more prominent with every contraction. Phase 2: This is the phase where the uterus contracts more frequently and the pain is maximum. Uterine contraction occurs after every 3-5 minutes and lasts for more than a minute. The uterus becomes hard and more prominent as the pain increases and softer as the uterus relaxes.

Causes of acquired long QT syndrome: Medications • Diuretics (due to electrolyte imbalances) • Antiemetics (eg, ondansetron) • Antipsychotics (eg, haloperidol, quetiapine, risperidone) • Tricyclic antidepressants • Selective serotonin reuptake inhibitors (eg, citalopram) • Antiarrhythmics (eg, amiodarone, sotalol, flecainide) • Antianginal drugs (eg, ranolazine) • Anti-infective drugs (eg, macrolides, fluoroquinolones, antifungals) Metabolic disorders • Electrolyte imbalances decreased K, Mg, and Ca) • Starvation • Hypothyroidism Bradyarrhythmias • Sinus node dysfunction • Atrioventricular block (2nd or 3rd degree) Others • Hypothermia • Myocardial ischemia/infarction • Intracranial disease • HIV infection **Primary dysmenorrhea: Nausea, vomiting, diarrhea, headache, dizziness, or back pain may accompany the crampy abdominal pain. The pain and associated symptoms typically begin several hours prior to the onset of menstruation and continue for one to three days.ysmenorrhea appears to be caused by excess production of endometrial prostaglandin (PG) F2 alpha or an elevated PGF2 alpha:PGE2 ratio. Excessive levels of endometrial, but not plasma, PGE2 and PGF2 alpha have been detected in women with primary dysmenorrhea.

Common causes of pericardial constriction include prior cardiac surgery and uremic pericarditis. Outside the United States, the most common cause is tuberculous pericarditis. Idiopathic pericarditis and prior bacterial pericarditis are uncommon causes. Associated physical findings include elevated jugular venous pressure with a rapid Y-descent. The rapid descent of the jugular veins can usually be seen to occur in conjunction with or just following the pericardial knock. Patients are frequently in atrial fibrillation and have physical findings of right-sided heart failure. **Lupus can cause acute Pericarditis and chronic constrictive pericarditis. Pericardial involvement is the most common echocardiographic lesion in systemic lupus erythematosus (SLE) and is the most frequent cause of symptomatic cardiac disease. Symptomatic pericarditis typically presents with pleuritic substernal chest pain with an audible rub on auscultation. There may also be signs of serositis at other sites (such as pleural effusion and ascites). PERICARDIAL KNOCK — Ventricular filling is confined to early diastole in constrictive pericarditis and terminates with a sharp S3; this is termed a "pericardial knock." Its timing is earlier than a normal S3 and typically occurs 0.10 to 0.12 second after S2. It is a common finding in constrictive pericarditis and can occur with or without pericardial calcification

Common Causes of Pericarditis and Pericardial Effusion: 1-Idiopathic 2-Infectious Viral (including HIV) Bacterial Mycobacterial Fungal and protozoal 3-Post-Myocardial infarction (early and late) 4-Postoperatively after open heart surgery 5-Chest trauma Blunt Sharp 6-Radiation 7-Malignancy Primary: mesothelioma, angiosarcoma Metastatic: lung, breast, bone, lymphoma, melanoma 8-Collagen vascular diseases Rheumatoid arthritis Systemic lupus erythematosus 9-Inflammatory/infiltrative diseases Sarcoidosis Amyloidosis 10-Metabolic Hypothyroidism Uremia 11-Pharmacologic Cromolyn sodium Doxorubicin Hydralazine Methysergide Minoxidil Penicillin Phenytoin Procainamide

Obstruction of the large intestine: Diagnosis: X-ray shows a distended proximal colon, air-fluid level, and absence of gas in the rectum Treatment: If there is severe pain, sepsis, free air, or sign of peritonitis there must be an urgent laporotomy Do laprotomy if cecal diameter is >=12 cm

Diabetic patients age 40-75 should be treated with statin therapy in addition to lifestyle modification and glucose control. Those with a 10-year risk of atherosclerotic cardiovascular disease <7.5% should receive moderate-intensity statin therapy, and those with a risk >=7.5% should receive high-intensity statin therapy. Anyone with LDL >=190 mg/dl should get High-intensity statin

Treatment of septic shock primarily consists of the following: (three main) 1- Fluids Because lowered blood pressure in septic shock contributes to poor perfusion, fluid resuscitation is an initial treatment to increase blood volume. Crystalloids such as normal saline and lactated Ringer's solution are recommended as the initial fluid of choice, while the use of colloid solutions such as hydroxyethyl starch have not shown any advantage or decrease in mortality. When large quantities of fluids are given, administering albumin has shown some benefit. 2- Antibiotics Treatment guidelines call for the administration of broad-spectrum antibiotics within the first hour following recognition of septic shock. Prompt antimicrobial therapy is important, as risk of dying increases by approximately 10% for every hour of delay in receiving antibiotics.[8] Time constraints do not allow the culture, identification, and testing for antibiotic sensitivity of the specific microorganism responsible for the infection. Therefore, combination antimicrobial therapy, which covers a wide range of potential causative organisms, is tied to better outcomes. 3-Vasopressors Among the choices for vasopressors, norepinephrine is superior to dopamine in septic shock.Norepinephrine is the preferred vasopressor, while epinephrine may be added to norepinephrine when needed. Low-dose vasopressin also may be used as an addition to norepinephrine, but is not recommended as a first-line treatment. Dopamine may cause rapid heart rate and arrhythmias, and is only recommended in combination with norepinephrine in those with slow heart rate and low risk of arrhythmia. In the initial treatment of low blood pressure in septic shock, the goal of vasopressor treatment is a mean arterial pressure (MAP) of 65 mm Hg.

Diagnostic tests for aortic (including traumatic) rupture: 1-Plain radiograph :Upright preferable; sensitivity of supine unclear. Normal PA radiograph has high negative predictive value; good test for patients with low to moderate suspicion If high clinical suspicion, or abnormal radiograph, further testing required. 2-Chest CT scan: Test of choice Highly sensitive and specific Requires IV contrast Can usually proceed directly to OR with a positive CT Equivocal study necessitates angiography 3-Arteriography Highly sensitive and specific Mainly used for equivocal CT scans Rarely adds value in the setting of a diagnostic CT and delays potentially life-saving operative intervention 4-Transesphosageal echocardiography Highly accurate Can be performed at bedside, in OR, or in patients who cannot tolerate contrast (renal failure) Limited in proximal ruptures, but overall an excellent test when CT is unavailable or contraindicated *Carotidynia is a neurological condition caused by inflammation of the carotids and the vagus. The pain is sharp and localized to the carotid artery distribution in the neck. The diagnosis is clinical, although an MRI is sometimes required.

Midsystolic click — Prolapse of the mitral valve is the most common cause for a non-ejection midsystolic click; Tricuspid valve prolapse also produces high-frequency midsystolic, "clicky" sounds; these are best heard with the diaphragm of the stethoscope over the lower left sternal border and occasionally over the lower right sternal border. The interval between S1 and the tricuspid valve click tends to increase following inspiration and after raising the legs and other maneuvers that increase right ventricular volume. Precordial honk — The systolic "whoop" or "precordial honk" are short musical systolic murmurs often preceded by a click and occurring in mid or late systole. These sounds can be transient, occur only in certain positions, or may be precipitated by exercise. Mitral valve prolapse is the cause for the "whoop" or "honk" in most cases.

ECG testing is the most sensitive routinely performed diagnostic test for HCM, but the ECG abnormalities are not specific to HCM and should prompt further diagnostic evaluation, usually with echocardiography. A normal ECG is uncommon, seen in less than 10 percent of patients with HCM: we see 1-Prominent abnormal Q waves, particularly in the inferior (II, III, and aVF) and lateral leads (I, aVL, and V4-V6). 2-P wave abnormalities, reflecting left atrial or biatrial enlargement. The combination of left ventricular hypertrophy (LVH) with right atrial enlargement is strongly suggestive of HCM. 3-Left axis deviation. 4-Deeply inverted T waves (so-called "giant negative T waves") may be seen in the mid-precordial leads (V2 through V4) in patients with the apical variant of HCM.

***Thyroid nodule: 1-Clinical evaluation, TSH level & US (first thing to do) + no cancer risk factors or suspicious US findings and Normal or elevated TSH, then do FNA and do treatment based on findings + no cancer risk factors or suspicious US findings and low TSH then do Iodine 123 scintigraphy and then if hyperfunction (hot) nodule then treat hyperthyroidism + no cancer risk factors or suspicious US findings and low TSH then do Iodine 123 scintigraphy and then if Hypofunctional ("cold") or indeterminate nodule then do FNA. 2-Clinical evaluation, TSH level & US (first thing to do) + Cancer risk factors or suspicious US findings then do FNA ***Although FNA is the most accurate modality for assessing thyroid nodules measuring >=1 cm, ultrasound and TSH are recommended first in patients without thyroid cancer risk factors to better differentiate which need FNA. However, FNA is indicated in all patients with thyroid cancer risk factors or suspicious ultrasound findings, even if the· nodule is <1 cm.

Eosinophilia refers to an absolute eosinophil count in the peripheral blood of ≥500 eosinophils/microL; this is considered abnormal in most laboratories [1,2]. The degree of eosinophilia can also be categorized as mild (500 to 1500 eosinophils/microL), moderate (1500 to 5000 eosinophils/microL), or severe (>5000 eosinophils/microL). Transpulmonary passage of helminth larvae (Löffler syndrome) — Three types of helminths, Ascaris lumbricoides, hookworms (Ancylostoma duodenale, Necator americanus), and Strongyloides stercoralis, have life cycles in which infecting larvae reach the lungs via the bloodstream, penetrate into alveoli, mature, and ascend the airways before descending the alimentary tract into the small bowel . The syndrome of transient pulmonary radiographic opacities and peripheral blood eosinophilia was originally described by Löffler; Ascaris infection acquired from the use of contaminated human night-soil as fertilizer was determined to be the cause. Lung tissue eosinophilia demonstrated in transbronchial or open lung biposies. Stool examinations are generally negative at the time of pulmonary symptoms and thus not useful in diagnosis of Loeffler syndrome.

PHARMACOLOGIC AGENTS FOR VTE PREVENTION in surgery: 1- Low dose unfractionated heparin — Low dose subcutaneous unfractionated heparin (UFH) for prophylaxis of VTE is usually given in a dose of 5000 units two hours preoperatively and then every 8 to 12 hours postoperatively (ie, either twice or three times daily). 2-Low molecular weight heparin — A number of low molecular weight heparin (LMW heparin) preparations are available. These drugs have the advantage that they can be given subcutaneously once or twice daily at a constant dose without laboratory monitoring for therapeutic effect. 3-Fondaparinux — The dosing of fondaparinux is discussed elsewhere in UpToDate, but issues related to its use in surgical patients will be reviewed here.

Epistaxis: 1- Anterior nosebleeds are by far the most common. A large proportion is self-limited and can be managed definitively in the primary care setting. Up to 90 percent occur within the vascular watershed area of the nasal septum known as Kiesselbach's plexus. Anastomosis of three primary vessels occurs in this area: the septal branch of the anterior ethmoidal artery; the lateral nasal branch of the sphenopalatine artery; and the septal branch of the superior labial branch of the facial artery. The sphenopalatine artery also gives off branches supplying the posterolateral wall and posterior choana; these vessels are the most likely source of posterior nosebleeds. 2- Posterior bleeds — Posterior epistaxis arises most commonly from the posterolateral branches of the sphenopalatine artery but may also arise from the carotid artery (internal).

Stress fracture: Risk factors • Repetitive activities (eg, running, gymnastics) • Abrupt increase in physical activity • Inadequate calcium & vitamin D intake • Decreased caloric intake • Female athlete triad: low caloric intake, hypomenorrhea/amenorrhea, low bone density Clinical presentation: • Insidious onset of localized pain • Point tenderness at fracture site presentation • Reduced weight-bearing for 4-6 weeks Management • Referral to orthopedic surgeon for fracture at high risk for malunion (eg, anterior tibial cortex, fifth metatarsal) • X-ray can be negative in the first 6 weeks

External hordeolum (stye). A hordeolum is an acute inflammatory disorder of the eyelash follicle or tear gland and presents as an erythematous, tender nodule at the lid margin. It is often due to infection with Staphylococcus aureus but can be sterile in many cases. A similar process arising in the meibomian gland (internal hordeolum) presents as a tender nodule visible at the palpebral conjunctiva but is less common. Within a few days, a minute pustule may appear at the lid margin (pointing), which will then rupture with discharge of pus and relief of pain. Warm compresses are advised to accelerate the process. FoJiowing resolution of infection, some patients have a residual granulomatous nodule (chalazion) that regresses slowly over several months. For patients with a persistent hordeolum (eg, >1 -2 weeks) or a large chalazion, additional management options include incision and curettage.

Causes of heart failure with preserved left ventricular function:(or diastolic dysfunction), 1- Diastolic heart failure • Hypertension with left ventricular hypertrophy • Restrictive cardiomyopathy • Infiltrative cardiomyopathy (eg, sarcoidosis) • Hypertrophic cardiomyopathy • Occult coronary artery disease 2-Valvular heart disease • Aortic stenosis or regurgitation • Mitral stenosis or regurgitation 3-Pericardial disease • Constrictive pericarditis • Cardiac tamponade 4-Systemic disorders (high-output cardiac conditions) • Thyrotoxicosis • Severe anemia Diagnostic features of acute bacterial rhinosinusitis • Persistent symptoms >= 10 days without improvement OR • Severe symptoms, fever >= 39 C (1 02 F), purulent nasal discharge, or face pain >= 3 days OR • Worsening symptoms > 5 days after initially improving viral upper respiratory infection Treatment: Oral amoxicillin-clavulanic acid is the treatment of choice for coverage of the most common organisms, Streptococcus pneumoniae and nontypeable Haemophilus influenzae, Intranasal corticosteroids may be a helpful adjunctive therapy in patients with a history of allergic rhinitis. However, oral antihistamines are not recommended for treatment of ABRS.

For patients with acute prostatitis who can take oral medications, we suggest trimethoprim-sulfamethoxazole (one double-strength tab orally every 12 hours) or a fluoroquinolone (ciprofloxacin 500 mg orally every 12 hours or levofloxacin 500 mg orally once daily) as empiric therapy. We typically choose one of these antimicrobial agents because they achieve high levels in prostatic tissue.Some patients with acute bacterial prostatitis may need to be hospitalized for parenteral antibiotic therapy if they cannot tolerate oral medication, demonstrate signs of severe sepsis, or have bacteremia. In such cases, intravenous levofloxacin or ciprofloxacin may be given with or without an aminoglycoside (gentamicin or tobramycin 5 mg/kg daily, if the creatinine clearance is normal). **Rheumatoid arthritis: give Methotrexate, if Persistent symptoms for >6 months then 1- do Parallel therapy Add another non biologic agent (eg, sulfasalazine, hydroxychloroquine) if no response after parallel or you can even reconsider it before starting parallel do Step-up therapy: Add biologic agent (eg, TNF inhibitor), if after step-up therapy not adequated response then Switch to alternate TNF inhibitor & continue methotrexate DMARDs include nonbiologic agents (eg. methotrexate. hydroxychloroquine. sulfasalazine. leflunomide. azathioprine) and biologic agents (eg, etanercept. infliximab, adalimumab, tocilizumab, rituximab). Methotrexate is the preferred initial DMARD in patients with moderately to severely active RA due to its efficacy and long-term safety profile. Patients should be tested for hepatitis B and C and tuberculosis before starting therapy. Methotrexate should not be used in patients who are pregnant or are planning to become pregnant in the near future and those with severe renal insufficiency, liver disease, or excessive alcohol intake.

DICROTIC PULSE — A dicrotic pulse results from the accentuated diastolic dicrotic wave that follows the dicrotic notch. It tends to occur when the dicrotic notch is low, as in patients with decreased systemic arterial pressure and vascular resistance (eg, fever). A dicrotic pulse also may be present in patients with severe heart failure, hypovolemic shock, cardiac tamponade, conditions associated with a decreased stroke volume and elevated systemic vascular resistance, and during the immediate postoperative period following aortic valve replacement

Grade 2 hypertensive retinopathy is considered mild for. Always assess organ damage before proceeding to evaluating the cause of hypertension such as creatine measurement. Urinary sodium to creatine ratio can be used for evaluating the damage caused by hypertension, but always screening for end organ damage is the high priority.

Relative risk (RR) is used as a measure of association in cohort studies. It is the ratio of the risk in the exposed group to that in the unexposed group. A RR >1 means that there is a positive association between the risk factor and the outcome. A RR <1 means that there is a negative association between the risk factor and the outcome. The farther the value of RR from 1, the stronger the association. In the example, the RR for bronchogenic cancer in smokers is >2, thereby indicating a strong association between smoking (risk factor/exposure) and bronchogenic cancer (outcome). When exposure is measured on a continuous scale (eg, number of packs per day [PPD)), the classification in 2 or more ordinal categories enables the risk to be assessed as a function of exposure, and the dose-response effect can be calculated for the exposure and outcome.

Guns are the most commonly used weapon in youth homicide in the United States, making access to firearms an important issue to address in any violence risk assessment. Homicides are most often committed by males, usually against friends or acquaintances. The majority of homicides occur one-on-one, with mass shootings being far less common. Homicide risk factors • Young male • Unemployed • Impoverished • Access to firearms • Substance abuse • Antisocial personality disorder • History of violence or criminality • History of childhood abuse • Impulsivity

Patients with cirrtlosis and portal hypertension frequently have abdominal ascites and peripheral edema due to low albumin levels and abnormal extracellular fluid volume regulation. A small number of these patients may also d evelop hepatic hydrothorax, a pleural effusion not due to underlying cardiac or pulmonary abnormalities. Hepatic hydrothorax generally results in transudative pleural effusions and is thought to occur due to small defects In the diaphragm. These defects permit peritoneal fluid to pass into the pleural space, which occurs much more commonly on the right side due to the less muscular hemidlaphragm. Patients have dyspnea, cough, pleuritic chest pain, and hypoxemia. Diagnosis Involves documentation of the effusion (eg, chest x-ray) and testing to exclude other causes (eg, thoracentesis, echocardiogram). Treatment involves salt restriction and diuretic administration. Therapeutic thoracentesis could be attempted In patients with prominent symptoms. Chest tube placement should be avoided as It can result In large-volume protein, fluid, and electrolyte losses as well as other severe complications (eg, renal failure). The definitive option for treatment Is liver transplantation, although this may not be appropriate for all patients depending on other factors. DDX: Hepatopulmonary syndrome results from intrapulmonary vascular dilations In the setting of chronic liver disease. Patients frequently have evidence of platypnea (increased dyspnea while upright) or orthodeoxia (oxygen desaturation while upright). *vesicovaginal fistula: Risk factors • Pelvic surgery • Pelvic irradiation • Prolonged labor/childbirth trauma • Genitourinary malignancy Fistulas may result from occult bladder injury during pelvic surgery or from tissue ischemia due to excessive surgical dissection. Urinary Incontinence (eg, persistent uncontrolled leakage) into the vagina may present within a month after surgery. The diagnosis is made clinically by visualization of urine leaking into the vagina. Sometimes a small area of granulation tissue or a hole may be seen. Dye tests and/or cystourethroscopy may be performed to identify a small fistula that is difficult to detect on visual inspection. Cystitis may be a complication, and urinalysis may Indicate infection (positive leukocyte esterase/nitrites, bacteriuria, pyuria).

Hepatopulmonary syndrome results from intrapulmonary vascular dilations In the setting of chronic liver disease. Patients frequently have evidence of platypnea (increased dyspnea while upright) or orthodeoxia (oxygen desaturation while upright). Management of hypercalcemia: 1-Severe (calcium >14 mg/dl) or symptomatic Short-term (immediate) treatment • Normal saline hydration plus calcitonin • Avoid loop diuretics unless volume overload (heart failure) exists Long-term treatment 2-Moderate (calcium 12-14 mg/dl) • Bisphosphonate (zoledronic acid) • Usually no immediate treatment required unless symptomatic • Treatment is similar to that for severe hypercalcemia 3-Asymptomatic or mild (calcium<12mg /dl) • No immediate treatment required • Avoid thiazide diuretics, lithium, volume (calcium <12 mg/dl) depletion & prolonged bed rest Hemodialysis is an effective treatment for hypercalcemia, but is typically reserved for patients with renal insufficiency or heart failure in whom aggressive hydration cannot be administered safely. This patient likely has confusion due to hypercalcemia not uremia.

In most patients with nonbleeding varices, prophylactic treatment with nonselective beta blockers (eg, propranolol. nadolol) is recommended to reduce the likelihood of progression to large varices as well as the risk of variceal hemorrhage. Endoscopic variceal ligation can be used as an alternate primary preventive therapy in patients with contraindications to beta blocker therapy.

High-output heart failure can occur in patients with severe anemia, hyperthyroidism, beriberi, Paget disease, and arteriovenous fistulas.

Osteolytic malignancies (eg, breast cancer, multiple myeloma) cause hypercalcemia due to stimulation of osteoclasts by local production of cytokines. This is significantly less common than HHM, and serum phosphorus levels are usually normal. In addition, most patients have significant associated bone pain. Primary hyperparathyroidism causes gradual-onset, mild-to-moderate· hypercalcemia (usually <14 mg/dl ). Symptoms (eg, renal stones, osteoporosis, constipation), if present, are typically chronic and nonspecific.

Humoral hypercalcemia of malignancy (HHM): • Squamous cell cancers (eg, lung, head, neck, PTHrP production esophagus) • Renal & bladder cancer • Ovarian & endometrial • Breast cancer hematocolpos due to imperforated hymen: An Imperforate hymen can result in an apparent amenorrhea due to vaginal obstruction. It can be distinguished from Mullerian agenesis by cyclic abdominal pain, the presence of a uterus, and the visualization of an imperforate hymen and hematocolpos. It can even happen in people with sexual activity!!

*** In aortic dissection: A new diastolic murmur in association with severe acute chest pain is a sign of acute aortic regurgitation. Characteristically, it is a diastolic decrescendo murmur associated with a wide pulse pressure, hypotension, and/or heart failure. Acute aortic valve regurgitation occurs in one-half to two-thirds of ascending dissections. The murmur of aortic regurgitation related to aortic dissection is most commonly heard along the right sternal border, as compared with the left sternal border for aortic regurgitation due to primary aortic valve disease. The duration of the diastolic murmur may be quite short due to rapid ventricular filling and early equilibration of aortic and left ventricular diastolic pressures. Beside mediastinum widing as a dominant CXR findings, radiographic evidence of a pleural effusion was found in 19 percent of dissections; this finding is more common in women than in men (26 versus 15 percent). Besides hypertension, hypotension may be present in 25 percent of dissections that involve the ascending aorta, potentially as a result of aortic valve disruption leading to severe aortic regurgitation and/or extravasation into the pericardial space leading to cardiac tamponade

Hypovolumic shock: Loss of intravascular volume leads to a decrease in venous return to the right atrium (decreased preload) and a consequent decrease in cardiac output and systemic blood pressure. In an effort to maintain adequate cardiac output and organ perfusion, the sympathetic nervous system is activated, resulting in peripheral vasoconstriction (increase in systemic vascular resistance) and an increase in heart rate. The left ventricle, decreased in size due to low filling volume, also compensates by increasing ejection fraction. These responses create the typical clinical presentation of hypovolemic shock, which includes hypotension, tachycardia, cold extremities, evidence of poor organ perfusion (eg, somnolence, unresponsiveness), and physical examination evidence of hypovolemia (eg, flat neck veins).

Hypecalcemia: 1-Mild hypercalcemia — Patients with asymptomatic or mildly symptomatic hypercalcemia (calcium <12 mg/dL [3 mmol/L]) do not require immediate treatment. However, they should be advised to avoid factors that can aggravate hypercalcemia, including thiazide diuretics and lithium carbonate therapy, volume depletion, prolonged bed rest or inactivity, and a high calcium diet (>1000 mg/day). 2-Moderate hypercalcemia — Asymptomatic or mildly symptomatic individuals with chronic moderate hypercalcemia (calcium between 12 and 14 mg/dL [3 to 3.5 mmol/L]) may not require immediate therapy. However, they should follow the same precautions described above for mild hypercalcemia. It is important to note that an acute rise to these concentrations may cause marked changes in sensorium, which requires more aggressive therapy. 3-Severe hypercalcemia — Patients with calcium >14 mg/dL (3.5 mmol/L) require more aggressive therapy. The acute therapy of such patients consists of a three-pronged approach: Treatment:Volume expansion with isotonic saline (0.9%) at an initial rate of 200 to 300 mL/hour that is then adjusted to maintain the urine output at 100 to 150 mL/hour. Administration of salmon calcitonin (4 international units/kg) and repeat measurement of serum calcium in several hours. If a hypocalcemic response is noted, then the patient is calcitonin-sensitive and the calcitonin can be repeated every 6 to 12 hours (4 to 8 international units/kg).

In alpha 1 anttitrypsin deficiency : Chest radiograph shows marked hyperexpansion with paucity of vascular strucures at the bases and redistribution of vascular flow to the lesser involved upper lobes. These findings are typical of severe panacinar emphysema. basilar predominant emphysematous bullae or hyperlucency at the base. ** Patients with Felty's syndrome (FS) comprise an infrequently occurring but severe subset of seropositive rheumatoid arthritis (RA) complicated by neutropenia and splenomegaly. Autoantibodies to deiminated histones (predominantly histone H3) and other components of neutrophil extracellular chromatin traps (NETs) that bind to activated neutrophils, which are then sequestered in the spleen

Inverse psoriasis — "Inverse psoriasis" refers to a presentation involving the intertriginous areas, including the inguinal, perineal, genital, intergluteal, axillary, or inframammary regions . This presentation is called "inverse" since it is the reverse of the typical presentation on extensor surfaces. This variant can easily be misdiagnosed as a fungal or bacterial infection since there is frequently no visible scaling.

In cases of slowly developing severe hypernatremia, it is best to use 5% dextrose and in 0.45% sodium chloride solution to adequately hydrate the patient. Ringer's lactate has a composition and osmolarity similar to that of plasma. It is usually used in treatment of hypovolemic shock or isotonic fluid loss when patient has normal ion level. Normal saline (0.9%) should not be used for correction of hypernatremia.

An oral glucose tolerance test is the gold standard for diagnosing type 2 diabetes mellitus in patients with PCOS as it is more sensitive in detecting glucose intolerance than standard screening tests (eg, fasting glucose, HbA1c). Due to obesity and metabolic syndrome, patients are at risk for developing obstructive sleep apnea, nonalcoholic fatty liver disease, and endometrial cancer.

In hypovolemic shock the cardiac index decreases. In septic shock the RA pressure (preload) and PCWP (preload) can be normal or decreased and mixed venous o2 increased (decreased in cardiogenic shock and hypovolemic shock).

Nueropathic arthropathy or Charcot joint: Diabetes is the foremost cause in America today for neuropathic joint disease, and the foot is the most affected region. In those with foot deformity, approximately 60% are in the tarsometatarsal joints (medial joints affected more than lateral), 30% Metatarsophalangeal joints and 10% have ankle disease. Other causes include: Alcoholic neuropathy Cerebral palsy Leprosy Syphilis (tabes dorsalis), caused by the organism Treponema pallidum Spinal cord injury **Classic FAP — In individuals at risk for classic FAP, we begin CRC screening around age 10 to 12 years. We begin with flexible sigmoidoscopy in children but perform a full colonoscopy after age 50 or if colorectal adenomas are detected. The number, size, and distribution of polyps should be noted during the colonoscopy and several polyps should be biopsied to evaluate the extent of the polyposis and for planning of colectomy. Patients should continue to undergo annual CRC surveillance with colonoscopy while awaiting colectomy. FAP screening:Yearly (start from age 10-12) flexible sigmoidoscopy to look for signs of FAP; counseling to consider genetic testing if it hasn't been done For HNPCC or Lynch: Age 20 to 25 years, or 10 years before the youngest case in the immediate family; Colonoscopy every 1 to 2 years with biopsies for dysplasia

Indications for colectomy — Indications for colectomy in patients with FAP include: **If genetic test is positive, removal of colon (colectomy) should be considered. ●Documented or suspected colorectal cancer ●Adenoma with high-grade dysplasia ●Severe symptoms related to colonic neoplasia (eg, severe gastrointestinal bleeding) ●Marked increases in polyp number from one exam to the next ●Inability to adequately survey the colon because of multiple diminutive polyps Timing of colectomy — The presence of symptoms, number, and size of adenomas, and the presence of high-grade dysplasia and cancer, determine the optimal timing of colectomy. A patient with FAP and hundreds of adenomas In the colon has a 100% risk of cancer, If he Is not treated appropriately with a proctocolectomy. Urgent colectomy should be performed in patients with: ●Documented or suspected colorectal cancer ●Adenoma with high-grade dysplasia Early (near the time of diagnosis) colectomy should be performed in patients with: ●Severe symptoms (eg, severe gastrointestinal bleeding) ●Multiple 6 to 10 mm polyps that cannot be cleared endoscopically ●Marked increase polyp number from one exam to the next Elective colectomy can be deferred to the late teens to early twenties in patients with classic FAP who are in the second decade of life with only sparse (<10), small (<5 mm) adenomas.

Asterixis: Bilateral, non-rhythmic, alternate flexion and extension movements at the wrist (also called the "flap") are classically seen when the patient is asked to extend his arms and hands and spread the fingers. This occurs likely as a result of interruption of the neural pathways that sustain muscle contraction. **Asterixis is seen in hepatic encephalopathy, uremic encephalopathy, and co2 retention. *The diagnosis of uremia is based on clinical symptoms/signs and not on an absolute BUN level. Typically symptoms appear at BUN level >100 mg/dL. Uremic encephalopathy is an indication for urgent hemodialysis. The presentation of aromatase deficiency of new born is that a new born with 46 XX karyotype, ambiguous genitalia and clitoromegaly, her mother has facial hair growth and voice deepning when pregnant. Increased 5-alpha reductase activity. DDX: In idiopathic hirsutism, the results from testing androgen levels are often normal. In some of these women, hirsutism is thought to be caused by increased skin sensitivity to androgen or by increased skin 5-alpha-reductase activity.

Indications for urgent dialysis (AEIOU): 1- Acidosis: • Metabolic acidosis - o pH <7 .1 refractory to medical therapy 2-E1ectrolyte abnormalities • Symptomatic hyperkalemia o ECG changes or ventricular arrhythmias • Severe hyperkalemia o K >6.5 mEq/L refractory to medical therapy 3-Ingestion • Toxic alcohols (methanol, ethylene glycol) • Salicylate • Lithium • Sodium valproate, carbamazepine 4- Qverload: Volume overload refractory to diuretics 5- Uremia • Symptomatic: o Encephalopathy o Pericarditis o Bleeding

Raised JVP, absent pulsation Superior vena cava syndrome Large 'a' wave (increased atrial contraction pressure) tricuspid stenosis Right heart failure Pulmonary hypertension Cannon 'a' wave (atria contracting against closed tricuspid valve) Atrial flutter Premature atrial rhythm (or tachycardia) third degree heart block Ventricular ectopics Ventricular tachycardia Absent 'a' wave (no unifocal atrial depolarisation) atrial fibrillation Large 'v' wave (c-v wave) Tricuspid regurgitation Absent 'x' descent Tricuspid regurgitation (sometimes 'x' wave is replaced by a positive wave) Prominent 'x' descent Constrictive pericarditis Slow 'y' descent Tricuspid stenosis Cardiac tamponade Prominent & Deep 'y' descent Constrictive pericarditis Parodoxical JVP (Kussmaul's sign: JVP rises with inspiration, drops with expiration) Pericardial effusion Constrictive pericarditis Pericardial tamponade

Inflammatory osteoarthritis is generally treated with nonsteroidal anti-inflammatory drugs and, very rarely, corticosteroid injections directly into the affected joints. The disease-modifying antirheumatic drugs, such as methotrexate and leflunomide (Arava) prescribed for RA are not appropriate for this type of arthritis. inflammatory osteoarthritis of the hand, which is an aggressive subtype of primary osteoarthritis frequently misdiagnosed as rheumatoid arthritis or psoriatic arthritis. **IF guaiac-based fecal occult blood test (gFOBT) is positive then do colonoscopy. **TCA toxicity causes prolongation of QT, PR and QRS copmplex. In **A tugging or pulling sensation is normal 2 to 3 days after delivery. After cesarean, tenderness and bulging can be sensed around incision and it is due to hematoma and seroma that are collections of blood and serum. **Klebsiella pneumonia is a Gram-negative, nonmotile, encapsulated, lactose-fermenting, facultative anaerobic, rod-shaped bacterium. Bulging interlobar fissure sign in CXR is s hallmark. Klebsiella can cause liver abscess, endophthalmitis and meningitis.

Anti centromere: The diagnosis of SSc is based primarily on clinical manifestations and serologic markers. Antinuclear antibodies are present in almost all patients but are nonspecific. Anti-topoisomerase I (anti-Scl-70) and anti-RNA polymerase Ill are less sensitive but more specific and are associated with extensive disease. Anticentromere antibodies may also be seen, primarily in patients with limited disease. Hepatorenal syndrome (HRS) Is one of the most dangerous complications of end-stage liver disease, occurring In up to 10% of patients with cirrhosis. HRS is characterized by decreased glomerular filtration In the absence of shock, proteinuria, or other clear cause of renal dysfunction, and a failure to respond to a 1.5 L normal saline bolus. It Is thought to result from renal vasoconstriction In response to decreased total renal blood flow and vasodilatory substance synthesis. There are 2 subtypes of HRS. Type 1 Is rapidly progressive: most patients die within 10 weeks without treatment. Type 2 progresses more slowly, with an average survival of 3-6 months. The most common causes of death are infection and hemorrhage. Unfortunately, no medication has consistently proven beneficial in HRS and the mortality for these patients placed on dialysis is very high. Liver transplantation is the only Intervention with established benefit.

Kleptomania: 1- Clinical features • Rare impulse control disorder with typical onset in adolescence • Repetitive failure to resist impulses to steal • Stolen objects have little value • Increasing tension prior to theft; pleasure or relief when committing theft • Stolen objects given away, discarded, or returned; guilt & remorse are common 2- Differential diagnosis • Shoplifting: Theft for personal gain; much more common • Antisocial personality disorder: General pattern of antisocial behavior • Bipolar disorder, manic episode: Impulsivity, impaired judgment • Psychotic disorders: Stealing in response to delusions, hallucinations Kleptomania can be treated with psychotherapy as well as medications. Psychotherapy involves a cognitive behavioral therapy orientation, focusing on techniques to resist and manage urges and anxiety. Medications that have been used include selective serotonin reuptake inhibitors, opioid antagonists, lithium, and anticonvulsants.

Tricuspid valve atresia (TVA) should be suspected in a cyanotic infant with left axis deviation and small or absent R waves in the precordial leads. The lack of communication between the right heart chambers results in a hypoplastic right ventricle and diminished right ventricular forces on ECG. The lack of blood flow to the right ventricle and pulmonary outflow tract consequently results in underdevelopment of the pulmonary valve and/or artery. Pulmonary undercirculation is the reason for decreased pulmonary markings on chest x-ray. Associated atrial and ventricular septal defects are necessary for survival, allowing for mixing of oxygenated and deoxygenated blood to provide some oxygenated blood for the systemic circulation. The atrial septal defect permits Increased blood flow to the right atrium and subsequent enlargement, resulting in tall, peaked P waves on ECG. The ventricular septal defect manifests as a holosystollc murmur that is loudest at the left lower sternal border. The cause of TVA is unknown, but it can occur in any patient with congenital heart disease risk factors (eg, congenital rubella syndrome, Down syndrome, maternal diabetes, family history of congenital heart disease). In the absence of surgical intervention, most children will die in the first year of life. Surgical repair improves 10-year survival rates to 80%.

LEAD I LEAD AVF QUADRANT AXIS Positive Positive Left lower quadrant Normal (0 to +90 degrees) LEAD I LEAD AVF Positive Negative Left upper quadrant Possible LAD (0 to -90 degrees) LEAD I LEAD AVF Negative Positive Right lower quadrant RAD (+90 to 180 degrees) LEAD I LEAD AVF Negative Negative Right upper quadrant Extreme Axis Deviation (-90 to 180 degrees Ebstein's anomaly is associated with maternal lithium use during pregnancy. The primary problem is displacement of a malformed tricuspid valve into the right ventricle. The droopy tricuspid valve results in severe tricuspid regurgitation and right atrial enlargement, resulting in tall P waves and right axis deviation on ECG. Extreme cardiomegaly from heart failure can be seen on chest x-ray.

Acute liver failure (ALF) Is a serious condition characterized by severe acute liver injury in a patient without cirrhosis or underlying liver disease. The diagnosis requires: • Severe acute liver injury as evidenced by elevated aminotransferases (often >1000 U/L) • Signs of hepatic encephalopathy (HE) . Impaired hepatic synthetic function (defined as INR >=1.5) Elbow fractures account for over half of all fractures in children, and the most common type is a supracondylar humerus fracture. These injuries occur most commonly in children ages 2-12 years old. The typical history usually consists of a fall onto an outstretched arm with the elbow extended. Radiographs often show a large or triangular anterior fat pad and the presence of a posterior fat pad sign. Due to its location, supracondylar humerus fractures may be complicated by neurovascular injury or compartment syndrome.

Large anterior mediastinal mass with elevated levels of beta-human chorionic gonadotropin beta hCG) and alpha fetoprotein (AFP), consistent with a nonseminomatous germ cell tumor. Primary mediastinal germ cell tumors occur predominantly in young male patients and are locally invasive. beta hCG is typically elevated in both seminomatous and nonseminomatous germ cell tumors, but nonseminomatous germ cell tumors typically also produce AFP, which is not produced by seminomas. A large mediastinal mass with associated elevations of AFP and beta hCG is virtually diagnostic of a nonseminomatous germ cell tumor. The diagnosis can be confirmed with biopsy. Testicular ultrasound should be performed to exclude a small primary tumor as management and prognosis differ between primary mediastinal and metastatic germ cell tumors. Almost all germ cell tumors in the anterior mediastinum are primary rather than metastatic.

Gastric bezoars: 1- Affected patients remain asymptomatic for many years, and symptom onset is insidious. The most common symptoms include abdominal pain, nausea, vomiting, early satiety, anorexia, and weight loss. 2-Gastrointestinal bleeding due to concurrent gastric ulcers is a common presentation in patients who have previously undergone surgery. The ulcers may be due to peptic ulcer disease or pressure necrosis. Although many bezoars become quite large, gastric outlet obstruction is an uncommon presentation. 3-Physical examination is unremarkable in most patients with a gastric bezoar except for an occasional abdominal mass or halitosis. Patients with trichobezoars may have patchy areas of alopecia.

Lipid normal and screening: Total Cholesterol Level: Desirable: Less than 200mg/dL LDL: Desirable: Less than 100mg/dL HDL:More than 60 mg/dl We begin screening lower-risk patients at a later age: ●In male patients at lower risk, we initiate lipid screening at age 35 ●In female patients at lower risk, we initiate lipid screening at age 45 We suggest assessing CVD risk and repeating measurements every five years.

Clinical clues to renovascular disease: HTN-related symptoms • Resistant HTN (uncontrolled despite 3-drug regimen) • Malignant HTN (with end-organ damage) • Onset of severe HTN (>180/120 mm Hg) after age 55 • Severe HTN with diffuse atherosclerosis • Recurrent flash pulmonary edema with severe HTN Supportive evidence: A:Physical examination • Asymmetric renal size (>1.5 cm) • Abdominal bruit B:Laboratory results • Unexplained rise in serum creatinine (>30%) after starting ACE inhibitors or ARBs C:Imaging results • Unexplained atrophic kidney Renal artery stenosis (RAS) is present in - 1% of patients with mild hypertension and in 25%-35% of patients with peripheral arterial disease. A systolic- diastolic abdominal bruit can be heard in -40% of patients; this finding has very high specificity for RAS. The diagnosis is confirmed by noninvasive assessment with renal duplex Doppler ultrasonography, CT angiography, or magnetic resonance angiography.

Lipomas are benign, painless subcutaneous masses with normal overlying epidermis. In contrast to epidermal cysts, lipomas are usually soft to rubbery and irregular, and do not typically regress and recur. Dermatofibroma is a benign fibroblast proliferation that typically appears as a firm, hyperpigmented nodule, most often on the lower extremities. Dermatofibromas have a fibrous component that causes dimpling in the center when the area is pinched ("dimple" or "buttonhole" sign). An epidermal inclusion cyst (EIC) occurs when the epidermis becomes lodged in the dermis due to trauma or comedones, or it can arise de novo. EICs can be seen anywhere on the body, but are most common on the face, neck, scalp, or trunk. The lesion can gradually increase in size and may intermittently produce a cheesy white discharge. Some patients may develop significant inflammation with rupture and involvement of surrounding tissue. An EIC will usually resolve spontaneously but can recur. Diagnosis is made clinically with examination showing a dome-shaped, firm, and freely movable cyst or nodule with a central punctum (small, dilated, pore-like opening). Excision is typically performed only for cosmetic reasons. Incision and drainage are occasionally needed for infected and fluctuant cysts that are painful and erythematous.

CLINICAL PRESENTATION of prolactinoma: Can present as Galactorrhea. 1- In most laboratories, a serum prolactin concentration above 15 to 20 ng/mL (15 to 20 mcg/L SI units) is considered abnormally high in women of reproductive age. 2- A serum prolactin concentration greater than 100 ng/mL (100 mcg/L SI units) is typically associated with overt hypogonadism, subnormal estradiol secretion and its consequences, including amenorrhea, hot flashes, and vaginal dryness. 3-Women with amenorrhea secondary to hyperprolactinemia have a lower spine and forearm bone mineral density compared with normal women or women with hyperprolactinemia and normal menses 4-The diagnosis of hyperprolactinemia is made by a serum prolactin concentration that is well above the normal range (>20 ng/mL [20 mcg/L]). If an initial serum prolactin concentration is only slightly elevated (21 to 40 ng/mL to 40 mcg/L SI units]), the test should be repeated before the patient is considered to have hyperprolactinemia. 5-Initial therapy (dopamine agonists): Cabergoline is the best initial choice in most circumstances because it is most likely to be effective and least likely to cause side effects. 6-For a woman who wishes to become pregnant, bromocriptine might be a better first choice because there is more evidence that bromocriptine does not cause birth defects

Maintenance fluid therapy always divided equally over the 24 hours. To prevent cerebral edema hypernatremic dehydration corrected over 48 hours. The free water deficit represents the extra free water that was lost to account for the increase in serum sodium. In addition to 24 hours maintenance, the entire solute deficit (the remainder of the deficit that contains electrolytes after the free water deficit has been subtracted) and one-half of the free water deficits are administrated over the 24 hours. During the next 24 hours, the maintenance is then administrated with the other half of the free water deficit. ** Many patients with osteosarcoma, particularly children, have a genetic predisposition. The majority of mutations were in the RB1 (the gene associated with hereditary retinoblastoma) and TP53 (the gene associated with Li-Fraumeni syndrome) genes. Paget is also a risk factor for osteosarcoma. The most important finding on physical examination is a soft tissue mass, which is frequently large and tender to palpation. Osteosarcomas have a predilection for the metaphyseal region of the long bones. The most common sites of involvement, in descending order, are: distal femur, proximal tibia, proximal humerus, middle and proximal femur, and other bones. On Xray: The destruction of the normal trabecular bone pattern, indistinct margins, and no endosteal bone response. The affected bone is characterized by a mixture of radiodense and radiolucent areas, destruction of the cortex, and periosteal new bone formation, with the formation of Codman's triangle (an incomplete response of host periosteal bone).

Clinical features of acute bronchitis: 1-Etiology • Preceding respiratory illness (90% viral) 2-Clinical presentation • Cough o >5 days to 3 weeks o Can be productive (yellow, green, or purulent sputum) • Absent systemic findings (eg, fever, chills) • Wheezing or rhonchi, chest wall tenderness • Diagnosis is clinical 3-Diagnosis & treatment o Chest x-ray only in patients with suspected pneumonia • Symptomatic treatment o NSAIDs/acetaminophen &/or bronchodilators • Antibiotics not recommended

Membrane rupture prior to the onset of labor is premature rupture of membranes (PROM), and PROM at <37 weeks gestation is preterm PROM (PPROM). The diagnosis of membrane rupture can be confirmed with the nitrazine or fern tests or with a speculum examination showing vaginal pooling of clear fluid or fluid emerging from the cervix. PPROM risk factors are similar to those for preterm delivery (eg, history of prior preterm delivery, multiple gestation) but also include a history of prior PPROM, genital tract infection (eg, bacterial vaginosis), and tobacco use. Complications of PPROM include chorioamnionitis/endometritis. cord prolapse, and abruptio placentae.

Change in milk composition of breastmilk (total and onprotein nitrogen alpha-lactalbumin, lactoferrin, and albumin) have been observed in women taking various combination contraceptives. but still within normal range. .Progestin-only contraceptives are the preferred choice for breastfeeding mothers when something hormonal is desired or necessary. **In normal pressure hydrocephalus, lumbar puncture and surgical intervention can improve gait abnormalities. We have enlarged ventricles but normal pressure. **When females pubic hair has filled in, it will form a triangle. Once this happens, the onset of the menarche is imminent.

Moderate to severe allergic rhinitis is defined as one or more of the following items: 1-impairment of the school or work performance 2-Impairment of daily activities, leisure and/or sport activities 3-sleep disturbance 4-Troblesome symptoms The most effective treatment (even if the nasal congestion is not the worst symptom) for moderate to severe or refractory allergic rhinitis is with intranasal glucocorticoids. Loratadine (oral antihistamine) can be used but have not proven to be as effective in moderate to severe form. Intranasal cromolyn is also recommended in the guidelines, however, most practitioners avoid this drug if possible because of undesired side effects. It is important to remember that intranasal cromolyn is first-line therapy for children <3 years of age who have allergic rhinitis.

Paget of bone can manifest as bone deformity and joint warmth and tenderness. We have areas of increased bone turnover. Areas of spindle cells and dysplastic bone is fibrosarcoma which is a primary bone tumor. **Low complement levels suggest postinfectious GN, lupus nephritis, MPGN, or mixed cryoglobulinemia associated with hepatitis C. Mixed cryoglobulinemia is most commonly due to hepatitis C and presents with immune complex deposition in small blood vessels, leading to endothelial injury, inflammation, and end-organ damage. The immune complexes are lgM antibodies (similar to rheumatoid factor) that form complexes with lgG anti-hepatitis C virus antibodies, hepatitis C virus RNA, and complement. Patients can be asymptomatic or develop findings in the skin (eg, palpable purpura, Raynaud's phenomenon), kidney (eg, MPGN), nervous system (eg, motor sensory axonopathy), and musculoskeletal system (eg, arthralgias). Diagnosis can be confirmed serologically (serum cryoglobulins, low complement levels) or with kidney/skin biopsy. We have abnormal live enzymes.

Moderate to severe glomerulonephritis: Nephritic urine sediment, • MPGN, vasculitis (eg, Moderate to decreased GFR & variable proteinuria (can be nephrotic range) • Postinfectious, lupus nephritis • MPGN, vasculitis (eg, cryoglobulinemia) • Rapidly progressive glomerulonephritis Thrombotic thrombocytopenic purpura is due to decreased ADAMTS13 activity. Patients can develop fever, microangiopathic hemolytic anemia, thrombocytopenia with possible purpura, renal failure, and neurologic findings (eg, headache, confusion). No change in complements. Episcleritis is a common cause of red eye and is distinguished by its localized or patchy distribution and generally mild associated pain and discharge. It may occur in association with rheumatoid arthritis and other autoimmune disorders, but many cases are idiopathic. Episcleritis is usually self-limited and does not affect vision or involve the cornea. Anterior uveitis (iritis) is inflammation of the anterior uveal tract, especially the iris. Patients often have associated conjunctival inflammation adjacent to the cornea, but the cornea itself is usually spared.

** in Iron deficiency anemia (e.g chronic bleeding) the reticulocyte count and MCV are low. Parapneumonic effusions: pleural effusions that occur in the pleural space adjacent to a bacterial pneumonia. 1. Uncomplicated： exudate interstitial fluid visceral membrane, antibiotics alone 2. Complicated: bacterial invasion of the pleural space→↑neutrophil, acidosis, lysis of neutrophils increases the LDH(>1000 IU/L)，In general, a pH <7.20 or a glucose <60 mg/dL is an indication for drainage of the effusion since such effusions are unlikely to resolve spontaneously. 3. Thoracic empyema: Gram stain and/or the aspiration of pus on thoracentesis

Most common cause of ATN: Muddy brown cast Aminoglycosides: Amikacin belongs to a class of drugs known as aminoglycoside antibiotics, Gentamicin, Streptomycin, Netilmicin Amphotericin B Cisplatin and other chemotherapy drugs Radiocontrast NSAIDs (especially when concurrent with poor renal perfusion or other nephrotoxic agents) Colistimethate Calcineurin inhibitors (eg, cyclosporine, tacrolimus, used systemically)

**Most common risk factor for preterm labor are prior preterm birth, short transvaginal cervical length, PROM, multiple gestation, uterine anomaly. Placental abruption beside bleeding and back pain we have: • High-frequency, low-intensity contractions • Hypertonic, tender uterus Risk factors: • Maternal hypertension or preeclampsia/eclampsia • Abdominal trauma • Prior placental abruption • Cocaine & tobacco use

Nausea and vomiting of pregnancy/hyperemesis gravidarum are clinical diagnoses without uniform criteria. The mean onset of symptoms is at five to six weeks of gestation, peaking at about nine weeks, and usually abating by 16 to 20 weeks of gestation(first trimester) Women who are dehydrated or have electrolyte abnormalities or acid-base disturbances (e.g high ketones) should receive intravenous fluids. Women should try to become aware of, and avoid, environmental triggers and foods which might provoke their nausea and vomiting. Where available, we suggest pyridoxine-doxylamine succinate combination therapy for initial pharmacologic treatment of nausea of pregnancy. The combination of 10mg of doxylamine succinate and 10mg of pyridoxine hydrochloride is a medication used to treat nausea and vomiting of pregnancy (NVP), also called "morning sickness."

Bacterial meningitis: 1- Age 2-50 :S pneumonia, N meningitides, Vancomycin + a third generation cephalosporin 2-Age >50 : S pneumonia, N meningitides, Listeria Vancomycin + ampicillin + a third-generation cephalosporin 3-Immunocompromised : S pneumonia, N meningitides, Listeria, gram-negative rods Vancomycin + ampicillin + cefepime 4-Neurosurgery/penetrating skull trauma Gram-negative rods, MRSA, coagulase negative staphylococci Vancomycin + cefepime • Third-generation cephalosporins: ceftriaxone or cefotaxime • Alternatives to cefepime: ceftazidime or meropenern • Alternative to ampicillin: trimethoprim-sulfamethoxazole for Listeria Corticosteroids should be started at the same time as antibiotics and discontinued if cultures show an organism other than Streptococcus pneomonia.

Nuetropenia associated sepsis: Start specific antibiotic therapy to combat infections. This often involves the use of fourth-generation cephalosporins or equivalents. Fever may be treated as an infection, as follows: 1- Cefepime, meropenem or ceftazidim, imipenem-cilastatin, or piperacillin-tazobactam can be used empirically as a single agent 2- Gentamicin or another aminoglycoside should be added if the neutropenic patient's condition is unstable or the individual appears septic 3- Vancomycin should be added if infection with methicillin-resistant Staphylococcus aureus or a Corynebacterium species is suspected

In liver disease we have: Hypokalemia may result from excess urinary potassium loss due to increased circulating aldosterone, renal retention of ammonium ion in exchange for K, secondary renal tubular acidosis, or diuretic therapy. Management consists of giving oral potassium chloride supplements and withholding K-wasting diuretics. Hyponatremia is common even though the kidneys may avidly retain sodium. it usually occurs with advanced hepatocellular disease and is difficult to correct. Relative water overload is more often responsible than total body sodium depletion; potassium depletion may also contribute. Water restriction and potassium supplements may help; diuretics that increase free water clearance can be used in severe or refractory cases In patients with hepatorenal syndrome who are critically ill, we suggest initial treatment with norepinephrine in combination with albumin. In patients with hepatorenal syndrome who are not critically ill, our suggestions depend upon the availability of certain drugs: •Where terlipressin therapy is available, we suggest initial treatment with terlipressin in combination with albumin. Where terlipressin therapy is not available (principally the United States), we suggest initial treatment with a combination of midodrine, octreotide, and albumin.

One of the earliest findings in macular degeneration is distortion of straight lines such that they appear wavy. The grid test described above is frequently used to screen for patients with macular degeneration. The primary risk factor for macular degeneration is increasing age, although smoking can increase the risk as well. Patients may be asymptomatic, but others complain of visual problems in either one or both eyes. Driving and reading are often some of the first activities that are affected since they require fine visual acuity, which is provided primarily by the macula.Metamorphopsia is a type of distorted vision in which a grid of straight lines appears wavy and parts of the grid may appear blank. People with this condition often first notice this when looking at mini-blinds in their home. It is mainly associated with macular degeneration, particularly age-related macular degeneration with choroidal neovascularization.

Hypernatremia should not be corrected at a rate greater than 1 mEq/L per hour. Carefully monitor all patients' inputs and outputs during treatment. Consider CNS imaging to exclude a central cause or to identify CNS bleeding from stretching of veins. Using isotonic sodium chloride solution, stabilize hypovolemic patients who have unstable vital signs before correcting free water deficits because hypotonic fluids quickly leave the intravascular space and do not help to correct hemodynamics. Once stabilization has occurred, free water deficits can be replaced either orally or intravenously. Euvolemic patients can be treated with hypotonic fluids, either orally or intravenously (ie, dextrose 5% in water solution [D5W], quarter or half isotonic sodium chloride solution), to correct free fluid deficits. Hypervolemic patients require removal of excess sodium, which can be accomplished by a combination of diuretics and D5W infusion. Patients with acute renal failure may require dialysis.

Oral glucocorticoids: Nearly all patients with significant asthma exacerbations requiring emergency department evaluation should receive a course of oral glucocorticoids for 5 to 10 days. A short course of oral glucocorticoids significantly reduces the likelihood of repeat severe exacerbation with emergency department bounce back ("relapse") within the succeeding two weeks. The most common mechanism of inflicted injury in infants involves violent shaking. Repetitive acceleration-deceleration forces cause shearing of the dural veins and coup-contrecoup injury with brain impact on the skull. Subdural bleeding can manifest as seizures, increasing head circumference, bulging/tense anterior fontanelle, and altered mental status. In addition, shaking causes vitreoretinal traction and retinal hemorrhages, a virtually pathognomonic finding for abusive head trauma. This infant's seizure, disproportionately large head circumference, and retinal hemorrhages are alarming for abusive head trauma.

of estrogen replacement therapy (ERT) Is commonly prescribed for menopausal symptoms (eg, hot flashes, vulvovaginal atrophy) and should be paired with progesterone for patients with an intact uterus. Unopposed estrogen stimulation causes uncontrolled proliferation of the endometrium and leads to endometrial hyperplasia and eventually endometrial adenocarcinoma. In a postmenopausal patient, evaluation of abnormal uterine bleeding can begin with either pelvic ultrasound or endometrial biopsy. In this patient, pelvic ultrasound should be performed first to confirm the presence of a uterus due to the unclear surgical history as well as to evaluate endometrial thickness and assess for any other pelvic pathology. If endometrial thickness Is >4 mm, endometrial biopsy must be performed to exclude malignancy. If endometrial pathology Is benign, the first-line treatment of PMB due to exogenous estrogen is discontinuation of unopposed ERT. If the patient wishes to continue hormone replacement therapy, progesterone must be added to prevent hyperplastic endometrial transformation. If endometrial biopsy Identifies malignancy, hysterectomy is Indicated. If after pelvic ultrasound the endometrial thickness Is <4 mm, then we should do observation. If after endometrial biopsy the result is benign then we should observe.

Ovarian epithelial tumours are classified according to the following histological subtypes: serous, mucinous, endometrioid, clear cell, Brenner, transitional cell, small cell, mixed mesodermal and undifferentiated. Usually each subtype can be classified as benign, borderline (low malignant potential, LMP), or malignant (invasive). Serous tumours are further subdivided into the following: Serous cystadenoma Borderline serous tumor Serous cystadenocarcinoma Adenofibroma Cystadenofibroma Mucinous tumors are further classified as: Mucinous cystadenoma Borderline mucinous tumor Mucinous cystadenocarcinoma Adenofibroma

Management of PPROM: 1- <34weeks A: Signs of infection or fetal compromise? No then • Antibiotics •Corticosteroids •Fetal surveillance B: Signs of infection or fetal compromise? Yes then • Antibiotics •Corticosteroids • Magnesium if <32 weeks • Delivery 2- 34-37 weeks • Antibiotics • +/- Corticosteroids • Delivery

P450 Inhibitors: SICKFACES.COM Group Sodium valproate Isoniazid Cimetidine Ketoconazole Fluconazole Alcohol (binge drinking)/ Acetaminophen (& NSAIDs)/ Amiodarone Chloramphenicol Erythromycin Sulfonamides Ciprofloxacin Omeprazole Metronidazole Grapefruit juice / Cranberry juice/ Vitamin E/ Ginkgo biloba + Thyroid hormones SSRI (Fluoxetine)

In Clinically significant atherosclerotic disease: • ACS, Ml • Stable or unstable angina • Coronary or other arterial revascularization stalin • Stroke, TIA, PAD If Age <=75: High-intensity statin • Age >75: Moderate-intensity statin **Targeted ultrasound is used with mammography to further characterize the mass (eg, solid versus cystic). In women <=30, ultrasound is preferred for a palpable abnormality, although mammography can be used for further characterization If an abnormality (eg, irregular borders, complex cyst, indistinct borders) Is seen on ultrasound.

Palpable breast mass: 1- Age >30 then do Mammogram +/-ultrasonogram, if Suspicious for malignancy then do Core biopsy 2-If Age <30 then Ultrasonogram +/- mammogram and A: Simple cyst then do Needle aspiration (if patient desires) B:Complex cyst/mass (solid mass) then Image-guided core biopsy **Cocaine and opiate intoxication both predispose to seizures, and cocaine (simultaneous use of cocaine and heroin (i.e., speedball) can also lead to rhabdomyolysis. The muscle breakdown can lead to significant myoglobinuria and eventual renal failure.

NPH is a clinical syndrome accompanied by increased ventricular size without persistent elevations in intracranial pressure. Symptoms result from dis.tortion of the periventricular brain matter. Affected patients typically have a slow, broad-based, shuffling gait. Urinary incontinence is classic, but fecal incontinence may develop at advanced stages. The dementia in NPH is characterized by memory loss but no focal neurologic changes. The prevailing theory for the pathogenesis of NPH is that patients have a transient increase in intracranial pressure that causes ventricular enlargement. After the ventricles enlarge, the pressure returns to normal. The initial increase in ventricular size may be due to either diminished CSF absorption at the arachnoid villi or obstructive hydrocephalus.

Pediatric abdominal wall defects: 1- Umblical hernia : • Defect at finea alba covered by skin • Sometimes contains bowel • Umbilical cord inserts at apex of defect 2-Gastroschisis • Defect to the right of the cord insertion not covered by membrane or skin • Contains bowel • Umbilical cord inserts next to defect 3-Omphalocele • Midline abdominal wall defect covered by peritoneum • Contains multiple abdominal organs • Umbilical cord inserts at apex of defect

Clinical features of chronic hepatitis c: Clinical presentation • Can be asymptomatic or develop fatigue (most common) • Other nonspecific symptoms (eg, nausea, anorexia, myalgia, arthralgia, weakness, weight loss) • Serum transaminases can be elevated or normal (up to 1/3 of patients) • Can progress to cirrhosis in up to 20% of patients • Increased risk of hepatocellular carcinoma Extrahepatic manifestations • Heme: Essential mixed cryo.globulinemia • Renal: Membranoproliferative glomerulonephritis • Skin: Porphyria cutanea tarda, lichen planus • Endocrine: Increased risk of diabetes

Polyarteritis nodosa is more commonly associated with hepatitis B rather than HCV. Polyarteritis nodosa is a necrotizing vasculitis in small and medium vessels likely due to the deposition of circulating antigen-antibody immune complexes in blood vessel wails. **Lambert-Eaton syndrome is a neuromuscular junction disorder that presents most commonly with muscle weakness and dry mouth. It is most often associated with small ceil lung cancer or lymphoprollferative disorders (eg, Hodgkin lymphoma). **Lactate dehydrogenase 16-17 years: 105-233 U/L > or =18 years: 122-222 U/L

Pancreatic cancer: The presentation can vary depending on the tumor's location. Most (60%-70%) cancers occur in the head of the pancreas. As these tumors expand, they compress the pancreatic duct and common bile duct (leading to painless jaundice), sometimes seen on imaging as the double duct sign. Subsequent backup of bile leads to Intra- and extrahepatic biliary duct dilation and a nontender, distended gallbladder at the right costal margin (Courvoisier sign). The jaundice can also lead to pruritus, pale stools, and dark urine. In contrast. cancers In the body or tail of the pancreas usually present with abdominal pain but without jaundice. ** Dilation of both the pancreatic duct and the common bile duct commonly referred to as the "double duct sign" is present in about 62 to 77 percent of cases of pancreatic cancer. CT of the abdomen can be reasonable. **Although hepatitis B virus DNA may be detectable prior to the appearance of HBsAg or HBeAg, this test is generally not performed to diagnose acute infection. Instead, hepatitis B virus DNA Is obtained In patients with chronic hepatitis B to determine candidacy for antiviral therapy or monitor response to treatment. HBsAg and anti-HBc are the most appropriate diagnostic tests for acute hepatitis B infection as they are both elevated during initial infection and anti-HBc will remain elevated during the window period.

Portal-vein thrombosis (PVT) is most often associated with cirrhosis. Acute PVT can present with gradual or sudden-onset abdominal pain, whereas chronic PVT most often presents as variceal bleeding. Intrahepatic biliary cysts are an uncommon cause of abdominal pain and jaundice. These cysts tend to occur more frequently in women (up to 50% of cases In Asian countries) and children. In addition, intrahepatic biliary cysts usually do not cause an enlarged gallbladder. Abnormal pancreatobiliary junction: Some biliary cysts may be the result of an abnormal pancreaticobiliary junction (APBJ), also called pancreaticobiliary maljunction or malunion. The APBJ may allow reflux of pancreatic juice into the biliary tree with resultant damage to the biliary epithelium and cyst formation. While APBJ is a rare congenital anomaly, with a prevalence of 0.03 percent in one population-based series from Japan , it is present in 50 to 80 percent of patients with biliary cysts

Postpartum day 0 fever: Atelectasis, Risk factors: general anesthesia with incisional pain (most common) and cigarette smoking. Clinical finding: Mild fever with mild rales on auscultation. Patient is unable to take deep breaths. Decreased breath sound heard bilaterally.

Postpartum day 5-6 fever: Septic Thrombophelebitis Risk factors: emergency cesarean section after prolonge membrane rupture and prolonged labor. Clinical findings: Persistent wide fever swings despite broad-spectrum antibiotics with normal pelvic and physical examination. Management is with heparin IV for 7-10 days, keeping heparin values at 1.5 to 2 times baseline.

Patients with PE commonly develop small pleural effusions due to hemorrhage or inflammation. The effusions tend to be exudative and grossly bloody, and they can be associated with pain due to pleural irritation. Patients with suspected PE should get confirmatory testing (eg, CT pulmonary angiography). Patients with PE commonly develop small pleural effusions due to hemorrhage or inflammation. The effusions tend to be exudative and grossly bloody, and they can be associated with Pain due to pleural irritation. Patients with suspected PE should get confirmatory testing (eg, CT pulmonary angiography). Can have dullness in percussion. ***DDx: Malignant effusions tend to be large and to present with progressive shortness of breath over several days or weeks (subacute) rather than with sudden-onset chest pain. Same physical exam, but may have friction rub.

Pretest probability of coronary artery disease: 1-Low (<10%) • Asymptomatic people of all ages • Atypical chest pain in women age <50 2-Intermediate (20%-80%) • Atypical angina in men of all ages • Atypical angina in women age >50 • Typical angina in women age 30-50 3-High • Typical angina in men age >40 (>90%) • Typical angina in women age >60

Atrial premature beats (APBs). also called premature atrial complexes (PACs), occur when there is premature activation of the atria originating from a site other than the sinoatrial node. ECG will show an early P wave. PACs by themselves represent a benign arrhythmia that can occur both in healthy individuals and in patients with a variety of cardiovascular and systemic diseases. They may occur singly or in a pattern of bigeminy. PACs are usually asymptomatic; however, in some patients, they can cause symptoms of "skipped" beats or palpitations. Occasionally they can precede atrial fibrillation. Treatment is required only when symptoms cause distress or when there is supraventricular tachycardia. Even in asymptomatic patients, precipitating factors such as tobacco, alcohol, caffeine, and stress should be identified and avoided. At the time of arrhythmia we have irregular rhythm and P vave shape is different from normal SA node and can be reverse.

Rh negative mother with uterine bleeding-administration of RhoGAM. We recommend administration of antenatal anti-D immunoglobulin when there is an increased risk of fetomaternal hemorrhage (Grade 1B). Some examples include miscarriage, abortion, ectopic pregnancy, multifetal reduction, amniocentesis, chorionic villus sampling, blunt abdominal trauma, external cephalic version, **antepartum bleeding, and fetal death. We administer 300 micrograms as soon as possible within 72 hours of the event.

We consider the initiation of menopausal hormone therapy (MHT) to be a safe option for healthy, symptomatic women who are within 10 years of menopause or younger than age 60 years and who do not have contraindications to MHT (such as a history of breast cancer, coronary heart disease [CHD], a previous venous thromboembolic event or stroke, or active liver disease). Starting estrogen — Once a decision has been made to treat a postmenopausal woman with estrogen, consideration should be given to the type of estrogen and the route by which it is to be given, as well as the need for progestin and the most appropriate progestin regimen. **Older patients with hip fracture should undergo definitive surgical correction as soon as reasonably possible. However, surgery (Hemiarthroplasty for femoral neck fracture) may be delayed up to 72 hours to evaluate surgical risk and ensure medical stability.

Risks of combined estrogen-progestin contraceptives: • Venous thromboembolism • Hypertension • Hepatic adenoma Risks • Very rarely stroke & myocardial infarction Patients with conversion disorder often have comorbid personality disorders, such as histrionic or dependent personality disorder. Somatic symptom disorder involves one or more persistent physical symptoms with disproportionate and excessive anxiety, concern, and energy devoted to these symptoms. While the underlying symptoms (eg, pain, heartburn, fatigue) are physiologic, they are generally minor and do not indicate a serious disease, though they generate significant worry. By contrast in conversion disorder, the symptoms are by definition non-physiologic.

** Do dialysis in AKI patient before surgery if: BUN is over 80 or ptassium is more than 5.5 **Either the Parkland or the modified Brooke formula is a reasonable starting point for determining fluid requirements in adult patients. The Parkland (also known as Baxter) formula is the most widely used guide to initial resuscitation fluid needs in the burn patient, although some studies have questioned its accuracyAccording to this formula, the fluid requirement during the initial 24 hours of treatment is 4 mL/kg of body weight for each percent of TBSA burned, given IV. Superficial burns are excluded from this calculation. One-half of the calculated fluid need is given in the first eight hours, and the remaining half is given over the subsequent 16 hours. luid resuscitation of the patient with moderate or severe burns consists of an IV crystalloid solution. The ideal solution has not been determined, but lactated Ringer's solution (LR) is typically given; it contains physiologic concentrations of major electrolytes, and lactate may reduce the incidence of hyperchloremic acidosis that may occur with administration of extremely large volumes of isotonic saline (ie, 0.9 percent sodium chloride).

Second stage arrest of labor: Definition: insufficient fetal descent after pushing for • >=3 hours if nulliparous • >=2 hours if multiparous Risk factors: • Maternal obesity • Excessive pregnancy weight gain • Diabetes mellitus Etiology: • Cephalopelvic disproportion • Malposition • Inadequate contractions • Maternal exhaustion Management: • Operative vaginal delivery • Cesarean delivery

Antibiotic prophylaxis with dental procedures is reasonable only for patients with cardiac conditions associated with the highest risk of adverse outcomes from endocarditis, including: • Prosthetic cardiac valve or prosthetic material used in valve repair • Previous endocarditis • Congenital heart disease only in the following categories: - Unrepaired cyanotic congenital heart disease, including those with palliative shunts and conduits - Completely repaired congenital heart disease with prosthetic material or device, whether placed by surgery or catheter intervention, during the first six months after the procedure* - Repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization) • Cardiac transplantation recipients with cardiac valvular disease/valvulopathy We give amoxicillin one hour before the surgery or clindamycin for patients who have a penicillin allergy. MRV even with regurgitation does not need prophylaxy.

Submucous fibrolds arise from the myometrium immediately under the endometrial lining and protrude Into the uterine cavity. They commonly cause heavy and prolonged menstrual bleeding (highest bleeding subtype) and can prolapse through the cervical os, presenting with a typical labor-like pain due to cervical distension by the solid mass. **We suggest using a beta blocker for pregnant women with moderate to severe hyperthyroidism and hyperadrenergic symptoms. Beta blockers should be weaned as soon as the hyperthyroidism is controlled by antithyroid drugs (ATDs). For women with moderate to severe hyperthyroidism complicating pregnancy, we suggest a thionamide (Propylthiouracil (PTU) and methimazole are the thionamide drugs available in the United States) as our first choice of treatment. We suggest using propylthiouracil (PTU) rather than methimazole (MMI) in the first trimester and switching to MMI at the start of the second trimester.

Roughly, hemoglobin = haematocrit/3 Red blood tranfusion threshold: 1- In Hgb below 7 generally recommended 2- 7-8 recommended in cardiac surgery, oncology treatment, and heart failure. 3- 8-10 in symptomatic anemia, ongoing bleeding, acute coronary syndrome, and noncardiac surgery 4- >10 not generally indicated

The mechanism by which hypothyroidism induces hyponatremia is incompletely understood. We also have tenderness on muscle palpation. Increased muscle CK. ●Edema, often nonpitting ●Pericardial effusions, which occur in approximately 25 percent of patients and may be quite large so we can have distant heart sound.

A paradoxical split S2 heart sound occurs when the splitting is heard during expiration and disappears during inspiration, the opposite of the physiologic split S2. A paradoxical split S2 occurs in any setting that delays the closure of the aortic valve, such as severe aortic stenosis, hypertrophic obstructive cardiomyopathy (HOCM) or in the setting of a left bundle branch block (LBBB). The Gallavardin phenomenon is a clinical sign found in patients with aortic stenosis. It is described as the dissociation between the noisy and musical components of the systolic murmur heard in aortic stenosis. The harsh noisy component is best heard at the upper right sternal border radiating to the neck due to the high velocity jet in the ascending aorta. The musical high frequency component is best heard at the cardiac apex. The presence of a murmur at the apex can be misinterpreted as mitral regurgitation.

The most important use of the Valsalva maneuver is to distinguish the murmur of aortic stenosis from hypertrophic obstructive cardiomyopathy — or simply to bring forth the murmur of HOCM. Aortic stenosis will soften or not change, whereas the murmur of HOCM becomes quite loud with Valsalva.

The most common drug causes of AIN (tubulointerstitial nephritis) now include : ●Nonsteroidal anti-inflammatory agents (NSAIDs), including selective cyclooxygenase (COX)-2 inhibitors ●Penicillins and cephalosporins (e.g cephazolin) ●Rifampin ●Antimicrobial sulfonamides, including trimethoprim-sulfamethoxazole ●Diuretics, including loop diuretics such as furosemide and bumetanide, and thiazide-type diuretics ●Ciprofloxacin and, perhaps to a lesser degree, other quinolones ●Cimetidine (only rare cases have been described with other H-2 blockers such as ranitidine) [24,25] ●Allopurinol ●Proton pump inhibitors (PPIs) such as omeprazole and lansoprazole ●Indinavir ●5-aminosalicylates (eg, mesalamine)

Thyroid storm, a life-threatening thyrotoxicosis usually triggered by a specific event (eg, thyroid or non-thyroid surgery, trauma, infection) in patients with undiagnosed or inadequately treated hyperthyroidism. Proposed mechanisms include a rapid increase in serum thyroid hormone levels or increased sensitivity to thyroid hormone. Characteristic features include tachycardia, hypertension, cardiac arrhythmias (eg, atrial fibrillation), and fever up to 40-41 C (104-106 F). Other findings include anxiety, altered mentation, seizure, severe nausea, vomiting, hepatic dysfunction, tremor, lid lag, and goiter.

In adults: Generalized myalgias, malaise, and headache are prominent. Fever occurs in approximately half of cases. In general, patients are uncomfortable but usually do not appear severely ill, although severe dehydration can occur. The white blood cell count is generally normal or may be slightly elevated; relative lymphopenia may be observed at the height of the illness. Renal function is generally normal unless dehydration ensues. Most cases of acute infectious gastroenteritis are viral, with norovirus being the most common cause of acute gastroenteritis and the second most common cause of hospitalization for acute gastroenteritis. Common findings on physical examination of patients with acute viral gastroenteritis include mild diffuse abdominal tenderness on palpation; the abdomen is soft, but there may be voluntary guarding. Fever (38.3 to 38.9°C [101 to 102°F]) occurs in approximately one-half of patients.Symptoms include nausea and vomiting (nonbloody, nonbilious), watery diarrhea (nonbloody), and abdominal pain. Vomiting is more prominent in the setting of norovirus infection than in gastroenteritis caused by other viruses. erson-to-person transmission of norovirus occurs via the fecal-oral route, with an incubation period of 24 to 48 hours [

Travelers' diarrhea: recent travel history, nausea and vomiting not common. fever not common. no bloody stool. Rotavirus: causes low-grade fever, vomiting, more in children but in adults who in contact with sick children. We have hyperactive bowel sound. Rectal examination may simulate the production of watery, heme-negative stool. **Nephritic syndrome can present in young adult with: hypertension hematuria mild to moderate proteinuria The renal biopsy is needed to diagnose the specific type of glomerulonephritis

A pleural fluid pH below 7.30 with a normal arterial blood pH is found with the same diagnoses associated with low pleural fluid glucose concentrations The mechanisms responsible for pleural fluid acidosis (pH <7.30) include; ●Increased acid production by pleural fluid cells and bacteria (empyema). ●Decreased hydrogen ion efflux from the pleural space, due to pleuritis, tumor, or pleural fibrosis. Specific examples include malignancy, rheumatoid pleurisy, and tuberculous pleurisy. A low pleural fluid glucose concentration (less than 60 mg/dL [3.33 mmol/liter], or a pleural fluid/serum glucose ratio less than 0.5) narrows the differential diagnosis of the exudate to the following possibilities : ●Rheumatoid pleurisy ●Complicated parapneumonic effusion or empyema ●Malignant effusion ●Tuberculous pleurisy ●Lupus pleuritis ●Esophageal rupture

Tuberculous pleurisy: pH of about 7.00 ~ 7.30, nucleated cells number (0.1 ~ 2.0) × 10^9 / L, the acute phase of neutrophils dominant, **then lymphocyte predominant protein quantification 30g / L or more, such as greater than 50g / L, more support for the diagnosis of tuberculous pleurisy, glucose content <3.4mmol / L, **lactate dehydrogenase (LDH)> 200U / L, adenosine deaminase (ADA)> 45U / L, interferon -γ> 3.7μ / ml, carcinoembryonic antigen (CEA) <20μg / L

Type I: Sliding hernia — A type I or sliding hiatus hernia is characterized by the displacement of the gastroesophageal (GE) junction above the diaphragm. The stomach remains in its usual longitudinal alignment and the fundus remains below the GE junction. Endoscopic and radiographic studies suggest that 50 to 94 percent of patients with GE reflux disease (GERD) have a type I hiatus hernia as compared with 13 to 59 percent of normals . The likelihood of symptomatic GE reflux increases with the size of the hiatal hernia. This can lead to Barret esophagus.

VIPomas are detected in 1 in 10 million people per year [1]. The majority of VIPomas arise within the pancreas, and are classified as functioning pancreatic neuroendocrine (islet cell) tumors. In adults, VIPomas are intrapancreatic in over 95 percent of cases: The majority of patients with VIPoma have VIPoma syndrome, which is also called the pancreatic cholera syndrome, Verner-Morrison syndrome, and the watery diarrhea, hypokalemia, and hypochlorhydria or achlorhydria (WDHA) syndrome. VIPoma syndrome is characterized by watery diarrhea that persists with fasting. Stools are tea-colored and odorless with stool volumes exceeding 700 mL/day.

Vestibular neuritis is generally understood to be a viral or postviral inflammatory disorder affecting the vestibular portion of the eighth cranial nerve. This pathophysiological mechanism is not necessarily accurate . There are little pathologic data to support this mechanism in patients with this disorder, and a history of a preceding viral illness is elicited in less than one-half of patients. AOM (you can find opaque tympanic membrane) can be found on physical exam in patients with labyrinthitis. Physical examination findings are consistent with an acute vestibular imbalance: ●Spontaneous vestibular nystagmus that is unilateral, horizontal, or horizontal-torsional, that is suppressed with visual fixation, and that does not change direction with gaze. The fast phase of nystagmus beats away from the affected side. ●Positive head thrust test. With rapid turning of the head toward the side of the lesion by the examiner, the patient is unable to maintain visual fixation. Gait instability with preserved ability to ambulate. If the patient sways or falls, it is opposite to the direction of the fast component of the nystagmus, ie, toward the affected side. ●Other neurologic signs and symptoms (dysarthria, dysphagia, weakness, sensory loss, facial droop, limb dysmetria) are absent. Vertical diplopia or skew eye deviation may be present due to an imbalance in otolithic-ocular reflexes, although its presence suggests that the patient has had a stroke. ●In pure vestibular neuritis, auditory function is preserved; when this syndrome is combined with unilateral hearing loss, it is called labyrinthitis.

Viral labyrinthitis Physical examination findings include spontaneous nystagmus towards the unaffected side, with diminished or absent caloric responses in the affected ear. The hearing loss is usually mild to moderate and is typically evident in the higher frequencies (>2000 Hz), although any degree or type of hearing loss may be present. *Hypertension is present in 70 percent of type B dissections, but only in 25 to 35 percent of type A dissections. The presence of hypotension complicating a type B dissection is rare, seen in less than 5 percent of patients, and usually implies rupture of the aorta. By contrast, hypotension may be present in 25 percent of dissections that involve the ascending aorta, potentially as a result of aortic valve disruption leading to severe aortic regurgitation and/or extravasation into the pericardial space leading to cardiac tamponade. Hypertension can be equal in both arms.

**1. A low plasma sodium concentration (less than 137 meq/L) with a low urine osmolality (eg, less than one-half the plasma osmolality) is usually indicative of water overload due to primary polydipsia 2. A high-normal plasma sodium concentration (greater than 142 meq/L, due to water loss) points toward DI, particularly if the urine osmolality is less than the plasma osmolality.

Zinc deficiency : alopecia, hypogonadism)无dysgeusia, anosmia, predispose to alcoholic cirrhosis, acrodermatitis enteropathica, Dermatitis, alopecia, diarrhea.

Local anesthetic side effect: **lidocaine is used for epidural block; CNS side effects: Depending on local tissue concentrations (and because it can be injected intravascularly) of local anesthetics, there may be excitatory or depressant effects on the central nervous system. Initial symptoms suggest some form of central nervous system excitation such as a ringing in the ears (tinnitus), a metallic taste in the mouth, or tingling or numbness of the mouth. As the concentration rises, a relatively selective depression of inhibitory neurons results in cerebral excitation, which may lead to more advanced symptoms include motor twitching in the periphery followed by grand mal seizures. A profound depression of brain functions occurs at higher concentrations which may lead to coma, respiratory arrest and death.

avoiding social interactions and hypersensitivity to rejection is characteristic of avoidant personality disorder. Patients with avoidant personality disorder typically limit their social relationships due to fears of being judged, embarrassed, or rejected. They struggle with feelings of inadequacy and pursue relationships only when they feel assured of uncritical acceptance. Occupational dysfunction due to difficulties interacting with coworkers or turning down promotions due to fear of criticism is common.

Corneal abrasion: Severe eye pain and reluctance to open the eye due to photophobia and/or foreign body sensation. Often patients are too uncomfortable to work, drive, or read, and the pain frequently precludes sleep. Multiple attempts by the patient to "wash out" the eye can further disrupt the epithelial surface. W can have mild ciliary flush and injected red eye. Occasionally we may have nausea. For the patient who is too uncomfortable to cooperate with examination, a penlight examination to confirm that there is no evidence of penetrating trauma should be performed, and then one drop of topical anesthetic (proparacaine 0.5 percent solution) may be instilled to facilitate the measurement of visual acuity and the subsequent examination such as slit-lamp examination.n corneal abrasion, the pupil is typically small (reactive miosis). Pupillary constriction in response to light may be difficult to detect in the presence of reactive miosis.

** Apnea of prematurity: A common problem that affects premature infants, and to a lesser degree term infants. Apnea is cessation of flow/exchange for >20 seconds and often associated with bradycardia and hypoxemia It occurs in approximately in 50% of infants born at 30 to 31 weeks gestations, and almost all infants born at less than 28 weeks gestation; an appears to be due to immaturity of the infants' neurologic and respiratory systems. The first line pharmacologic agents of choice for the management of AOP are methylxanthine (caffeine and theophylline) which act to stimulate respiratory neurons. AOP usually resolves by the time the infant is 34 to 36 weeks gestational age.

DDx Malaria: 1-Babesiosis, caused by a tick-transmitted RBC parasite, has a similar presentation to malaria but is more commonly seen in the northeastern and midwestern United States.he most common are fever and hemolytic anemia, symptoms that are similar to those of malaria. People with symptoms usually become ill 1 to 4 weeks after the bite, or 1 to 9 weeks after transfusion of contaminated blood products. A person infected with babesiosis gradually develops malaise and fatigue, followed by a fever. Hemolytic anemia, in which red blood cells are destroyed and removed from the blood, also develops. Chills, sweats, and thrombocytopenia are also common. More common in asplenia. 2- Mosquito-borne dengue fever can present with fever and headache. However, symptoms typically develop 4-7 days (and almost never >2 weeks) following the mosquito bite and classically include marked muscle and joint pains, retroorbital pain, rash, and leukopenia (diagnostically useful). 3- In East Africa, human African trypanosomiasis (sleeping sickness), transmitted by tsetse flies, causes an acute febrile illness with a skin lesion (trypanosoma! chancre), myocarditis, and progression to central nervous system involvement. A more chronic form with similar manifestations evolving over years is seen in West Africa due to infection by a different trypanosoma! species.

** In malaria: The typical cycle (uncommon) consists of a cold phase (chills, shivering), then a hot phase (high-grade fevers), then a sweating stage (diaphoresis, fever resolution). Headache, malaise, myalgias, vomiting, and diarrhea are often seen. Anemia and thrombocytopenia are classic. Blood smears are the diagnostic gold standard. **Patients who receive solid organ transplantation require high-dose immunosuppressant medication to prevent organ rejection. This creates an immunocompromised state that puts patients at high risk for opportunistic infections, most notably Pneumocystis pneumonia (PCP) and cytomegalovirus. Post-transplant patients with PCP typically have acute respiratory failure (tachypnea, hypoxia), dry cough, and fever (the course is more indolent in patients with HIV). Lactate dehydrogenase (LDH) levels are often elevated, and chest x-ray classically reveals bilateral, diffuse interstitial infiltrates. P jirovecii (the causative organism of PCP) cannot be cultured; diagnosis requires the examination of respiratory samples using microscopy with specialized stains. Induced sputum is the least invasive method for obtaining an adequate respiratory sample. If this does not yield a diagnosis bronchoscopy with bronchoalveolar lavage is required.

Disruptive mood dysregulation disorder involves severe, pervasive irritability and poor frustration tolerance, resulting in frequent temper outbursts. Inattention, hyperactivity, and disorganization are not prominent, but ADHD can be diagnosed as a comorbid condition if criteria are met. Oppositional defiant disorder. This disorder is characterized by a pattern of angry/irritable mood and argumentative/defiant behavior toward authority figures. These patients are temperamental and hostile and defiantly break rules. This patient's mood is good and his arguments with his mother and classroom behavior are more likely related to his impulsivity than defiance. **Atopic dermatitis in school-age children presents as dry, thickened, erythematous plaques on flexor surfaces (eg, popliteal and antecubital fossae). The groin and genitals are typically spared, and symptoms would be present throughout the day. **Lichen sclerosus can cause perianal and vulvar pruritus as well as vaginal discharge or bleeding. Physical examination may show hypopigmentation and ecchymoses of the affected area.

***Atelectasis is a common postoperative complication that results from shallow breathing and weak cough due to pain. It is most common on postoperative days 2 and 3 following abdominal or thoracoabdominal surgery. Adequate pain control, deep-breathing exercises, directed coughing, early mobilization, and incentive spirometry decrease the incidence of postoperative atelectasis. Cause: Atelectasis is one of the most common postoperative pulmonary complications and is particularly common after abdominal and thoracoabdominal surgery. Following such surgeries, pain and changes in lung compliance can cause impaired cough and shallow breathing. Shallow inhalations limit recruitment of alveoli at the lung bases, and weak cough predisposes to small-airway mucus plugging. *Chest pain that is reproducible with palpation (even on sternum) suggests a musculoskeletal etiology.

Presentation of chronic systemic symptoms (eg, fever, weight loss, fatigue), embolic phenomenon (left-sided weakness), and mass in the left atrium on echocardiogram are suggestive of cardiac myxoma. Myxomas are the most common benign primary cardiac tumors with approximately 80% located in the left atrium. Left atrial myxomas can cause obstruction of blood flow across the mitral valve, mimicking mitral valve disease and producing early diastolic sound ("tumor plop"). It can manifest in any age. Patients often present with fatigue, cough, dyspnea, orthopnea, pulmonary edema, or hemoptysis. Left atrial tumors can also cause systemic embolization (eg, transient ischemic attack, stroke, splenic infarcts). About 50% of patients report constitutional symptoms (due to overproduction of interleukin-6) such as fever, weight loss, or Raynaud phenomenon. Although transesophageal echocardiography is the most sensitive test for diagnosis, transthoracic echocardiography is usually adequate. Once diagnosis is established, prompt surgical resection is recommended to avoid complications of embolization and risk of sudden death. o Heart failure due to anatomic obstruction o Myocardial invasion causing arrhythmias, heart block, or pericardiaI effusion • Embolization • Lung invasion causing respiratory symptoms mimicking bronchogenic carcinoma **Erythromycin ophthalmic ointment is recommended for all newborns regardless of prenatal screening results. It is applied to prevent gonococcal conjunctivitis (ie, ophthalmia neonatorum), which typically presents at age 2-5 days with copious purulent eye discharge and eyelid swelling. However, topical erythromycin ointment is not effective in preventing or eradicating chlamydia.

**Acquired chlamydiaI conjunctivitis, one of the most common causes of neonatal conjunctivitis. Maternal infection may be asymptomatic but can be transmitted to the neonate during vaginal delivery. Up to 50% of exposed infants develop conjunctivitis, but up to 30% develop pneumonia. Chlamydia! conjunctivitis typically develops at age 5-14 days and presents with bilateral chemosis (thickened, injected conjunctivae), eyelid swelling, and watery or mucopurulent discharge. Eye discharge can also be bloody due to the friable conjunctivae. Untreated infection can lead to corneal and conjunctival scarring. Chlamydial pneumonia typically manifests at age 4-12 weeks with a paroxysmal staccato cough. First-line treatment for both chlamydia! conjunctivitis and pneumonia consists of a course of oral erythromycin. Oral erythromycin is associated with risk of infantile hypertrophic pyloric stenosis, but the benefits of treating and preventing complications of chlamydia! infection outweigh this risk. The Centers for Disease Control and Prevention recommends that all pregnant women should be screened for chlamydia at the first prenatal visit. Maternal screening should be repeated in the third trimester in all high-risk women (eg, age <25, new or multiple sexual partners). Treatment of maternal chlamydia is the best method to prevent neonatal infection. *Sexual intercourse is one of the most important risk factors for Ecoli infection. We see numerous white blood cells in urine analysis. ** Atrial myxoma is diastolic murmur which heard at the apex and disapears with when patient lies on the right side. The murmur is low pitch.

Although MRI of the brain has greater sensitivity for the diagnosis of ischemic stroke, noncontrast CT of the head is the preferred screening modality for cerebral hemorrhage due to better availability and testing rapidity. Patients with large or embolic ischemic strokes and those treated with thrombolytics are at high risk for hemorrhagic transformation. This condition usually occurs within 48 hours of the stroke and often manifests with deteriorating mental status. Diagnosis requires emergent noncontrast CT scan of the head.

**An inevitable abortion presents with heavy vaginal bleeding, cramping, and a dilated cervix without passage of gestational tissue. Surgical management (eg, suction curettage) is indicated for hemodynamically unstable patients. Expectant or medical (eg, misoprostol) management is appropriate in hemodynamically stable patients with minimal bleeding. Both types of management avoid the risk of surgical complications (eg, uterine perforation, intrauterine adhesions) but typically require a longer time until treatment is completed and are, therefore, inappropriate for a hemodynamically unstable, bleeding patient.

**Aspirin-exacerbated respiratory disease (AERO), a pseudoallergic reaction to nonsteroidal anti-inflammatory drugs (NSAIOs). Pseudoallergic reactions are not lgE-mediated but typically occur in patients with comorbid asthma, chronic rhinosinusitis with nasal polyposis, or chronic urticaria. About 10%-20% of patients with asthma may develop AERO. AERO usually presents with asthmatic symptoms (cough, wheezing, chest tightness), nasal and ocular symptoms (nasal congestion, rhinorrhea, or periorbital edema), and facial flushing within 30 minutes to 3 hours after NSAID ingestion. AERO symptoms are similar to flares of the underlying asthmatic or allergic condition, and patients may not relate the symptoms to medication use, especially if they have been accustomed to taking the medication without difficulty. AERO pathogenesis involves increased production of pro-inflammatory leukotrienes and decreased production of anti-inflammatory prostaglandins. The breakdown of arachidonic acid to prostaglandins is mediated by the cyclooxygenase (COX1, COX2) pathway and is inhibited by aspirin. Instead, arachidonic acid is diverted to the production of leukotrienes via the 5-lipoxygenase pathway. Treatment includes management of the patient's underlying asthma and chronic rhinosinusitis, avoidance of NSAIDs, and desensitization if NSAID use is required. The use of leukotriene inhibitors (zileuton) and leukotriene receptor antagonists (eg, montelukast) can also improve respiratory and nasal symptoms. **Emergent treatment for hyperkalemia is indicated if the serum potassium level is rapidly rising or is >=6.5 mEq/L, or if there are ECG changes attributable to hyperkalemia. The most immediate measure is intravenous calcium (chloride or gluconate) administration to stabilize the cardiac myocyte membrane, making it resistant to the effect of hyperkalemia. **Nephrogenic diabetes insipidus presents with copious excretion of dilute urine and polydipsia. In contrast to type 1 DM, it is uncommon in children.

**Cell-mediated (or delayed) hypersensitivity involves T cell activation and is not mediated by antibodies. Symptoms often occur 48-72 hours after antigen exposure. Because the skin is a repository of T cells, cell-mediated hypersensitivity reactions often present with prominent skin findings (eg, contact dermatitis, Stevens-Johnson syndrome, toxic epidermal necrolysis). Clinical features of hyperkalemia: Sequence of ECG changes • Tall peaked T waves with shortened QT interval • PR prolongation & QRS widening • Disappearance of P wave • Conduction blocks, ectopy, or sine wave pattern Treatment: 1-Cardiac membrane stabilization • Calcium (gluconate)infusion 2-Rapidly acting treatment options • Insulin with glucose • Beta-2 adrenergic agonists • Sodium bicarbonate 3-Removal of potassium from the body • Diuretics • Cation exchange resins • Hemodialysis (slow-acting) 4-Definitive measures to reduce total body potassium are still required and include the following: 1. Reversal of correctable etiology (eg, intravenous fluids for pre-renal azotemia) 2. Diuretics (contraindicated in dehydrated patients) 3. Exchange resins (eg, sodium polystyrene sulfonate), which remove potassium via the gastrointestinal tract (effect takes hours) 4. Hemodialysis

**The most common sites for hypertensive hemorrhage in descending order include the basal ganglia (putamen), cerebellar nuclei, thalamus, pons, and cerebral cortex. Patients with intraparenchymal hemorrhage usually present with gradual onset of symptoms (minutes to a few hours) in contrast to brain embolism or subarachnoid hemorrhage, in which symptoms are abrupt. Typical features of cerebellar hemorrhage include occipital headache (may radiate to neck/shoulders), neck stiffness (due to extension of blood into the 4th ventricle), nausea/vomiting, and nystagmus. Patients may also have ipsilateral hemiataxia of the trunk (cerebellar vermis) and/or limbs (cerebellar hemispheres) as the corticopontocerebellar fibers decussate twice. Hemiparesis and sensory loss are usually absent, but extension of the bleed to the brainstem can cause cranial neuropathies (eg, ipsilateral facial nerve palsy). Further hematoma expansion may lead to brainstem compression resulting in stupor, coma, and ultimately death. Early diagnosis with noncontrast head CT scan is crucial as emergency decompression may be life-saving, especially if the hemorrhage is >3 cm.

**Contralateral hemiplegia can occur with cortical, subcortical, or upper brainstem lesions that injure the descending corticospinal tract. This is frequently seen with intracerebral hemorrhage affecting the basal ganglia, thalamus, or frontal lobe. **Contralateral hemisensory loss may occur with cortical, subcortical (eg, thalamic), or upper brainstem lesions that injure the ascending somatosensory pathways (eg, dorsal column-mediallemniscal and anterolateral pathways). This often occurs with intracranial hemorrhage affecting the basal ganglia, thalamus, or parietal lobe. **Pinpoint pupils are typically observed in patients with a large pontine hemorrhage due to damage to the descending sympathetic fibers.

Fanconi anemia also presents with short stature and anemia. However, diagnosis is typically early in life due to associated congenital malformations ( eg, hypoplastic thumbs) and developmental delays. Pancytopenia (including decreased leukocytes) is common, but severe splenomegaly is not typical. During childhood, short stature and skin pigmentation, including café au lait spots, may become apparent. The first sign of a hematologic problem is usually petechiae and bruises, with later onset of pale appearance, feeling tired, and infections Acute lymphocytic leukemia can present with anemia, thrombocytopenia, bone pain, and hepatosplenomegaly. However, leukocyte count would be abnormal, lymphadenopathy or fevers are frequently present, and age at onset is typically under the age of 15 or over the age of 45.

**Gaucher disease: Autosomal recessive, increased prevalence in Ashkenazi Jews Etiology •Glucocerebrosidase deficiency =>glucocerebroside accumulation in macrophages Typical features • Severe splenomegaly, hepatomegaly • Anemia, thrombocytopenia • Bony pain • Failure to thrive, delayed puberty Management • Enzyme replacement therapy

Functional hypothalamic amenorrhea: is defined as suppression of the hypothalamic-pituitary-ovarian (HPO) axis without a known anatomic (eg, uterine malformation) or metabolic (eg. hyperprolactinemia) cause. It may occur in women undergo excessive physical training (with or without weight loss or caloric restriction), as well those with anorexia nervosa, marijuana use, starvation, stress, depression. and chronic illness. Studies have suggested that fat restriction in the diet may play a role. Factors Implicated in suppression of the HPO axis are low body fat mass and leptin, and elevated Ghrelin, neuropeptide Y, GABA, beta-endorphin, and corticotropin-releasing hormone. Patients are at high risk for bone loss despite physical training due to low estrogen levels offsetting the bone-building effects of exercise. **Servere weight loss can also cause NASH.

**In Tourette syndrome: Symptoms are exacerbated by stress and tend to subside during sleep. **in alpha-thalassemia minor and beta-thalassemia minor: We have Normal/increased iron & ferritin (RBC turnover) and no improvement/Response to iron supplementation. No specific therapy is required for beta-thalassemia minor. ** in Alpha thalassemia major • Hb Barts, Hb Portland & Hb H present • Absent Hb A, Hb F & HbA2 **in beta-thalassemia major: Absent Hb A, only Hb A2 & Hb F present in Intermediate we have increased HbF in trait we have Increased Hb A2

Fragile X syndrome (FXS) Is an X-llnked disorder that is the most common cause of inherited intellectual disability. Expansion of CGG' trinucleotide repeats In the fragile X mental retardation 1 gene of the X chromosome leads to the classic phenotype in affected males: large head. long face, prominent forehead, protruding ears, and macroorchidlsm. Female patients with the full mutation may have normal intellect. but many have mild Intellectual disability and behavioral problems. In addition to the physical features, patients with FXS often have speech and motor delays in early childhood and display features of attention-deficit hyperactivity disorder and autism spectrum disorder.

**Lead poisoning can be associated with basophilic stippling, but it causes microcytic anemia (MCV <80 fL). Alcoholism can also cause basophilic stippling, ribosomal precipitates that form varying sizes of blue granules in the RBC cytoplasm. However, basophilic stippling is nonspecific and can also be due to thalassemias. *Chronic lymphocytic leukemia is usually characterized by significant leukocytosis (often >100,000/mm3), lymphadenopathy and 8 symptoms. Peripheral smear typically shows "smudge cells".

Avascular necrosis ( e.g. osteonecrosis of the femoral head): Etiology: • Steroid use • Alcohol abuse • Systemic lupus erythematosus • Antiphospholipid syndrome • Hemoglobinopathies (eg, sickle cell) • Infections (eg, osteomyelitis, HIV) • Renal transplantation • Decompression sickness Clinical manifestations: • Groin pain on weight bearing • Pain on hip abduction & internal rotation • No erythema, swelling, or point tenderness Laboratory findings: • Normal white blood cell count • Normal ESR & CRP Radiologic imaging • Crescent sign seen in advanced stage • MRI is most sensitive modality

**Methylphenidate is a central nervous system stimulant that is frequently used to treat attention-deficit hyperactivity disorder. Common side effects include decreased appetite, weight loss, and insomnia. **Patients with hyperemesis gravidarum commonly have hypochloremic metabolic alkalosis, hypokalemia, hypoglycemia, and elevated serum aminotransferases, all of which occur as the result of protracted vomiting. Wernicke encephalopathy: pathophysiology is thiamine deficiency Associated conditions • Chronic alcoholism (most common) • Malnutrition (eg, anorexia nervosa) • Hyperemesis gravidarum Clinical features • Encephalopathy • Oculomotor dysfunction (eg, horizontal nystagmus & bilateral abducens palsy) • Postural & gait ataxia Treatment • Intravenous thiamine followed by glucose infusion Treatment of generalized anxiety disorder: • Cognitive behavioral therapy • SSRis or SNRis

**Legg-Calve-Perthes disease (LCP), a syndrome of idiopathic osteonecrosis (avascular necrosis) of the femoral head. It classically affects boys age 4-10 years, with peak incidence at age 7 years. The etiology for LCP is unclear, but in some patients underlying thrombophilia may be a predisposing factor. Patients generally present with mild chronic hip or knee pain of insidious onset as well as an antalgic gait (shorter time weight bearing on the affected side due to pain). Diagnosis requires a high index of suspicion as initial x-rays may be negative, resulting in an initial diagnosis of transient synovitis (ddx) Persistent symptoms should prompt clinicians to repeat imaging as it can take months for concerning changes to appear on x-ray. As the disease progresses, internal rotation and abduction at the hip joint can become markedly limited. Proximal thigh atrophy may also be present.flattened and fragmented left femoral head. Magnetic resonance imaging and bone scans can show subtle femoral head necrosis weeks to months earlier than x-rays and may be helpful to aid in early diagnosis. Treatment is aimed at maintaining the femoral head within the acetabulum via splinting or surgery. Patients should refrain from weight-bearing activities. DDX of Legg-Calve-Perthes disease : Slipped capital femoral epiphysis also presents with limp and insidious hip pain. However, this classically occurs in obese adolescents. The mean age of presentation is 12 years in girls and 13.5 years in boys. Although transient synovitis typically follows a viral infection, symptoms should resolve within 1-4 weeks.

**Nonallergic rhinitis (NAR), also known as vasomotor rhinitis: Features that help differentiate NAR from allergic rhinitis include predominant nasal congestion or stuffiness, postnasal drip (dry cough), and no specific identifiable triggers. In contrast, patients with allergic rhinitis have predominant eye symptoms, itching, and sneezing, along with specific identifiable triggers in most cases. Diagnosis is typically clinical. NAR patients usually have negative testing for allergens. Those with prominent rhinorrhea and/or postnasal drip sometimes respond to first-generation oral H 1 antihistamines ( eg, chlorpheniramine) but rarely ever to antihistamines without anticholinergic properties (eg, loratadine). These patients are best managed with either a topical intranasal antihistamine spray (eg, azelastine, olopatadine) or intranasal glucocorticoids. **Irritant contact dermatitis (ICD) is nonimmunologically mediated but can resemble allergic contact dermatitis (other type which is type 4 immunologic reaction) with pruritus, erythema, local swelling, and vesicles. Symptoms can develop acutely (within hours of exposure) but are often chronic, leading to excoriations, hyperkeratosis, and fissuring of involved skin.

Type of infant conjunctivitis: 1-Chemical: <24 hr, Mild conjunctival irritation/ injection & tearing after silver, nitrate ophthalmic prophylaxis, treat with eye lubricant 2- Gonococcal: 2-5 days, Marked eyelid swelling; profuse purulent discharge, corneal edema/ulceration; interavenous or intramuscular ceftriaxone or cefotaxime **Sigmoidoscopy or colonoscopy is contraindicated in the setting of acute diverticulitis as it may cause perforation; colonoscopy can be done to exclude underlying malignancy following resolution of the diverticulitis. Acute diverticulitis: Diagnosis • Abdominal CT (oral & intravenous contrast): Findings suggestive of diverticulitis include increased Inflammation In pericolic fat, presence of diverticula, bowel wall thickening, soft tissue masses (eg. phlegmons), and pericolic fluid collections suggesting abscess. Management • Bowel rest • Antibiotics (eg, ciprofloxacin, metronidazole) **Intrauterine fetal demise: 1- Definition: Fetal death at >=20 weeks 2- Diagnosis: Absence of fetal cardiac activity on ultrasound 3- Management 20-23 weeks • Dilation & evacuation OR • Vaginal delivery (cesarean delivery by maternal choice if history of prior classical cesarean/myomectomy) •>=24 weeks Vaginal delivery(cesarean delivery by maternal choice if history of prior classical cesarean/myomectomy) 4- Complication: Coagulopathy after several weeks of fetal retention Risk factors for IUFD include nulliparity, obesity, hypertension, and diabetes mellitus. Patients typically present with decreased or absent fetal movement. Inability to find the fetal heart rate by Doppler sonography is not diagnostic and can be due to fetal malpresentation or maternal obesity. The diagnosis of IUFD must be confirmed by absence of fetal cardiac activity on **ultrasound. **Licorice, or anise contains a mineralocorticoid-like substance called glyccerhetinic acid. Ingestion may lead to hypokalemia, hypernatremia, hypertension and metabolic alkalosis.

**Vaccines for adults with HIV: 1-HAV: • Chronic liver disease (including HBV & HCV) • Men who have sex with men • IV drug users 2-HBV • All patients without documented immunity to HBV 3-HPV • All patients age 11-26 4-Influenza • Annually for all patients (inactivated formulation) 5- Meningococcus (serogroups A, C, W, Y) • All patients age 11-18 • Large groups living in close proximity (eg, college students, military recruits, incarcerated individuals) • Asplenia or complement deficiency 6-Pneumococcus • PCV13 once • PPSV23 8 weeks later, 5 years later & at age 65 7-Tdap • Tdap once (repeat with each pregnancy in women) • Td every 10 years 8-• Many experts also recommend varicella vaccine for adults with HIV born after 1979 who do not have evidence of immunity, provided that their CD4+ count is >200/mm3. In patients with negative anti- varicella lgG antibody result we should give the vaccine. Live vaccines (eg, MMR, zoster, varicella) are contraindicated if CD4+ cell count <200/mm3. *The nonstress test uses the same technology as bedside fetal Doppler to determine the fetal heart rate, but then plots the fetal heart rate over time on a fetal heart rate monitoring strip. A nonstress test is unlikely to provide any new information as the bedside fetal Doppler is unable to demonstrate audible fetal heart tones. **Vaginismus is one of the sexual pain disorder. It is defined as involuntary muscle contraction of the outer third of the vagina that interferes with intercourse. it is prevalent in women who have history of sexual trauma, emotional abuse, rigid religious upbringing, or psychosexual conflicts. It is treated with help of Kegel exercises and dilators. Squeeze and stop-and-go is the treatment of premature ejaculation in males, which is characterized by ejaculation before the man wishes to do so.

Chronic venous insufficiency (CVI), which is most commonly caused by incompetence of venous valves leading to venous hypertension in the deep venous system of the legs. Patients may present with leg discomfort, pain, or swelling that is typically worse in the evening or following prolonged standing and improves after walking or leg elevation. Pitting edema is the most common physical examination finding. In relatively severe cases, redirection of blood from the deep venous system to the superficial venous system may lead to other physical examination findings, including abnormal venous dilation (eg, telangiectasia, varicose veins), skin discoloration, lipoderm atosclerosis, or skin ulceration (characteristically on the medial aspect of the lower leg). Risk factors for CVI include advancing age, obesity, family history, pregnancy, sedentary lifestyle, previous LE trauma, and previous LE venous thrombosis. The diagnosis of CVI is often based on history and physical examination, and initial treatment includes leg elevation, exercise, and compression stockings. Patients who do not respond to initial conservative measures should undergo venous duplex ultrasound to confirm the diagnosis of CVI by identification of venous reflux (retrograde venous blood flow) in the deep venous system.

*The presence of "succussion splash" can indicate gastric outlet obstruction. Initial management of GOO Includes nasogastrlc suctioning to decompress the stomach, intravenous hydration, and endoscopy for definitive diagnosis. The most common histologic lesion in diabetic nephropathy is diffuse glomerulosclerosis. Nodular glomerulosclerosis (with Kimmelstiei-Wilson nodules) is pathognomonic. Disease progression can be slowed with strict glycemic control, treatment of hypertension, and angiotensin axis blockade. **Chest radiography has been advocated as a screening test for lung cancer in patients with a history of smoking but is no longer recommended as it does not improve survival. However, low-dose chest computed tomography has been shown to improve the risk of lung cancer death in patients with a significant smoking history.

Treatment of acute cystitis & pyelonephritis in nonpregnant women: 1- Uncomplicated cystitis • Nitrofurantoin for 5 days (avoid in suspected pyelonephritis or creatinine clearance <60 mUmin) • Trimethoprim/sulfamethoxazole for 3 days Uncomplicated (avoid if local resistance rate >20%) • Fosfomycin single dose • Fluoroquinolones only if above options cannot be used • Urine culture needed only if initial treatment fails **It is estimated that cervical spondylosis affects 10% of people older than 50 years of age. The history of chronic neck pain is typical. Limited neck rotation and lateral bending is due to osteoarthritis and secondary muscle spasm. Sensory deficit is due to osteophyte-induced radiculopathy and isolated sensory abnormalities are associated with good prognosis. Typical radiographic findings include bony spurs and sclerotic facet joints. Interestingly, such 'osteoarthritic' changes are common in asymptomatic patients older than 50 years of age; therefore, specificity of these findings are low. Other findings during cervical spondylosis may include narrowing of the disk spaces and hypertrophic vertebral bodies. Cervical spondylosis is degeneration of the bones in the neck (vertebrae) and the disks between them, putting pressure on (compressing) the spinal cord in the neck. Osteoarthritis is the most common cause. The first symptoms are often an unsteady, jerky walk and pain and loss of flexibility in the neck. Magnetic resonance imaging or computed tomography can confirm the diagnosis. Treatment includes a soft neck collar, nonsteroidal anti-inflammatory drugs, and sometimes surgery. If spinal nerve roots are compressed, the neck is usually painful, and the pain often radiates to the head, shoulders, or arms. Muscles in one or both arms may become weak and waste away, making the arms weak. Osteophytes are the most common findings on cervical radiography in patients with cervical spondylosis, but specificity of these findings is low.

2- Complicated cystitis (Associated with diabetes, pregnancy, renal failure, urinary tract obstruction, indwelling catheter, urinary procedure (eg, cystoscopy), immunosuppression & hosp al quired. • Fluoroquinolones (5-14 days), extended-spectrum antibiotic (eg, ampicillin/gentamicin) for more severe cases ("Do not use fluoroquinolones in pregnancy. Consider cefpodoxime, cephalexin, amoxicillin-davulanate & fosfomycin) • Obtain sample for urine culture prior to initiating therapy & adjust antibiotic as needed 3- Pyelonephritis: • Outpatient: Fluoroquinolones (eg, ciprofloxacin, levofloxacin) • Inpatient: Intravenous antibiotics (eg, fluoroquinolone, aminoglycoside +/- ampicillin) • Obtain sample for urine culture prior to initiating therapy & adjust antibiotic as needed *Torticollis, a focal dystonia of the sternocleidomastoid muscle. Dystonia is defined as sustained muscle contraction resulting in twisting, repetitive movements, or abnormal postures. It may be focal (affecting only one muscle) or diffuse. Torticollis can be congenital, idiopathic, secondary to trauma or local inflammation, or drug-induced. Medications commonly responsible include the typical antipsychotics, metoclopramide, and prochlorperazine. **The hallmark of ischemic hepatopathy is a rapid and massive increase in the transamlnases with modest accompanying elevations in total bilirubin and. alkaline phosphatase. In patients who survive the underlying cause of their hypotension (e.g. septic shock, heart failure), liver enzymes typically return to normal within one to two weeks.

Differential diagnosis of otalgia: 1-Acute otitis media Middle ear effusion plus acute eardrum inflammation (eg, bulging eardrum, fever) 2-Otitis media with effusion Middle ear effusion without acute inflammation 3-Bullous myringitis Serous liquid-filled blisters on the tympanic membrane 4-Cerumen impaction: Liquid or hard wax in auditory canal obstructing eardrum visualization 5-Hemotympanum Purple or red eardrum+/- bulging Barotrauma or blunt trauma can cause bleeding in the middle ear space (hemotympanum), which can be extremely painful and give a purple or red hue to the eardrum. 6-Otitis externa Pain with tragal traction, erythematous & swollen external auditory canal +/-otorrhea

AOM affects mostly children age 6-18 months (especially those in day care) and those around age 5 years (school initiation). Young children are predisposed to middle ear infections due to narrower and straighter Eustachian tubes. AOM often follows an upper respiratory infection (often viral), as nasal congestion contributes to Eustachian tube inflammation, fluid accumulation (effusion) in the middle ear space, and bacterial growth and infection of the tympanic membrane (eardrum). **Acute gastrointestinal perforation requires emergent laparotomy. If an affected patient Is on warfarin, then reversal of anticoagulation must be rapidly achieved pre-operatively by infusion of fresh frozen plasma. **Platelet counts greater than 50,000/mm3 provide adequate hemostasis for most invasive procedures.

Graft-versus-host disease (GVHD or Activation of the donor T lymphocytes), which is common after bone marrow transplantation. Up to 50% of patients with bone marrow transplantation from matched siblings develop the disease. The target organs for GVHD are the skin (maculopapular rash involving palms, soles, and face that may generalize is typical), intestine (blood-positive diarrhea), and liver (abnormal liver function tests and jaundice). The basic pathophysiologic mechanism involved is recognition of host major and minor H LA-antigens by donor T -cells and consequent cell-mediated immune response. **Primary spontaneous pneumothorax (PSP) management of PSP depends on the size of the lesion and the clinical status of the patient. Small pneumothoraces in clinically stable patients (such as this) can be managed with observation and supplemental oxygen, which enhances the speed of resorption. Stable patients with large pneumothoraces should undergo decompression with a large-bore needle ( eg, 14-to 18-gauge) inserted in the second or third intercostal space in the midclavicular line or at the fifth intercostal space in the mid or anterior axillary. Patients who are hemodynamically unstable should undergo emergent placement of a tube thoracostomy. If tube thoracostomy is not available or will be delayed, urgent needle decompression can be performed. PSP occurs in patients without a history of lung disease and is most common in tall, thin men in their early 20s. Other risk factors include smoking, Marfan syndrome, and thoracic endometriosis. PSP occurs due to rupture of subpleural blebs and commonly develops while patients are at rest. Clinical manifestations include dyspnea, hypoxemia, reduced chest excursion and breath sounds on the affected side, and hyperresonance to percussion. Diagnosis is confirmed by identifying a visceral pleural line on chest x-ray with absent lung marking beyond the line.

Acute appendicitis of pregnancy may result in a ruptured appendix if the diagnosis Is delayed beyond 24-36 hours. Many of the symptoms, including nausea and vomiting, mimic symptoms of pregnancy. The most common symptom of appendicitis in pregnancy is right lower-quadrant pain. Depending on the gestational age of the pregnancy, the location of pain and tenderness may be higher than expected due to displacement of the appendix upward by the gravid uterus. The patient may or may not have a fever. An elevated leukocyte count may be present in appendicitis as well as in a normal pregnancy. Ultrasound should be the first diagnostic test used to confirm the diagnosis of appendicitis in pregnancy and can also be helpful to rule out other potential diagnoses. Graded compression technique Is preferred. Nonvisualization of the appendix on ultrasound does not exclude the diagnosis of acute appendicitis. If ultrasound is nondiagnostic, MRI can be performed In pregnant patients to assess further for possible appendicitis. A diagnostic laparoscopy with laparoscopic appendectomy may be an option in pregnancy. However, a lower, midline vertical laparotomy is a more common procedure, especially when the diagnosis is uncertain. Neither of these procedures Is the next step In management for this patient. *Hypervitaminosis A Is usually due to the ingestion of excessive doses of vitamin A for several weeks or months. Symptoms include anorexia, pruritus, lack of weight gain, Increased Irritability, limitation of motion, tender swelling of the bones, alopecia. seborrheic cutaneous lesions, fissuring of the corners of the mouth, Increased intracranial pressure, and hepatomegaly.

Revised 2010 American College of Rheumatology criteria suggest using the widespread pain index and symptom severity scale rather than trigger points for fibromyalgia (FM) diagnosis. The index and severity scale better emphasize cognitive problems, fatigue, and severity of somatic symptoms. Initial FM treatment should emphasize patient education, regular aerobic exercise, and good sleep hygiene. Patients who do not respond to conservative measures may require medications. Tricyclic antidepressants (eg, amitriptyline) are preferred first-line drugs. Serotonin and norepinephrine reuptake inhibitors (eg, duloxetine, milnacipran) and pregabalin are alternate therapies that may be useful for patients not responding to tricyclic antidepressants. Patients with persistent symptoms may require combination drug therapy, referral for supervised rehabilitation, pain management consultation, or cognitive-behavioral therapy. • Young to middle-aged women • Chronic widespread • >=3 months of symptoms pain with widespread pain • Fatigue, impaired index or symptom concentration severity score • Tenderness at trigger • Normal laboratory points (eg, mid trapezius, costochondral junction)

Acute liver failure (ALF) due to acetaminophen toxicity: ALF is defined as severe acute liver Injury without underlying liver disease and is characterized by elevated aminotransferases (often >1000 U/L), hepatic encephalopathy (HE), and synthetic liver dysfunction (defined as prolonged prothrombin time [PT) with INR >=1.5). Approximately only half of patients with ALF will survive without liver transplantation (LT). Reliable Indicators of worsening ALF include rising serum bilirubin and PT. as seen In this patient. Acute renal insufficiency, likely due to decreased renal perfusion, is common and portends a lower chance of recovery without LT. The degree of HE is also of prognostic importance as grade Ill HE (characterized by marked confusion and Incoherence) is associated with only a 40%-50% chance of spontaneous recovery. Cerebral edema is a potential complication of ALF that may lead to coma and brain stem herniation, and is the most common cause of death. In ALF due to acetaminophen toxicity, LT is firmly indicated in patients with grade Ill or IV HE, PT >100 seconds, and serum creatinine >3.4 mg/dl. One-year survival following LT for ALF Is approximately 80%.

Aspergillus is a ubiquitous fungus that most people encounter daily. Conidia are inhaled into the lung and convert to potentially pathogenic hyphae. Patients with immunocompetency rapidly clear the organism and rarely develop infection: however, a subset of immunocompetent patients with a history of pulmonary disease (eg, cavitary tuberculosis) may develop chronic pulmonary aspergillosis (CPA) at sites of lung damage. Diagnosis is made by the presence of all 3 of the following: • >3 months of symptoms( - fever)c, weight loss, fatigue, cough, hemoptysis, and/or dyspnea • Cavitary lesion(s) containing debris, fluid, or an aspergilloma (fungus ball) • Positive Aspergillus lgG serology Therapy depends on symptoms and severity of disease: antifungal medication (eg, itraconazole, voriconazole), surgery (to prevent hemoptysis), and bronchial artery embolization (for hemoptysis with extensive disease) may be used together or separately.

Advanced sleep phase syndrome is a circadian rhythm disorder characterized by the inability to stay awake in the evening (usually after 7:00 PM) and early-morning insomnia, making social functioning difficult. Delayed sleep phase syndrome is characterized by the inability to fall asleep at "normal" bedtimes, difficulty waking in the morning, and excessive early daytime sleepiness. When allowed to set their own schedule (eg, on weekends), these patients have normal sleep quality and duration for age. the American Medical Association (AMA) guidelines (Opinion 8.061 - Gifts to Physicians from Industry) suggest accepting nonmonetary gifts from interested parties only if the gifts directly benefit patient care and are of small monetary value (eg, unbiased educational materials, drug samples). No gifts of cash or high value, or with implied reciprocity, should be accepted.

Common causes of macrocytic anemia (MCV > 100 fl): • Folate deficiency • Vitamin 812 deficiency • Myelodysplastic syndromes • Acute myeloid leukemias • Drug-induced (eg, hydroxyurea, zidovudine, chemotherapy agents) • liver disease • Alcohol abuse • Hypothyroidism

After blunt chest trauma, hemorrhagic shock associated with decreased breath sounds and dullness to percussion over one hemithorax and contralateral tracheal deviation is most likely due to a large ipsilateral hemothorax. A systolic blood pressure less than 90, heart rate >= 120, and respiratory rate >= 30 are signs consistent with Class 11-111 hemorrhagic shock, resulting from loss of around 30% of the circulating blood volume.

The arterial supply (from the radial artery) enters the scaphoid through foramina in the bone's distal pole before proceeding to the proximal pole. As a result of this tenuous blood supply to the proximal pole, scaphoid fractures are at risk for avascular necrosis and nonunion. Displaced scaphoid fractures may be visible on x-ray immediately following injury, but compressed or nondisplaced fractures may not be visible for 7-10 days. If immediate diagnosis is needed, CT or MRI of the wrist can confirm the fracture. As an alternative, the wrist can be immobilized in a thumb spica cast for **7-10 days, followed by repeat imaging to confirm or exclude fracture and to evaluate for osteonecrosis.

Age-dependent idiopathic sclerocalcific changes are the most frequent cause of isolated aortic stenosis in elderly patients. These changes are common and usually have minimal hemodynamic significance, but sometimes may be severe (and manifest with syncopal episodes). **Hypertension may contribute to aortal sclerocalcific changes, but does not cause aortic stenosis.

Side effects of vancomycin include ototoxicity, "red man syndrome," and nephrotoxicity. **haloperidol lowers the seizure threshold and should be avoided in alcohol withdrawal, which can itself precipitate seizures. **Bipolar disorder is a lifelong and highly recurrent illness that requires maintenance treatment to delay or prevent recurrence of new mood episodes, reduce the risk of suicide, and improve psychosocial functioning. Maintenance treatment typically involves continuation of mood stabilizers used to treat the acute mood episode. Evidence-based options include lithium, valproate, quetiapine, and lamotrigine. Patients with inadequate response to monotherapy and/or severe episodes (eg, psychotic features, aggression, high risk of suicide, frequent episodes with marked impairment requiring hospitalization) often require combination therapy. Lithium or valproate combined with a second-generation antipsychotic (eg, quetiapine) is recommended as first-line treatment.

Alcohol withdrawal syndrome: 1- Mild withdrawal: Anxiety, insomnia, tremors, diaphoresis, palpitations, gastrointestinal upset, intact orientation, onset since last drink is usually 6-24 hrs 2-Seizures: Single or multiple generalized tonic-clonic, onset since last drink is usually 12-48 hours 3-Alcoholic hallucinosis: Visual, auditory, or tactile; intact orientation; stable vital signs, onset since last drink is usually 12-48 hours 4-Delirium tremens: Confusion, agitation, fever, tachycardia, hypertension, diaphoresis, hallucinations, onset since last drink is usually 48-96 hrs

** Commonly abused inhalants include glue, toluene, nitrous oxide ("whippets"), amyl nitrite ("poppers"), and spray paints. Inhalants may be abused by sniffing, huffing (inhaled from a saturated cloth), or bagging (bag over mouth or nose) to concentrate the inhaled substance. Signs of acute intoxication may include brief transient euphoria and loss of consciousness and vary depending on the specific chemicals inhaled. Inhalants are highly lipid soluble and produce immediate effects that typically last 15-45 minutes. They act as central nervous system depressants and may cause death. Dermatitis (glue sniffer's rash) due to chemical exposure can be seen around the mouth or nostrils. Inhalants are rapidly eliminated and are not included in most routine hospital toxicology screens. Liver function tests may be elevated with repeated use. Boys age 14-17 are at highest risk for inhalant abuse, which may go unnoticed because common household products are used and no drug paraphernalia is found. DDx: Although heroin intoxication can cause loss of consciousness, it would be detected on urine toxicology and its effects would likely last longer than a few minutes. Heroin and other opiates cause pupillary constriction.

Amiodarone can cause (hard ones to remember): 1- Ocular • Corneal microdeposits • Optic neuropathy 2- Oermatologic • Blue-gray skin discoloration 3- Neurologic • Peripheral neuropathy 4-Gastrointestinal/ Hepatic • Elevated transaminases, hepatitis **Hypothyroidism can cause additional metabolic abnormalities such as hyperlipidemia, hyponatremia and asymptomatic elevations of creatinine kinase and serum transaminases (aspartate aminotransferase and alanine aminotransferase). Most patients have hypercholesterolemia alone (due to decreased low-density lipoprotein [LDL) surface receptors and/or decreased LDL receptor activity) or combined with hypertriglyceridemia (due to decreased lipoprotein lipase activity).

Homocysteine is a highly reactive amino acid. Increased levels predispose to venous thrombosis as well as atherosclerosis, presumably due to a combination of direct vascular damage, activation of clotting mechanisms, and inhibition of antithrombotic pathways. Thus, this patient's DVT treatment should include an attempt to correct her homocysteine level. Homocysteine can be metabolized to cysteine or methylated to form methionine. If either of these pathways is disrupted by an enzyme or cofactor deficiency, elevated homocysteine levels result. The homocysteine to cysteine pathway is catalyzed by cystathionine beta-synthase (CBS) using the cofactor pyridoxine (B6). The homocysteine to methionine pathway is catalyzed by methylenetetrahydrofolate reductase (MTHFR) and methionine synthase (MS), with folate and cobalamin (B12) as essential cofactors Independent of the underlying cause, homocysteine levels can usually be normalized by administration of pyridoxine (B6) and folate. Vitamin B12 should be added if a B12 deficiency is documented. Although this treatment does correct homocysteine levels, it is still unclear whether it reverses hypercoagulability.

An electrocardiogram (ECG) is the essential first step in a patient with history and risk factors for coronary artery disease who has symptoms consistent with acute coronary syndrome (ACS). There are a number of well-known atypical presentations (ie, no overt chest pain) of ACS that should prompt a cardiac evaluation. Unfortunately, patients with atypical symptoms are more like to have a delay in diagnosis and under-treatment, which contributes to worsened outcomes. Women, the elderly, and patients with diabetes in particular are more likely to have atypical symptoms; up to 20% of these patients do not report chest pain at the time of presentation. Dyspnea, epigastric pain, and nausea/vomiting are common atypical presentations.

Hematologic manifestations of SLE include anemia, leukopenia, thrombocytopenia, and antiphospholipid syndrome. Anemia is most commonly due to anemia of chronic disease, renal insufficiency from SLE nephritis (low erythropoietin), iron deficiency anemia (gastrointestinal loss due to medications such as nonsteroidal anti-inflammatory drugs), and autoimmune hemolytic anemia. Leukopenia and thrombocytopenia are most commonly due to immune-mediated destruction. although there are other less common mechanisms. SLE can cause pancytopenia due to concurrent peripheral immune-mediated destruction of all 3 cell lines. Bone marrow suppression can also cause pancytopenia. However. this is not usually due to SLE but rather from other coincidental conditions (eg. drugs. leukemia. myelodysplasia, malignant invasion of bone marrow). As a result, bone marrow biopsy is frequently done in SLE patients to exclude these other causes.

Anemia in SLE: • Anemia of chronic disease • Renal insufficiency from SLE nephritis • Iron deficiency anemia (gastrointestinal loss) • Autoimmune hemolytic anemia Leukopenia is mostly autoimmune mediated and thrombocytopenia is mostly immune mediated destruction.

Capillary (fingerstick) blood specimens are widely used in screening for lead poisoning, but false-positive results are common. Confirmatory venous lead measurement is required if a screening capillary lead level is >=5 micro g/dl. Lead accumulates throughout the body, but measuring it in hair, teeth, bone, or urine is not recommended. The larger the area of placental detachment, the greater the risk for maternal complications such as disseminated intravascular coagulation (due to tissue factorreleased by decidual bleeding) and hypovolem ic shock. Potential fetal complications include hypoxia and preterm delivery. **Umbilical cord prolapse occurs when the umbilical cord delivers through the cervix ahead of the presenting fetal part. It is associated with abnormal fetal heart tracings, malpresentation, and an unengaged fetal presenting part. Even if malpresentation like breach but engaged then there will be no risk.

Approach to childhood lead poisoning: Does the child have the following risk factors? • Home built before 1978 under renovation or with peeling paint • Pica • Sibling with lead poisoning • Low socioeconomic status (eg, Medicaid) • Immigrant or international adoptee If yes then Draw venous lead level 1-Mild: 5-44 mcg/dL then no medication, repeat level in <1 month. 2-Moderate: 45-69 mcg/dL: give Dimercaptosuccinic acid (DMSA), also called succimer 3-Severe: >=70 mcg/dL: Dimercaprol (British Anti-Lewisite) plus calcium disodium edetate (EDTA)

Acute liver failure 1-Etiology: • Viral hepatitis (eg, HSV; CMV; hepatitis A, B, 0 & E) • Drug toxicity (eg, acetaminophen overdose, idiosyncratic) • Ischemia (eg, shock liver, Budd-Chiari syndrome) • Autoimmune hepatitis • Wilson disease • Malignant infiltration 2-Clinical presentation • Generalized symptoms (eg, fatigue, lethargy, anorexia, nausea) • Right upper quadrant abdominal pain • Pruntus & jaundice due to hyperbilirubinemia • **Renal Insufficiency • Thrombocytopenia • Hypoglycemia 3-Diagnostic requirements • Severe acute liver injury (ALT & AST often >1000 U/L) • Signs of hepatic encephalopathy (eg, confusion, asterixis) • Synthetic liver dysfunction (INR >=1.5)

Approximately 95% of trisomy 18 patients die during their first year of life, most commonly due to cardiac failure from congenital heart disease or respiratory failure from hypoventilation or aspiration. Bell's palsy: Lesions in the central nervous system (above the pons) occurring above the facial nucleus will typically cause a contralateral lower facial weakness that spares the forehead. Upper facial weakness can occur with central lesions, however these lesions must occur at the level of the facial nucleus or exit of the fascicle of the facial nerve at the pontomedullary junction.

Management of new-onset AF includes assessing for rate versus rhythm control strategy and preventing systemic embolization. Hemodynamically unstable patients require emergency cardioversion. Stable patients can receive medical therapy (eg, beta blockers, diltiazem, digoxin) to control the ventricular rate. Rhythm control for maintaining sinus rhythm should be considered in patients unable to achieve adequate heart rate control or in those with recurrent symptomatic episodes (eg, palpitations, lightheadedness, dyspnea, angina) or heart failure symptoms in the setting of underlying left ventricular systolic dysfunction. Regardless of whether rate control or rhythm control is used to treat AF, all patients should undergo a CHA2OS2-VASc score assessment to estimate thromboembolic risk.

Attempting cardioversion In patients with AF for an unknown duration or >48 hour without adequate anticoagulation increases the risk of systemic thromboembolism. **Arterial thrombosis usually develops at the site of an atherosclerotic plaque in patients with preexisting peripheral vascular disease. Due to the presence of collateral circulation in these patients, limb ischemia manifestations are typically less severe than they are in patients with an acute embolus. In addition, pulses are often diminished in both extremities in patients with peripheral vascular disease.

Breastfeedlng decreases the risk of ovarian and breast cancer in BRCA 1 mutation carriers as well as the general population, presumably due to prolonged periods of anovulation. The risk decrease gained by breastfeeding would not be as significant as a premenopausal BSO. Honnone replacement therapy after surgical menopause due to BSO does not appear to have any Influence on the risk of ovarian cancer, but it can theoretically increase breast cancer risk. **The diagnosis of an ectopic pregnancy should be suspected in a patient with a missed menstrual period (amenorrhea), abdominal pain and/or vaginal bleeding. **Vaginal bleeding is typically intermittent and can range from scant staining of undergarments to hemorrhage.

BRCA mutations & ovarian cancer: 1-Genetics • BRCA 1 & BRCA2 mutations • Autosomal dominant inheritance • Ashkenazi Jewish ancestry 2- Cancer risks • Premenopausal epithelial ovarian cancer • Fallopian tube cancer • Primary peritoneal cancer • Breast cancer at age <50 • Breast cancer in male 3-Risk modification • Bilateral salpingo-oophorectomy • Oral contraceptive use • Age <30 at first live birth • Breastfeeding • Tubal ligation

The sensitivity and specificity of adenosine stress test are similar to dobutamine test. Adenosine test is contraindicated in patients with asthma and can trigger ventricular tachyarrhythmia and ectopy.

Because not all symptoms are always present, there should be a high suspicion for reactive arthritis in the case of any asymmetric oligoarthritis associated with urethritis, conjunctivitis or mouth ulcers. Synovial fluid analysis is usually sterile. Nonsteroidal anti-inflammatory agents (NSAIDs) are the first line therapy during the acute phase of this condition. DDX: gonococcal septic arthritis (fever and no triad)

Catatonia: Clinical features • Immobility or excessive purposeless activity • Mutism, stupor (decreased alertness & response to stimuli) • Negativism (resistance to instructions) • Catalepsy (limbs remain in fixed posture for long periods) • Posturing (assuming positions against gravity), waxy flexibility (resistance to positioning) Management • Echolalia, echopraxia (mimicking speech & movements) • Benzodiazepines (lorazepam) • Electroconvulsive therapy

Catatonia is a syndrome (not a specific disorder) of marked psychomotor disturbance that occurs in severely ill patients with mood disorders with psychotic features, psychotic disorders, autism spectrum disorder, and medical conditions (infectious, metabolic, neurologic, rheumatologic). Common features include decreased motor activity, lack of responsiveness during interview, and posturing. Catatonia can range from stupor to marked agitation (catatonic excitement), which contributes to difficulties in recognition. Treatment of catatonia includes benzodiazepines and/or electroconvulsive therapy (ECT). A lorazepam challenge test (lorazepam 1-2 mg iV) resulting in partial, temporary relief within 5-10 minutes confirms the diagnosis. Catatonia generally r.esponds to benzodiazepines within a week: ECT is the treatment of choice in patients who do not improve.

In patients age >50, repeat chest x-ray to assess for malignancy is generally recommended between 6 and 12 weeks following treatment of a **single episode of pneumonia. However, in patients with a significant smoking history and evidence of localized airway obstruction (eg, recurrent pneumonia) warrants more immediate evaluation. CT scan of the chest has better sensitivity than chest x-ray for detecting lung malignancy, especially in the presence of alveolar infiltrate. **premature atrial contractions (PACs), also known as atrial premature complexes: PACs are often completely asymptomatic and may be noted only with Holter monitoring, but occasionally they can be perceived as a skipped beat or a jolt in the chest. In most cases, no treatment other than reassurance is needed for PACs, although medications such as beta blockers can reduce the frequency of symptomatic PACs.

Causes of recurrent pneumonia: 1- Involving same region of lung A: Local airway obstruction • Extrinsic bronchial compression (eg, neoplasm, adenopathy) • Intrinsic bronchial obstruction (eg, bronchiectasis, foreign body) B: Recurrent aspiration (region may vary depending on body position) of lung • Seizures • Alcohol or drug use • GERD, dysphagia 2- Involving same regions of lung • Immunodeficiency (eg, HIV, leukemia, CVID) • Sinopulmonary disease (eg, cystic fibrosis, immotile cilia) • non-infectious (eg, vacluitis, BOOP)

Routine administration of the PCV1 3 is recommended for all infants and young children. PPSV23 is administered to adults age <65 with predisposing comorbidities (eg, chronic heart or lung disease, diabetes mellitus, cirrhosis). Immunocompromised patients and all individuals age >65 should receive both vaccines to maximize protection. Pneumococcal polysaccharide vaccine (PPSV23) contains capsular material from 23 serotypes that have historically been responsible for the majority of pneumococcal infections. Because polysaccharides alone cannot be presented to T cells, the vaccine induces a relatively T -cell-independent B-cell response that is less effective in young children and the elderly.

Certain vaccines induce a predominantly lgA (mucosal) response. An example is the oral polio vaccine, which promotes the secretion of anti-poliovirus lgA antibodies into the gastrointestinal tract. Proliferation of CDS+ T cells occurs mainly in response to intracellular pathogens. Certain live attenuated vaccines, such as the measles (MMR) and intranasal influenza vaccines, produce a predominately CDS+ T -cell response.

Neurogenic arthropathy (Charcot joint) due to diabetes: Pathogenesis involves decreased proprioception, pain, and temperature perception, which can occur due to diabetes, peripheral nerve damage, syringomyelia, spinal cord injury, vitamin B12 deficiency, or tabes dorsalis. As normal neurologic input is lost, patients unknowingly traumatize their weight-bearing joints. This causes secondary degenerative joint disease, joint deformation, and functional limitation. X-rays will reveal loss of cartilage, osteophyte development, and loose bodies (eg. effusions in several of the tarsometatarsal joints, large osteophytes, and several extra-articular bone fragments.). In diabetes, vasculopathy also contributes to disease pathogenesis. Associated pain is typically mild. Management of a Charcot joint involves treating the underlying disease and providing mechanical devices (eg, special shoes) to assist in weight bearing and decrease further trauma. **Hereditary telangiectasia (Osler-Weber-Rendu syndrome), an autosomal dominant disorder characterized by diffuse telangiectasias, recurrent epistaxis, and widespread AV malformations (AVMs). In hereditary telangiectasia, AVMs tend to occur in the mucous membranes, skin, and gastrointestinal tract, but may also be present in the liver, brain, and lung. AVMs in the lungs can shunt blood from the right to the left side of the heart, causing chronic hypoxemia and a reactive polycythemia. Pulmonary AVMs can also present as massive, sometimes fatal, hemoptysis. Ruby-colored papules on his lips that blanch partially with pressure. Digital clubbing may also present.

Charcot joint (neurogenic arthropathy): 1-Associated conditions • Vitamin 812 deficiency • Diabetes • Peripheral nerve damage • Spinal cord injury • Syringomyelia • Tabes dorsalis (tertiary syphilis) 2-Clinical manifestations • Deformed joints • Lacking/decreased sensation (proprioception, pain, temperature) with loss of neurologic input • Arthritis or arthropathy • Mild pain • Fractures (may be unsuspected by patient) • Degenerative joint disease & loose bodies on joint imaging Management • Treat underlying condition • Mechanical devices (assist in weight bearing, decrease further trauma) • X-rays (if trauma is present)

**Isolated amenorrhea with well-developed secondary sexual characteristics can be considered normal up to the age of 16. However, if secondary sexual characteristics are absent work-up should not be delayed beyond age 14. **In a patient with primary amenorrhea: • FSH measurement should be ordered if there is no breast development but uterus is present • Pituitary MRI is the next step if FSH is decreased • Karyotyping is the next step If FSH is increased If from beginning uterus is absent then we should do karyotyping and measuring serum testosterone

Clinical features of diabetic autonomic neuropathy: only two confusing one mentioned here 1-Cardiovascular • Tachycardia, impaired exercise tolerance • Postural hypotension with loss of diurnal blood pressure variation • Dry skin, pruritus, callus formation 2- Peripheral nerves • Foot ulcers & poor wound healing • Charcot arthropathy (increased fracture risk with resultant secondary ulceration)

Septic pelvic thrombophlebitis: 1-Risk factors: • Cesarean delivery • Pelvic surgery • Endometritis • Pelvic inflammatory disease • Pregnancy • Malignancy 2-Pathophysiology • Hypercoagulability • Pelvic venous dilation • Vascular trauma • infection 3-Presentation • Fever unresponsive to antibiotics • No localizing signs/symptoms • Negative infectious evaluation • Diagnosis of exclusion 4-Treatment • Anticoagulation • Broad-spectrum antibiotics

Clinical features of esophageal perforation: 1- Diagnosis: • CXR or CT scan: Wide mediastinum, pneumomediastinum, pneumothorax, air around paraspinal muscles, pleural effusion (late) • CT scan: Esophageal wall thickening, mediastinal air fluid level • Water-soluble contrast esophagogram: Leak at perforation site 3-Management • Anbb1otics & supportive care for all patients • Surgical repair for significant leakage with systemic Inflammatory response Water-soluble contrast is preferred (less inflammatory to tissues). but a barium study has higher sensitivity and would be advised if the initial water-soluble contrast study Is nondiagnostic. If perforation is confirmed, primary closure of esophagus and drainage of mediastinum must be attempted urgently to prevent the development of mediastinitis.

Hairy cell leukemia is a chronic B-cell malignancy that occurs primarily in people age >50. Manifestations arise due to the neoplastic infiltration of the bone marrow, spleen, and peripheral blood as follows: • Bone marrow infiltration- causes bone marrow fibrosis with cytopenias. This may lead to recurrent infections (granulocytopenia), bleeding/bruising (thrombocytopenia), or fatigue/weakness (anemia). • Splenic infiltration - causes splenomegaly. Mass effect may lead to symptoms of abdominal fullness or early satiety (gastric compression). • Peripheral blood infiltration - peripheral blood smear shows abnormal circulating lymphocytes with "hairy" cytoplasmic projections. Although most patients are leukopenic due to bone marrow infiltration, a minority (such as this patient) have mild leukocytosis due to increased circulating lymphocytes. Hairy cell leukemia does not typically cause hepatomegaly, lymphadenopathy, or B symptoms. Diagnosis requires bone marrow biopsy with flow cytometry. Treatment • Chemotherapy (for moderate/severe) • Life expectancy is often near-normal

Clinical manifestations of trace mineral deficiencies: 1- Chromium • lmpatred glucose control in diabetics 2- Copper •Brittle hair • Sktn depigmentation • Neurologic dysfunction (eg, ataxia, peripheral neuropathy) • Sideroblastic anemia • Osteoporosis 3- Selenium • Thyroid dysfunction • Cardiomyopathy • Immune dysfunction 4- Zinc • Alopecia • Pustular skin rash (perioral region & extremities) • Hypogonadism • Impaired wound healing • Impaired taste • Immune dysfunction 5-Niacin (vitamin B,) deficiency (rare in developed countries) causes pellagra, which is characterized by dermatitis, diarrhea, and dementia. The rash associated with pellagra is hyperpigmented, occurs symmetrically in sun-exposed areas, and Is not pustular.

Factitious diarrhea has a female predominance, and most patients are employed in the health care field and have a history of multiple hospitalizations. Diarrhea associated with laxative abuse Is typically described as watery, frequent (10-20 bowel movements dally), and voluminous. Nocturnal bowel movements and abdominal cramps are common accompanying symptoms. Hypokalemia is due to increased loss of potassium in the stool. This then Impairs chloride reabsorption and resuHs In decreased activity of the chloride-bicarbonate exchange, increasing serum bicarbonate concentrations (metabolic alkalosis). Patients may also have hypermagnesemia if a magnesium-containing laxative Is used. Diagnosis is supported by a positive stool screen for diphenolic (eg, bisacodyl) or polyethylene-containing laxatives. Diagnosis is further suggested by the characteristic colonoscopy finding of melanosis coli, which is dark brown discoloration of the colon with pale patches of lymph follicles that can give the appearance of alligator skin. Melanosis coli can develop within a few months of the onset of regulat laxative Ingestion and can similarly disappear If laxative use Is discontinued. If melanosis coli is not seen on gross inspection, histological examination may demonstrate the pigment In the macrophages of the lamina propria. DDx: VIPomas are associated with diarrhea during fasting and dehydration, patients typically describe tea-colored stools and have hypokalemia with hypochlorhydria.

Cocaine is a stimulant that produces increased energy and decreases appetite and need for sleep. Individuals who abuse cocaine often present with mood changes (eg, euphoria, irritability) and weight Joss secondary to decreased appetite. The diagnostic hallmark in this scenario is erythema of the turbinates and nasal septum, which is a common finding in individuals who snort cocaine. In severe cases, perforation of the nasal septum can occur. In addition to mood disturbance, other psychiatric complications of cocaine use include anxiety, panic attacks, grandiosity, and psychosis (delusions and hallucinations). MDMA (ecstasy) is a commonly abused drug with stimulant and hallucinogenic properties. Due to its stimulant properties, users can present with decreased appetite, increased energy, euphoria, and disinhibition similar to that seen in cocaine use. However, it is taken in oral form and would not cause nasal erythema.

breast engorgement, which can occur 3-5 days after delivery, when colostrum is replaced by milk. Although it may occur at any point during breastfeeding due to milk accumulation with inadequate drainage, breast engorgement is especially common early in the postpartum period, when milk production is particularly robust. Symptoms of engorgement include bilateral, symmetric breast fullness, tenderness, and warmth, without fever. Intrapartum intravenous fluid administration can also cause breast edema and exacerbate pain. Cool compresses, acetaminophen, and nonsteroidal anti-inflammatory drugs may be used for symptom control. Patients should experience improvement as breastfeeding or regular pumping is established.

Common problems related to lactation: 1- Engorgement: Bilateral, symmetric fullness, tenderness & warmth 2-Nipple injury: Abrasion, bruising, cracking &/or blistering from poor latch 3-Plugged duct: Focal tenderness & firmness &/or erythema; no fever 4-Galactocele: Subareolar, mobile, well-circumscribed, nontender mass; no fever 5-Mastitis: Tenderness/erythema +fever 6-Abscess: Symptoms of mastitis + fluctuant mass

Conjunctival inflammation and watery discharge in the setting of an upper respiratory illness, has typical features of viral conjunctivitis ("pink eye"). Most cases are caused by adenovirus, and outbreaks are common among small children and caregivers in late summer and early fall. ***Can involve only one eye. Symptoms typically last several days and are self-limited. Occasional cases can develop a secondary bacterial infection ("bacterial superinfection") with more severe pain and grossly purulent exudate. Purulent bacterial conjunctivitis responds to topical antibiotic therapy, but uncomplicated viral conjunctivitis can be managed symptomatically. **Mast cell stabilizing agents, such as olopatadine and azelastine, are indicated for treatment of allergic conjunctivitis. Although symptoms of allergic and viral conjunctivitis are often similar, allergic conjunctivitis typically occurs episodically with a shorter duration of symptoms. In addition, although many viral conjunctivitis symptoms may be due to release of histamine from mast cells, mast cell stabilizers have not been well studied for this purpose and are generally not needed.

Conjunctivitis treatment: 1- Bacterial conjunctivitis • Erythromycin ointment • Polymyxin-trimethoprim drops • Azithromycin drops • Preferred agent in contact lens wearers: fluoroquinolone drops 2-Viral conjunctivitis • Warm or cold compresses • +/- Antihistamine/decongestant drops 3- Allergic conjunctivitis • Over-the-counter antihistamine/decongestant drops for intermittent symptoms • Mast cell stabilizer/antihistamine drops for frequent episodes **Amiodarone or lidocaine is often used in the treatment of hemodynamically stable patients with wide-QRS-complex tachycardia (ventricular tachycardia). Amiodarone is also used to treat atrial fibrillation. These drugs have no role in the management of PSVT.

Focal seizures may be motor (eg, turning of head). sensory (eg, paresthesias). or autonomic (eg, sweating). While all focal seizures originate in a single hemisphere, they may generalize to involve both hemispheres and can potentially cause impairment of consciousness. Patients who have focal seizures with impairment of consciousness (previously known as complex partial seizures). Patient cannot respond to stimuli during the episode, whereas those without impairment of consciousness remain alert, awake, and responsive. Repetitive semi-purposeful movements (eg, chewing, sucking, swallowing) called automatisms involve both hemispheres and are seen in focal seizures with impairment of consciousness. School-aged children with such subtle presenting signs may also present with a decline in academic performance. An EEG will show abnormal electrical activity that is sustained with a distinct start and stop different from the patient's background EEG. Focal seizures are not provoked by hyperventilation. ***Staphylococcus aureus is the most common pathogen isolated in infants and young children with cystic fibrosis (CF). Pseudomonas aeruginosa is the most common cause of CF-related pneumonia in adults and contributes to life-threatening decline of pulmonary function (reach each other at 20).

DDx of Focal seizures is absence seizure: Absence seizures are generalized seizures (originate from both cerebral hemispheres) and present with an arrest in activity without a postictal period. Typical absence seizures, which are easily provoked by hyperventilation, usually last for 10-20 seconds with an abrupt onset and resolution. Automatisms may also be present. A 3-Hertz spike-and-wave pattern is seen on EEG. Risk factors for acute mesenteric ischemia: • Atherosclerosis (acute on chronic) • Embolic source (thrombus, vegetations like IE) • Hypercoagulable disorders Diagnosis • CT (preferred) or MR angiography • Mesenteric angiography, if diagnosis unclear **Arthralgia due parvo B19 virus in children is symmetrical and involves large joints, we have lacy eruptions as cutaneous findings and in adults we have symmetrical arthralgia primarily involve small joints.

A hydrqcele is a fluid collection within the processus or tunica vaginalis - the peritoneal projection that accompanies the testis during its descent into the scrotum. When the processus vaginalis fails to obliterate, peritoneal fluid may accumulate within the processus vaginalis causing a communicating hydrocele. A collection of fluid within a tunica vaginalis that has properly obliterated its communication with the peritoneum is a noncommunicating hydrocele. Hydrocele can be differentiated from other testicular masses by transillumination; a hydrocele will transilluminate while other masses will not. Most hydroceles, both communicating and noncommunicating, will resolve spontaneously by the age of 12 months and can be safely observed during that period. **Smudge cells seen in CLL. Mantle cell lymphoma (MCL) is a type of non-Hodgkin's lymphoma (NHL), comprising about 6% of NHL cases. MCL cells generally over-express cyclin D1 due to a t(11:14). T-cell Acute lymphoblastic leukemia T-ALL: The t(11 ;14)(p15 ;q11) occurs in less than 1% of patients with T-cell ALL.

Dead space ventilation refers to ventilation of areas of the lung that are not perfused with blood (eg, pulmonary embolism). Alveolar consolidation in pneumonia causes hypoxemia due to right-to-left intrapulmonary shunting. Positional changes that make the consolidation more gravity dependent worsen ventilation/perfusion mismatch, increase intrapulmonary shunting, and lead to worsened hypoxemia. **Leukemoid reactions usually have lesser degree of leucocytosis and lack the myelocyte bulge seen in CML. Additionally there is an absence of basophilia. Leukocyte alkaline phosphatase is usually elevated in leukemoid reactions, and toxic granulations and Dohle bodies are noted.

Lichen sclerosus (LS) Is a chronic Inflammatory condition of the anogenltal region that can affect women at any age. This condition can have an autoimmune pathogenesis and often coexists with other autoimmune conditions (eg, type 1 diabetes mellitus. thyroid abnormalities). Extragenital Involvement (eg, buttocks, lower back, abdomen, under breasts, shoulders, armpits) is also possible. The perianal skin may also be involved, resulting in a "figure of 8" appearance. Anogenital symptoms include intense pruritus. dyspareunia, dysuria, and painful defecation. Physical examination reveals porcelain-white polygonal patches with atrophy (eg, regression, obliteration) of normal genital structures. The skin is classically described as "cigarette paper" quality (eg, thin, white, crinkled). Sclerosus and scarring lead to obliteration of the labia minora and clitoris and a decrease in the diameter of the Introitus, all findings seen In this patient. Although the diagnosis can be made clinically, a punch biopsy is recommended for definitive diagnosis. LS is a vulvar premalignant lesion as vulvar squamous cell carcinoma (SCC) occurs with greater frequency in these patients. A vulvar punch biopsy can rule out vulvar malignancy. Treatment of diffuse esophageal spasm: • Calcium channel blockers • Alternate: Nitrates, tricyclics

Diuretic abuse, which leads to hypovolemia, best explains the laboratory findings in this patient as follows: • Normally, dehydrated patients with hyponatremia are expected to have low urine sodium (<20 mEq/L); however, this patient has elevated urine sodium, which suggests salt wasting (eg, diuretic use, cerebral salt wasting [CSW], adrenal insufficiency). • Normally, patients with hypokalemia respond by reducing urine potassium excretion, except in cases of renal potassium wasting (eg, diuretic use, hyperaldosteronism, renal tubular acidosis). • Hypochloremia is likely a result of diuresis and contraction alkalosis; urine chloride levels can vary. **A reliable test gives similar or very close results on repeat measurements.Validity or accuracy is defined as the test's ability to measure what it is supposed to measure. In order to determine the validity of a test, the results are compared to those obtained from the gold standard test.

Diabetes insipidus (DI) is a leading cause of euvolemic hypernatremia. It typically presents with severe polyuria and mild hypernatremia. It can be divided into two types based on urine osmolality, as well as etiology. Based on urine osmolality, Dl may be complete or partial. 1. Complete Dl - the urine osmolality is less than 300 mOsm/kg (often less than 100 mOsm/kg) 2. Partial Dl - urine osmolality ranges from 300-600 mOsm/kg. The serum osmolality is elevated in both types. **Nephrogenic Dl results from renal ADH resistance. Common causes include hypercalcemia, severe hypokalemia, tubulointerstitial renal disease, and medications. The most commonly implicated mediations are lithium, demeclocycline, foscarnet, cidofovir, and amphotericin.

Divalproic acid is a mood stabilizer that is also used in the treatment of bipolar disorder. Common side effects include nausea, vomiting, somnolence, and weight gain. Anticonvulsant effect has been attributed to the blockade of voltage-dependent sodium channels and increased brain levels of gamma-aminobutyric acid (GABA). Used as anti-epileptic, for manic nd mixed episodes and as prophylaxis for migrains. Tolterodine Antimuscarinic drug that is used for symptomatic treatment of urinary incontinence. Treatment for Urge Incontinence and Other Overactive Bladder works on M2 and M3.

Prophylaxis criteria for Lyme disease (must meet all 5) • Attached tick is an adult or nymphal Ixodes scapularis (deer tick) • Tick attached for >36 hours or engorged • Prophylaxis started within 72 hours of tick removal • Local Borrelia burgdorferi infection rate >=20% (eg, New England area) • No contraindications to doxycycline ( eg, age <8, pregnant, or lactating) Ticks must be removed as soon as they are noticed as delay may increase risk of transmission. **Nummular eczema can appear very similar to early tinea corporis and is treated with emollients and topical corticosteroids.

Diverticulosis Is most common in the sigmoid colon, but diverticular bleeding is more common in the right colon. Diverticular bleeding Is typically painless, but large-volume bleeding may be associated with lightheadedness and hemodynamic Instability. low- or moderate-volume bleeding from the right colon will mix with stool and pass as dark or maroon-colored hematochezia. large-volume hemorrhage can lead to passage of frank red blood. The diagnosis is confirmed on colonoscopy. Most cases of diverticular hemorrhage will resolve spontaneously, but a minority of patients will require endoscopic or surgical intervention. May not be detected on abdominal x-ray. Colonic angiodysplasia can cause painless bleeding in the right colon. However, it Is significantly less common than diverticular hemorrhage. Angiodysplasia usually also causes low-volume (venous) bleeding. whereas diverticulosis can cause large-volume arterial hemorrhage.

Infective endocarditis: The most appropriate next step is to obtain serial blood cultures. It is recommended that a minimum of 3 blood cultures be obtained from separate venipuncture sites (not from a vascular catheter) over a specified period prior to initiating antibiotic therapy. In patients with acute illness, all 3 blood cultures should be obtained over a 1-hour period before beginning empiric antibiotic therapy. Patients with stable subacute illness (eg, general malaise with no fever) should have blood cultures obtained over several hours, and antibiotic therapy can be delayed until the blood culture results become available. Clinical findings (frequency) • Fever (>90%) • Heart murmur (85%) • Petechiae (<50%) • Subungual .splinter hemorrhages (<50%) • Osier nodes, Janeway lesions (<50%) • Neurologic phenomena (embolic) (~Oo/o) • Splenomegaly ( <30%) • Roth spots (retinal hemorrhage) (<5%)

Duke IE criteria: Major criteria • Blood culture positive for typical microorganism (eg, Streptococcus viridans, Staphylococcus aureus, Enterococcus) • Echocardiogram showing valvular vegetation Minor criteria • Predisposing cardiac lesion • Intravenous drug use • Temperature >38 C • Embolic phenomena • Immunologic phenomena (eg, glomerulonephritis) • Positive blood culture not meeting above criteria Definite IE: 2 major OR 1 major + 3 minor criteria Possible IE : 1 major + 1 minor OR 3 minor criteria

Abnormal uterine bleeding (AUB) Is any menstrual bleeding that is heavy, lasts >7 days, or occurs more often than every 21 days or less frequently than every 35 days. Other than pregnancy, AUB may be due to structural causes (eg, fibroids, adenomyosis, endometrial polyps, endometrial hyperplasia/malignancy) or nonstructural conditions (eg, coagulopathy, ovulatory dysfunction). Once pregnancy is ruled out, the Initial workup for AUB includes a complete blood count along with pelvic ultrasound to evaluate for structural abnormalities. In a patient age <45 with AUB and risk factors for endometrial hyperplasia (eg, obesity, oligomenorrhea). Endometrial biopsy Is also Indicated. Prolonged periods of oligomenorrhea (eg, menses less than every 35 days for 5 years} is evidence of chronic anovulation and increased risk of abnormal endometrial proliferation. Evaluation for endometrial hyperplasia or malignancy Is also necessary in all patients age >45 with AUB.

Endometrial biopsy indications: Age>=45 • Abnormal uterine bleeding • Postmenopausal bleeding Age <45 Abnormal uterine bleeding PLUS any of the following: • Unopposed estrogen exposure (obesity, chronic anovulation) • Failed medical management • Lynch syndrome (hereditary nonpolyposis colorectal cancer)

Painless testicular mass in men over 40 usually is testicular lymphoma and less likely to be testicular cancer. LDH and hCG may be elevated in both seminoma and non-seminoma cancer. CT scan of the abdomen needed to rule out the metastasis. Typically present as painless mass in men between 15 to 35. Orchiectomy required for definitive diagnosis.

Epinephrine is always the first-line treatment for anaphylaxy regardless of the timing. There is no contraindication for epinephrine usage. Endotracheal intubation is indicated if stridor or respiratory arrest present.

An adnexal mass may arise from the ovary or fallopian tube and requires further investigation once identified on physical examination. An asymptomatic, palpable, smooth adnexal mass without any additional signs of ovarian cancer (eg, ascites. cul-de-sac nodularity} Is likely benign. However, an adnexal mass may be the only sign of ovarian cancer, and reassurance is not appropriate until further investigation. **Hypoglossal nerve injury can cause tongue palsy. Surgery below the mandible, such as for a tumor of the submandibular salivary gland, would put one at risk for this type of injury. Parotid surgery involving the deep lobe of the parotid gland carries a significant risk of facial nerve palsy resulting in facial droop.

Epithelial ovarian carcinoma: Clinical presentation • Acute: Shortness of breath, obstipation/constipation with vomiting, abdominal distension • Subacute: Pelvic/abdominal pain, bloating, early satiety • Asymptomatic adnexal mass Increased CA-125 Ultrasound findings •Solid mass •Thick septation •Ascites Management •Exploratory laparotomy

Management of shoulder dystocia (BECALM): B: Breathe, do not push; lower head of the bed E: Elevate legs into McRoberts position -sharp hip flexion while in supine position C: Call for help - nurses, anesthesiologists, pediatricians, another physician A: Apply suprapubic pressure - downward & lateral to release anterior shoulder L: Enlarge vaginal opening with episiotomy to facilitate extra maneuvers M: Maneuvers • Delivery of posterior arm • Pressure against baby's posterior shoulder either anteriorly or posteriorly & anterior rotation (Woods corkscrew or Rubin maneuver) • Mother on hands & knees- "all fours" (Gaskin maneuver) • Replacement of baby's head to vagina followed by cesarean delivery (Zavanelli maneuver) **Replacement of the fetal head into the maternal pelvis (eg, Zavanelli maneuver) is performed if all other dystocia maneuvers fail in order to perform an emergency cesarean delivery.

Erb-Duchenne palsy: 1- Upper arm adducted & internally rotated 2-Elbow extended 3-forearm pronated 4-Wrist & fingers flexed Klumpke palsy: 1-Metacarpophalangeal joints hyperextended 2-Interphalangeal joints flexed 3-Forearm supinated and Wrist extended **Delirium is characterized by a fluctuating disturbance in attention that can develop acutely in association with an underlying condition. It is common postoperatively or in the setting of new or worsening infections. It may also occur after the introduction of new medications (eg, opioids, benzodiazepines, anticholinergics) that can potentially lead to confusional states. The elderly are at higher risk for delirium. Delirium may be associated with psychotic symptoms, particularly visual hallucinations, in addition to sleep and behavioral changes. Symptoms of fluctuating cognitive impairment and acute onset in association with an underlying condition can help differentiate delirium-induced psychosis from primary psychotic disorders (in which the sensorium is clear). Although antipsychotics can be used to target the psychotic manifestations of delirium, the primary treatment is the identification and treatment of the underlying condition.

Medulloblastoma is the second most common posterior fossa tumor in children after cerebellar astrocytoma. The vast majority of medulloblastomas occur in the cerebellar vermis (red circle), which is particularly important for balance and gait coordination. As a result, symptoms include truncal or gait instability. Less commonly, medulloblastomas occur in the lateral cerebellar hemispheres similar to pilocytic astrocytomas, which affect fine motor planning and cause dysmetria, intention tremor , and dysdiadochokinesia. Given the proximity to the fourth ventricle, medulloblastoma can also cause obstructive hydrocephalus (red arrow), resulting in signs of increased intracranial pressure (eg, headache, vomiting).

Eyelid retraction occurs in Parinaud syndrome, which results from pressure on the pretectal region of the midbrain. Findings include limitation of upward gaze with a downward gaze preference, bilateral eyelid retraction, and light-near dissociation. Pineal tumors are associated with Parinaud syndrome. Aphasia (ie, insult to frontal or temporal/language center) and hemiparesis (ie, insult to frontal lobe/motor cortex) can occur in patients with brain tumors in the cerebral hemispheres. The most common hemispheric tumors in children are low-grade astrocytomas.

An untoward effect of the widespread use of pneumococcal conjugate vaccines has been the emergence of "replacement strains," a term used to describe nonvaccine pneumococcal serotypes that appear as colonizers of the nasopharynx and as a cause of pneumococcal disease in recipients of PCV One advantage of Pneumococcal polysaccharide vaccine (PPSV23) is that we will have decreased incidence of replacement strains due to lack of mucosal immunity (those strains will come in but get killed by the Ab, but the range of coverage is lower anyhow) **In febrile xeizure: Multiple studies have shown that interventions such as imaging or lumbar puncture in the fully vaccinated child with a normal neurologic examination are low yield, unnecessarily invasive, and anxiety-provoking. Brain Imaging should be considered in a child with a complex febrile seizure with a persistently abnormal neurologic examination, macrocephaly, or signs/symptoms of elevated intracranial pressure. Erectile dysfunction (ED) is common in patients with cardiovascular disease due to decreased penile blood flow, endothelial dysfunction, and vasoactive medications. First-line treatment for most patients with ED, including those with cardiovascular disease, is a phosphodiesterase-5 (PDE-5) inhibitor (eg, sildenafil). These medications are safe and effective in treating ED in low-risk patients with cardiovascular disease. However, PDE-5 inhibitors are contraindicated in patients taking nitrates as concomitant use can cause a precipitous drop in blood pressure, leading to syncope. Coadministration of alpha blockers with PDE-5 inhibitors can also cause severe hypotension. Other common side effects of PDE-5 inhibitors include headaches and disturbances in vision and hearing. We should not discontinue selective beta blocker only because of sexual side effects.

Febrile seizure: 1-Risk factors • Fever from mild viral (eg, influenza, adenovirus, HHV-6) or bacterial infection • Immunizations (DTaP, MMR) • Family history 2-Diagnostic criteria • Age 6 months-6 years • Temperature >38 C (100.4 F) • No history of previous afebrile seizures • No CNS infection • No acute systemic metabolic cause of seizure 3-Subtypes • Simple: o Nonfocal (tonic-clonic or atonic) o 1 episode <15 minutes or multiple "episodes <30 minutes • Complex: o Focal o 1 episode >15 minutes or multiple "episodes >30 minutes 4- Management • Abortive therapy if seizure >5 minutes • Reassurance/education 5- Prognosis • Normal development/intelligence • - 30% risk of recurrence • <5% risk of epilepsy

Clinical features of type 2 heparin-induced thrombocytopenia: 1-Clinical signs Suspected with heparin exposure >5 days & any of the following: • Platelet count reduction >50% from baseline • Arterial or venous thrombosis • Necrotic skin lesions at heparin injection sites • Acute systemic (anaphylactoid) reactions after heparin 2-Diagnostic evaluation • Serotonin release assay: Gold standard confirmatory test • Start treatment in suspected cases prior to confirmatory tests 3- Therapy • Stop ALL heparin products • Start a direct thrombin inhibitor (eg, argatroban) or fondaparinux (synthetic pentasaccharide)

Fondaparinux is a synthetic pentasaccharide factor Xa inhibitor. Fondaparinux (trade name Arixtra) is an anticoagulant medication chemically related to low molecular weight heparins. One potential advantage of fondaparinux over LMWH or unfractionated heparin is that the risk for heparin-induced thrombocytopenia (HIT) is substantially lower. Furthermore, there have been case reports of fondaparinux being used to anti-coagulate patients with established HIT as it has no affinity to PF-4. However, its renal excretion precludes its use in patients with renal dysfunction. In contrast to heparin, fondaparinux does not inhibit thrombin.

Coarctation of the aorta, a usually congenital narrowing of the descending aorta typically located just distal to the left subclavian artery. The narrowing creates a proximal arterial pressure load affecting the upper body. Patients can sometimes present in adulthood, typically with asymptomatic hypertension (of the upper extremities) and less often with accompanying epistaxis and headaches. Physical examination typically demonstrates brachial-femoral pulse delay. There may be a systolic murmur (due to blood flow through a constricted aorta) heard at the left infraclavicular area anteriorly and left interscapular area posteriorly; the murmur may be continuous if collateral vessels are present. A fourth heart sound (due to hypertension-induced left ventricular hypertrophy) may also be present. Clinical features o Hypertension (headaches, epistaxis) • Lower extremities o Underdeveloped o Claudication • Brachial-femoral pulse delay • Upper & lower extremity blood pressure differential • Left interscapular systolic or continuous murmur Physical findings: o Inferior notching of the 3rd to 8th ribs o "3" sign due to aortic indentation

However, excessive maternal hyperglycemia due to gestational diabetes mellitus results in excessive fetal hyperglycemia, which increases fetal pancreatic insulin secretion and thereby causes fetal hyperinsulinemia. Excessive production of insulin, an anabolic hormone, leads to a macrosomic fetus (eg, estimated fetal weight ~4.5 kg [9.9 lb]) with disproportionate growth and fat accumulation over the shoulders and abdomen. As a result, the shoulders can become impacted in the maternal pelvis, resulting in shoulder dystocia, an obstetric emergency. Potential complications include clavicle fracture, brachial nerve palsies, perinatal asphyxia, and neonatal hypoxic encephalopathy. **Macrocytic anemias are characterized by mean corpuscular volume (MCV) >100 fl. The most likely cause of macrocytic anemia in this patient with sickle cell disease (SCD) is folate deficiency. SCD is a chronic hemolytic anemia with an appropriate reticulocytosis response. Red blood cells are generally normocytic and normochromic unless there is coexisting hemopathy (eg, alpha or beta thalassemia, iron deficiency, folate/B12 deficiency). Chronic hemolysis contributes to the anemia seen in SCD. Folate deficiency often ensues (often in the form of macrocytic anemia) as the bone marrow tries to make more red blood cells to compensate. Daily folic acid supplementation is recommended in all SCD patients to correct the underlying folate deficiency.

Self-mutilation in the presence of dystonia is characteristic of Lesch-Nyhan syndrome. It is an X-linked recessive disorder (all victims of Lesch-Nyhan syndrome are male) resulting from a deficiency in hypoxanthine-guanine phosphoribosyl transferase (HPRT), an enzyme involved in purine metabolism. This deficiency results in increased levels of uric acid and its consequent accumulation in peripheral tissue. The condition generally presents around the age of 6 months with hypotonia and persistent vomiting. The clinical picture worsens thereafter with the progressive mental retardation, choreoathetosis, spasticity, dysarthric speech, dystonia and compulsive self-injury, especially biting of the upper extremities. The uric acid excess deposits in different tissues, resulting in gouty arthritis, tophus formation and obstructive nephropathy. Allopurinol is used to reduce the uric acid levels. Patients should be advised to take adequate intake of fluids.

In minimal change disease: The majority of patients respond rapidly to corticosteroid therapy; >90% of have complete remission with the disappearance of proteinuria. Therefore, biopsy is reserved for steroid-resistant or pro.gressive disease. Older children or adolescents should undergo renal biopsy to exclude other causes of nephrotic syndrome. Ovarian cancer can present as an adnexal mass with pelvic pain and bloating due to abnormal proliferation of ovarian or tubal epithelium or peritoneum. Ultrasound features suggesting malignancy are a solid mass with thick septations and the presence of ascites. Management is with exploratory laparotomy.

Nicotine replacement therapy (NRT), varenicline, and bupropion are the 3 available FDA-approved, first-line pharmacological treatments for smoking cessation. NRT replaces the nicotine from tobacco to decrease nicotine withdrawal and aid in smoking cessation. It can be delivered in multiple ways (eg, transdermal patch, gum, lozenge, inhaler, nasal spray). The combination of patch and gum or lozenge is commonly used to control both shorter-term and longer-term nicotine withdrawal symptoms. Varenicline, an alpha-4 beta-2 nicotinic acetylcholine receptor partial agonist, can diminish nicotine cravings. However, varenicline has been associated with mood changes and suicidality as well as cardiovascular events in patients with pre-existing cardiovascular disease. The antidepressant bupropion is a norepinephrine and dopamine reuptake inhibitor that has been found to be an effective smoking cessation aid. However, it is contraindicated in patients with bulimia or seizures

In the heart, acromegaly causes concentric myocardial hypertrophy leading to diastolic dysfunction, along with left ventricular dilation and global hypokinesis. Flail mitral leaflet is caused by rupture of the chordae tendineae due to mitral valve prolapse, endocarditis, or myxomatous degeneration or by rupture of the papillary muscles in acute myocardial infarction. Acute mitral regurgitation due to a flail leaflet is characterized by severe pulmonary edema and hypotension with a hyperdynamic precordium. The putamen is a common site of hypertensive intraparenchymal brain hemorrhage. The internal capsule that lies adjacent to the putamen is almost always involved, leading to contralateral hemiparesis, sensory loss, and conjugate gaze palsy toward the side of the lesion.

Clinical features of absence seizures & inattentive staring spells: Absence seizures • Occurrence during all activities • Length <20 seconds • Lack of response to vocal or tactile stimulation • Presence of automatisms **Postural tone is preserved with absence seizures. **Absence seizures are not associated with a postictal state.Sleepiness after an episode should raise suspicion for alternate seizure semiologies. **may be accompanied by simple automatisms (eg, eyelid fluttering, lip smacking) but not more complex motor events.

Inattentive staring spells: • Occurrence primarily during "boring" activities • Variable length, often >1 minute • Response to vocal or tactile stimulation • Lack of automatisms

The initial treatment for severe hypovolemic hypernatremia is isotonic 0.9% saline, which acts to gradually correct the hyperosmolality while normalizing the patient's volume status. Isotonic saline is usually hypoosmolar in comparison to the hypernatremic plasma. Once the volume deficit has been restored, such patients are then switched to half-normal (0.45%) saline in order to better replace the free water deficit. The goal rate of plasma sodium correction is no more than 1 mEq/L/h. A greater rate of correction may result in cerebral edema. **5% dextrose in water (D5W) is the treatment of choice for patients with euvolemic and hypervolemic hypernatremia. 5% dextrose in 0.45% saline is the treatment of choice for mild hypovolemic hypernatremia.

Inclusion body myositis is a condition involving adult-onset distal muscular weakness and atrophy. Majority of patients may also present with dysphagia and decreased oral intake. There is no standard course of treatment to slow or stop the progression of the disease. IBM patients do not reliably respond to the anti-inflammatory, immunosuppressant, or immunomodulatory drugs that have been tried. Management is symptomatic. The presence of anti-cN1A autoantibody in some patients with polymyositis may raise a possibility that those patients may in fact have had IBM. CK may be normal or elevated.

Septic arthritis is often preceded by a seemingly mild infection ( eg, cellulitis) in which there may be intermittent bacteremic showers, allowing for hematogenous spread of bacteria into the synovial fluid. Therefore, blood cultures should be obtained in addition to synovial fluid cultures. The most common offending organisms in children are Staphylococcus aureus and streptococci. Empiric intravenous antibiotics (eg, vancomycin) should be administered immediately after culture collection and adjusted according to speciation and sensitivity data. Gram stains and cultures can be falsely negative and confounded as this patient was pretreated with outpatient antibiotics for his recent skin infection. Synovial fluid aspiration with>100,000/micro L leukocytes, >90% neutrophils, and purulent fluid should prompt orthopedic consultation for emergency surgical drainage. Debridement and irrigation of the joint space is the most important intervention in preventing long-term disability. **Supportive therapy is a reasonable therapy for many viral encephalitis except HSV. Treatment with IV acyclovir significantly decreases the mortality. Without treatment the mortality rate is 70%. **gross hematuria is more commonly associated with benign prostatic hyperplasia than prostate cancer.

Inflammatory (eg, crystal, RA) Translucent or opaque 2000-1000 often >50% neutrophil Septic joint: Opaque, 50000-150000 >80% to 90% neutrophils **History of diabetic retinopathy is an absolute contraindication for thrombolytic therapy. Relative contraindication of thrombolytic therapy: 1-Uncontrolled hypertension (BP > 180/110), either currently or in the past 2-Intracranial abnormality not listed as absolute contraindication (i.e. benign intracranial tumor) 3-Ischemic stroke more than 3 months prior 4-Bleeding within 2 to 4 weeks (excluding menses) 5-Traumatic or prolonged 6-cardiopulmonary resuscitation (>10 min) 7-Major surgery within 3 weeks 8-Pregnancy 9-Current use of anticoagulants 10-Non-compressible vascular puncture 11-Dementia

Iron deficiency anemia in children age <2: Risk factors • Prematurity • Lead exposure • Infants who consume: o Low-iron formula o Cow's milk, soy milk, or goat's milk before age 1 year o Exclusive breastfeeding after age 6 months • Toddlers who consume: o >24 ounces/day of milk o <3 servings/day of iron-rich foods (eg, meat, fortified cereal) Universal screening • Complete blood count in all children at age 9-12 months Treatment • Empiric trial of iron supplementation In absence seizure events can occur infrequently or up to 100 times a day without warning. Absence seizures may be accompanied by simple automatisms (eg, eyelid fluttering, lip smacking) but not more complex motor events. Patients generally are unaware that a seizure has occurred and do not remember what happened during it. The events are often first noticed by teachers and are frequently mistaken for attention deficit hyperactivity disorder (ADHD) or normal childhood staring spells.

Iron deficiency is the most common nutritional deficiency in children. An infant's iron stores are affected by the maternal iron stores, prenatal or perinatal hemorrhage, and the gestational age of the infant at delivery; also, prematurity is a risk factor for iron deficiency. Term infants usually have adequate iron stores for the first 6 months of life. After 6 months, inadequate dietary intake becomes the most important cause of iron deficiency. Early introduction or excessive intake of cow's milk is problematic as cow's milk is low in iron and can cause occult intestinal blood loss in infants. Children should not be started on cow's milk until age 1 year, and children age <: 1 year should consume <24 ounces/day. Children with iron deficiency are often asymptomatic and may not have telltale symptoms such as pica, fatigue, or pallor. Therefore, universal screening is recommended by age 1 year, and the diagnosis is typically based on a complete blood count. A peripheral smear would be expected to show microcytic hypochromic erythrocytes, although it is usually not needed in the initial workup. Further testing is not necessary in children with the classic presentation. The most cost-effective approach to treatment is empiric oral iron therapy. Hemoglobin should be rechecked in 4 weeks; if the hemoglobin level has risen 1 g/dL, the oral iron therapy should be continued for 2-3 months after the hemoglobin normalizes to iron stores.

Open angle glaucoma is usually asymptomatic in the earlier stages. It is more common in African Americans, and has an increased prevalence in those with a family history of glaucoma and diabetes. There is a gradual loss of peripheral vision over a period of years, and eventual tunnel vision. On examination, the intraocular pressure is high. There may be cupping of the optic disc with loss of peripheral vision. Annual examination in high-risk populations is of great benefit in prevention of the condition. Beta-blockers such as Timolol eye drops are effective in the initial management of the patient. Laser trabeculoplasty is used as an adjunctive measure. If there is a continuous increase in intraocular pressure, surgical trabeculectomy is done.

Juvenile myoclonic epilepsy presents with generalized seizures during adolescence, most commonly myoclonic jerks that are most prominent in the first hour after awakening. Absence seizures and generalized tonic-clonic seizures may also be seen. Lennox-Gastaut syndrome typically presents by age 5 with intellectual disability and severe seizures of varying types (eg, atypical absence, tonic). EEG demonstrates a slow spike-wave pattern.

Myotonic muscular dystrophy type 1 (Steinert disease): It is the most common adolescent/adult-onset muscular dystrophy, affecting - 1 in 8000 persons in the United States. An autosomal dominant expansion of trinucleotides on the dystrophia myotonica protein kinase gene causes myotonia; weakness of skeletal, smooth, and cardiac muscles; and problems in multiple other organ systems (Table). Myotonia (delayed muscle relaxation) is most notable when the patient is unable to release the hand after a handshake (grip myotonia). Skeletal muscle weakness is prominent in the face, forearms, hands, and ankle dorsiflexors (eg, bilateral foot drop). Onset can be between 12-30 of age. Dysphagia, the most dangerous smooth muscle manifestation, significantly increases the risk of aspiration pneumonia. Cardiac involvement includes conduction problems and arrhythmias. Other manifestations include cataracts, testicular atrophy/infertility, frontal baldness, and insulin resistance. Death from heart heart failure depending on age of onset. DDX: Duchenne and Becker 1- Both X-linked recessive deletion of dystrophin 2- Becker Onset: age 5-15, Death by age 40-50 from heart failure. Duchenne Onset: age 2-3, Death by age 20-30 from respiratory or heart failure.

Leber Hereditary Optic Neuropathy (LHON) is the most common inherited mitochondrial disorder, and typically affects young males. It typically begins as a unilateral progressive optic neuropathy, with sequential involvement of the fellow eye months to years later. Treatment options are limited, but include the use of antioxidant supplements. Gene therapy trials are currently underway. Mitochondrial mutations cause defects in several NADH-ubiquinone oxidoreductase chains. This is thought to impair glutamate transport and increase reactive oxygen species production. **This patient has trigeminal neuralgia, a disorder characterized by recurrent and sudden-onset severe, stabbing pain along the V2 (maxillary) and V3 (mandibular) branches of the trigeminal nerve, which usually occurs unilaterally. The episodes last for a few seconds to minutes and can be triggered by minor stimuli (eg, touch, wind, chewing). Multiple sclerosis (MS), an autoimmune demyelinating central nervous system disorder, is one of the few conditions that may present with trigeminal neuralgia bilaterally. This occurs due to demyelination of the nucleus of the trigeminal nerve or the nerve root, which leads to improper signaling of the nerve and paroxysms of severe pain.Multiple sclerosis should be suspected when trigeminal neuralgia presents bilaterally.

Cutaneous Kapusi Sarcoma develops most often on the lower extremities, face, oral mucosa, and genitalia. The lesions commonly appear as multiple violaceous (or pink, red, brown) papules due to increased vascularity. Patients do not usually have significant pruritus or skin necrosis. Prominent lymphedema (due to vascular obstruction by KS lesion or to cytokine production), which can manifest extremity swelling, can sometimes be seen.

Leukocytoclastic vasculitis can be due to infections, medications, inflammatory conditions, or malignancy. It typically presents as non-blanching, 1-3 mm violaceous papules that can cluster/coalesce into plaques. Older lesions appear brownish-red: newer ones are more violaceous. Compared to KS are smaller, lighter in color and more flat.

In a young patient from a developing country, the clinical presentation of progressive dyspnea, nocturnal cough, and hemoptysis is highly suggestive of rheumatic MS. Long-standing MS leads to an increase in left atrial pressure, which in turn leads to elevated pulmonary pressures and pulmonary vascular congestion; these changes can cause dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and hemoptysis. In addition, the left atrial enlargement resulting from increased left atrial pressure predisposes to the development of atrial fibrillation (eg, palpitations, irregular heartbeat), which increases the risk of left atrial thrombus formation and systemic thromboembolic complications (eg, stroke) . *Amiodarone is a class Ill antiarrhythmic drug used occasionally for acute management of ventricular arrhythmias (which would present as wide complex arrhythmias) and for maintenance of sinus rhythm in patients with atrial fibrillation. It should not be used In hemodynamically unstable patients as it can further aggravate hypotension and will delay definitive therapy with cardioversion. **Immediate synchronized cardioversion is the initial treatment of choice in patients with persistent tachyarrhythmia (narrow or wide complex) associated with clinical or hemodynamic instability (hypotension, cardiogenic shock, signs of ischemia, acute heart failure). After synchronized cardioversion consider sedation and adenosine administration.

Mitral stenosis: 1-Clinical features • Dyspnea, orthopnea, PND, hemoptysis • Atrial fibrillation, systemic thromboembolism • Voice hoarseness from recurrent laryngeal nerve compression due to LAE (Ortner syndrome) Physical examination • Mitral facies (pinkish-purple patches on cheeks) • Loud 51 , loud P2 if pulmonary hypertension • Opening snap (high-frequency early diastolic sound) • Mid-diastolic rumble (best heard at cardiac apex) Diagnosis • CXR: Pulmonary blood flow redistribution to upper lobes, dilated pulmonary vessels, LAE, flattened left heart border • ECG: "P mitrale" (broad & notched P waves), atrial tachyarrhythmias, RVH (tall R waves in V1 & V2) • TTE: MV thickening/calcification/! mobility, coexisting MR

Mobitz type I: Level of block is Usually AV node QRS complex Narrow Exercise or atropine Improves type I AV block Worsens type II AV block Vagal maneuvers (carotid sinus massage) Worsens type I AV block AV block. Paradoxically improves type II.

Mobitz type II: Level of block is Below the level of AV node (eg, bundle of His) QRS complex Narrow or wide Exercise or atropine Improves type I AV block Worsens type II AV block Vagal maneuvers (carotid sinus massage) Worsens type I AV block AV block. Paradoxically improves type II. Indication for pacemaker

Signs and symptoms suggestive of necrotizing surgical site infection: • Pain, edema, or erythema spreading beyond the surgical site • Systemic signs such as fever, hypotension, or tachycardia • Paresthesia or anesthesia at the edges of the wound • Purulent, cloudy-gray discharge ("dishwater drainage") • Subcutaneous gas or crepitus Necrotizing surgical site infections occur more commonly in patients with diabetes and are usually polymicrobial. These infections are considered emergencies if they involve the fascial plane and develop into necrotizing fasciitis. The most important step in management of this condition is early surgical exploration to assess the extent of the process and debride necrotic tissues. Adjunctive therapies, including broad-spectrum antibiotics, adequate hydration, and tight glycemic control, are also important but are secondary to surgical exploration.

Negative-pressure wound therapy (ie, vacuum-assisted wound closure) is a wound-dressing system that applies sub-atmospheric pressure to a wound to accelerate the healing process. It is reserved for healthy, granulating wounds. It is not used initially when the wound is infected or necrotic. **Intravenous antibiotics alone are sufficient therapy for wound infections limited to cellulitis, but surgical debridement is required when the infection penetrates the deeper skin layers and adjacent tissue. **Topical antimicrobial agents do not have a clear role in surgical site infections. They are not useful for prevention as they may inhibit wound healing, and they are not a substitute for parenteral therapy once infection has been established.

**Patients with BAT should be assessed for intraperitoneal free fluid or hemorrhage. The most commonly used approach is the Focused Assessment with Sonography for Trauma (FAST), which evaluates both the abdomen and pericardium for evidence of organ injury or hemorrhage; it should be the first step in alert and hemodynamically stable (eg, systolic blood pressure >90 mm Hg) patients. FAST can be performed rapidly at the bedside and has good sensitivity and specificity for detecting hemoperitoneum, pericardial effusion, and intraperitoneal fluid. If FAST Is limited or equivocal, a diagnostic peritoneal lavage (DPL) can be done to evaluate for hemoperitoneum. Hemodynamically stable patients with positive findings may undergo subsequent testing with abdominal CT scan to determine the need for laparotomy. Hemodynamically unstable patients with a positive finding on either DPL or FAST should undergo exploratory laparotomy. If FAST is negative then serial abdominal examination +/- CT scan should be done. *UTI is typically acquired when bacteria around the vaginal introitus ascend the urethra to the bladder. Compared to men, women are at increased risk for UTI due to a shorter urethra. Recent sexual activity (eg, honeymoon cystitis) is a common predisposing factor, as bacteria can be introduced to the introitus during intercourse. Enteric organisms, particularly coliforms such as Escherichia coli, are the most common causes of UTI.

Neonatal polycythemia: 1-Definition: Hematocrit >65% in term infants 2-Causes Increased erythropoiesis from intrauterine hypoxia • Maternal diabetes • Maternal hypertension • Smoking • Intrauterine growth restriction Erythrocyte transfusion • Delayed cord clamping • Twin-twin transfusion 3-Clinical presentation • Ruddy skin • Hypoglycemia** • Respiratory distress** • Cyanosis** • Apnea, irritability, jitteriness • Abdominal distension 4-Treatment Partial exchange transfusion (remove blood, infuse normal saline)

Idiopathic guttate hypomelanosis is a common finding with aging and is characterized by small macules in sun-exposed areas. A skin biopsy demonstrates that there is no pigment (melanin) in the skin cells (keratinocytes). There is also a reduction in the number of pigment-producing cells (melanocytes). The skin is slightly thinner than normal and flattened out. The cause of guttate hypomelanosis is speculative. It is thought to be an inevitable part of the ageing process, with a gradual reduction in melanocytes - a similar process to greying of hair. **If spirometry is not readily available or is difficult in an unstable patient, peak flow meter testing should be performed to assess the maximum speed of expiration. However, peak expiratory flow rate is less accurate than FVC in determining ventilation adequacy.

Neuromuscular respiratory failure is the most life-threatening complication found in up to 30% of patients. After the diagnosis of GBS is suspected, the most important next step in management is assessing the patient's pulmonary function by serial spirometry. Measurement of forced vital capacity (FVC) is the gold standard for assessing ventilation; a decline in FVC (especially s20 mUkg) indicates impending respiratory arrest requiring endotracheal intubation. Severe autonomic dysfunction (eg, heart rate and blood pressure instability), flaccid quadriparesis, inability to hold the neck erect, and bulbar palsy are other indications for critical care. With early diagnosis and cardiopulmonary support, most young patients have a good prognosis, experiencing spontaneous recovery within a year.

Causes of secondary enuresis: Psychological stress • Behavior regression, mood lability Urinary tract infection • Dysuria, hesitancy, urgency, abdominal pain Diabetes mellitus • Polyuria, polydipsia, polyphagia, weight loss, lethargy, candidiasis Diabetes insipidus • Polyuria, polydipsia Obstructive sleep apnea • Snoring, dry mouth, fatigue, hyperactivity, irritability

Normal individuals have a blind spot in their visual fields at the location of the optic nerve head; this blind spot enlarges in those with papilledema. Papilledema can cause momentary vision loss that varies according to changes in head positioning. It can also lead rapidly to permanent vision loss and requires urgent diagnostic evaluation. Although headaches can be due to a variety of etiologies, those secondary to increased ICP are often worse in the morning. Amaurosis fugax is painless, transient monocular blindness that lasts a few seconds. It is usually vascular (eg, embolus to ophthalmic artery) in origin.

Basilar migraines occur due to cerebral vasospasm involving the brainstem. Patients typically have basilar aura symptoms (eg, vertigo, dysarthria, tinnitus, diplopia) without motor weakness, followed by a migraine-type headache. Nitrates (and calcium channel blockers) relax not only myocytes in coronary vessels, but also those in the esophagus, thereby alleviating the pain. Esophagography may or may not show other anomalies (eg, corkscrew shape). Esophageal m anom etry should show repetitive, non-peristaltic, high-amplitude contractions, either spontaneously or after ergonovine stimulation.

Normal parameters: 1-right atrial pressure (preload): mean of 4mm Hg. Increased in cardiogenic shock. 2-Cardiac index (pump function): 2.8-4.2 Umin/m2: only increased in septic shock and decreased in both hypovolemic and cardiogenic shock 3- Mixed venous oxygen saturation: 60%-80%. increased in septic shock

In general, oxygenation may be improved by increasing either the fraction of inspired oxygen (FiO,) or positive end-expiratory pressure (PEEP) provided by the mechanical ventilator. • PEEP prevents alveolar collapse during respiratory cycles and may also reopen some alveoli that have already collapsed, reducing shunting. Therefore, in this patient, increasing PEEP is the best next step as it would not only improve oxygenation but also directly counteract one of the mechanisms by which ARDS causes hypoxemia. High PEEP approaches may improve mortality in patients with severe ARDS. • Fio2 ,patients are often provided high Fio2 immediately after intubation. Although it could be increased further, Fi02 is usually weaned to <60% as quickly as possible because prolonged high FiO2 increases the risk of pulmonary oxygen toxicity (formation of proinflammatory oxygen free radicals). Therefore, in patients requiring high levels of Fi0 2 , PEEP levels should be increased (as long as a normal plateau pressure can be maintained [to reduce the risk of barotrauma]) to allow for reductions in the Fi0 2 as oxygenation improves **Fevers, chills, left upper-quadrant pain, splenic fluid collection is consistent with a likely splenic abscess. Splenic abscess usually presents with the classic triad of fever, leukocytosis, and left upper-quadrant abdominal pain. Patients can also develop left-sided pleuritic chest pain, left pleural effusion, and splenomegaly. Risk factors for splenic abscess include infection (eg, infective endocarditis) with hematogenous spread, immunosuppression, IV drug use, trauma, and hemoglobinopathies. Diagnosis is usually confirmed by computed tomography scan of the abdomen. Some studies have documented a 10%-20% incidence of associated splenic abscess or infarction with left-sided endocarditis. Likely mechanisms include hematogenous seeding or septic emboli to the spleen. Splenic abscess is most commonly due to Staphylococcus, Streptococcus, and Salmonella. Antibiotics alone for treating splenic abscess have a high mortality (up to 50% in some studies). As a result, splenectomy is recommended for all patients. Percutaneous drainage may be an option in poor surgical candidates. DDx: Infectious mononucleosis is due to the Ebstein-Barr virus. Patients usually develop lymphadenopathy, fever, and possible hepatosplenomegaly. However, infectious mononucleosis is usually not associated with left pleural effusion or splenic abscess.

Parkinson disease (PD), a neurodegenerative disorder caused by accumulation of alpha-synuclein within the neurons of the substantia nigra pars compacta, which ultimately leads to the death of these neurons. The three cardinal signs of PD are rest tremor, rigidity and bradykinesia. The presence of two of these three signs suggests a clinical diagnosis of PD, which can be further confirmed by physical examination. To date, there are no imaging or laboratory tests that can be used to confirm this diagnosis with any gr.eater accuracy than physical examination. The most common presenting sign of PD is an asymmetric resting tremor in the distal part of an upper extremity. To summarize, physical examination findings that contribute to a clinical diagnosis of PD include: Tremor: • A resting 4 to 6 Hz tremor with a "pill rolling" quality • Frequently first manifests in one hand, and may then slowly generalize to involve the other side of the body and the lower extremities Bradykinesia: • Difficulty initiating movements, as when starting to walk or rising from a chair • Narrow-based, shuffling gait with short strides and without arm swing (festinating gait) • Micrographia (small handwriting) • Hypomimia (decreased facial expression) • Hypophonia (soft speech) Postural instability: • Flexed axial posture • Loss of balance during turning or stopping • Loss of balance when pushed slightly from a stationary bipedal stance • Frequent falls

A history of a recent upper respiratory tract infection followed by sudden onset of cardiac failure in an otherwise healthy patient is suggestive of dilated cardiomyopathy, most likely secondary to acute viral myocarditis. Dilated cardiomyopathy is the end result of myocardial damage produced by a variety of toxic, metabolic, or infectious agents. Viral or idiopathic myocarditis is most commonly seen following Coxsackievirus B infection, and occurs in about 3.5 - 5% of infected patients. Other viruses commonly implicated include parvovirus 8 19, human herpesvirus 6, adenovirus, and enterovirus. Viral myocarditis can cause dilated cardiomyopathy via direct viral damage and as a result of humoral or cellular immune responses to persistent viral infections. The diagnosis of dilated cardiomyopathy is made by echocardiogram, which typically shows dilated ventricles with diffuse hypokinesia resulting in a low ejection fraction (i.e. ,systolic dysfunction). Treatment is largely supportive, involving mainly the management of CHF symptoms. DDX: Primary pulmonary hypertension that has progressed to cor pulmonale can present with dyspnea, elevated jugular venous pressure, and lower extremity edema. However, bilateral crackles would not be present. Symptoms would be gradual in onset, progressing over months to years. Major acute rheumatoid fever criteria: Jones • Joints (migratory arthritis) • (Carditis) • Nodules (subcutaneous) • Erythema marginatum • Sydenham chorea **Benztropine is an anticholinergic medication used to treat extrapyramidal side effects of antipsychotic medications. **The serotonin antagonist cyproheptadine has been used to treat severe cases of serotonin syndrome, which is characterized by a triad of autonomic instability, altered mental status, and neuromuscular irritability. **Dantrolene is used to treat muscular rigidity associated with neuroleptic malignant syndrome. This syndrome is characterized by fever, diffuse muscular rigidity, autonomic instability, and significant laboratory abnormalities (eg, elevated creatine kinase).

Pathogenesis of refeeding syndrome: 1- Starvation: Catabolic state: we have decreased insulin, increased glucagon and increased cortisol 2- So, we will have decreased use of ketone bodies in muscles and increased use in brain (fuel during starvation) 3- Due to starvation we have increased Glycogenolysis, increased lipolysis and increased protein catabolism 4-Depletion off fat; protein, vitamins, minerals & intracellular electrolytes 5-**Start refeeding: anabolic state then we have increased insulin (culprit of syndrome) 6- So, we will have increased Glycogen synthesis, increased protein synthesis and increased Intracellular uptake of phosphorus, potassium, magnesium & thiamine, and so 7- Decreased in Serum phosphorus, potassium, magnesium. Decreased Serum thiamine and increased serum sodium and water retention. 8- These will lead to clinical manifestation of syndrome: • Arrhythmia • Congestive heart failure (pulmonary edema, peripheral edema) • Seizures • Wernicke encephalopathy Carbohydrate ingestion, whether enteral or intravenous, causes pancreatic insulin secretion and cellular uptake of phosphorus, potassium, and magnesium. Phosphorus is the primary deficient electrolyte as it is required for energy (adenosine triphosphate). Deficiencies in potassium and magnesium potentiate cardiac arrhythm ias in a heart that is already atrophic from prolonged malnutrition. Therefore, aggressive initiation of nutrition without adequate electrolyte repletion can quickly precipitate cardiopulmonary failure.

Coins are the most common foreign body ingested by children. If a coin Is visualized in the esophagus and the patient Is symptomatic or if the time of ingestion is unknown, the coin should be removed promptly. Flexible end os copy Is the diagnostic and treatment method of choice because the foreign body can be directly visualized and manipulated, and the surrounding gastrointestinal tract can be examined for complications. Rigid endoscopy has a higher risk of esophageal abrasion and perforation and is usually reserved for impacted sharp objects in the proximal esophagus. Patients who have ingested batteries, sharp objects, or multiple magnets are at high risk of perforation, obstruction, or ischemia and require preemptive removal. Immediate endoscopy is required if these objects are visualized in the esophagus. Dangerous symptoms such as hematochezia, melena, and severe abdominal pain are indications for surgical removal. Sturge-Weber syndrome can include focal or generalized seizures, mental retardation, and a port wine stain or nevus flammeus along the territory of the trigeminal nerve, which represents a congenital unilateral cavernous hemangioma. Seizures are the usual neurological presentation and may start at any age. Other pertinent findings are hemianopia, hemiparesis, hemisensory disturbance, and ipsilateral glaucoma. Skull x-rays, taken after the age of 2 years, reveal gyriform intracranial calcifications that resemble a tramline. Treatment is aimed at controlling the seizures and reducing intraocular pressure. Argon laser therapy is successful in removing the skin lesions.

Periorbital (preseptal) cellulitis is a mild infection of the eyelid anterior to the orbital septum and can present with fever and eyelid erythema/edema. It is unilateral, there is no headache and focal neurologic symptom and no restriction in eye movements. Bird fancier's lung, a form of hypersensitivity pneumonitis (HP). HP is caused by repeated inhalation of an inciting antigen, which leads to alveolar inflammation. Common responsible antigens include aerosolized bird droppings ("bird fancier's lung") and molds associated with farming ("farmer's lung"). HP can vary significantly in its clinical presentation and severity. A history of antigen exposure in the setting of compatible symptoms is highly suggestive. Acute episodes may present with cough, breathlessness, fever and malaise that occur 4-6 hours after antigen exposure. With chronic exposure, patients may develop pulmonary fibrosis and a restrictive pattern on lung spirometry. Classic radiographic findings include ground glass opacity, or "haziness," of the lower lung fields. Studies have shown that the best treatment for HP is avoidance of antigen exposure. Systemic corticosteroids speed recovery from the acute symptoms of HP and are also a critical component of the management of severe episodes. However, systemic corticosteroids do not slow or reverse disease progression.

Mild hypercalcemia in the setting of metastatic breast cancer to bone. Asymptomatic or mild hypercalcemia (calcium <12 mg/dL) does not require urgent therapy, but hypercalcemia of malignancy may worsen over time. Bisphosphonates (eg, zoledronic acid) inhibit the osteoclastic activity of bone, stabilizing destructive bony tumors and reducing the risk of skeletal-related events such as pathologic fracture and malignant hypercalcemia. Opioids are the first-line treatment for metastatic bone pain that is not adequately controlled by acetaminophen or nonsteroidal anti-inflammatory drugs. Radiation therapy can treat moderate to severe** pain caused by bone metastases (not hypercalcemia). **Bisphosphonates (eg, zoledronic acid, pamidronate) are the drugs of choice for stabilizing bony metastatic lesions to prevent hypercalcemia of malignancy and pathologic fractures. Also used in Paget disease. Bisphosphonates are recommended as a first line treatments for post-menopausal osteoporosis. Bisphosphonates reduce the risk of fracture and bone pain in people with breast, lung, and other metastatic cancers as well as in people with multiple myeloma. In osteoporosis and Paget's, the most popular first-line bisphosphonate drugs are alendronate and risedronate. If these are ineffective or if the person develops digestive tract problems, intravenous pamidronate may be used. Strontium ranelate or teriparatide are used for refractory disease. The use of strontium ranelate is restricted because of increased risk of venous thromboembolism, pulmonary embolism and serious cardiovascular disorders, including myocardial infarction. **Myxomatous valve degeneration is the pathologic cause of mitral valve prolapse, which causes a midsystolic click. It should not cause systemic symptoms or a mass on echocardiography.

Pernicious anemia is the most common cause of vitamin B 12 deficiency and is associated with at least double the risk of gastric cancer as compared to the general population. **Suspect Diamond-Blackfan syndrome (DBS), also called congenital hypoplastic anemia, in a child with macrocytic anemia, low reticulocyte count, and congenital anomalies. The majority of cases are sporadic, although dominant and recessive inheritance is found in 15 percent of cases. The primary pathology is an intrinsic defect of erythroid progenitor cells which results in increased apoptosis (programmed cell death). The condition often presents with pallor in the neonatal period. Over 90 percent of cases are diagnosed within the first year of life, with the average age of diagnosis being 3 months. Congenital anomalies (webbed neck, cleft lip, shielded chest, triphalangeal thumbs, upper limb abnormalities, cardiac defects, urogenital malformations, and cleft palate)are present in over 50 percent of cases. Low birth weight and generalized growth delay are sometimes observed. The macrocytic anemia of DBS is distinct from that of megaloblastic anemia because there is no hypersegmentation of the nucleus in neutrophils and other blood cells in the former. Electrophoresis reveals elevated fetal Hb levels. Chromosomal studies are normal. Therapy is mainly corticosteroids. For unresponsive patients, transfusion therapy is indicated. **Fanconi's anemia is an autosomal recessive disorder characterized by progressive pancytopenia and macrocytosis. The average age at diagnosis is 8 years. Associated deformities include cafe-au-lait spots, microcephaly, microphthalmia, short stature, horseshoe kidneys and absent thumbs (not triphalangeal thumbs).

Esophageal rupture following blunt trauma is rare. Iatrogenic (e.g., with endoscopy) and esophagitis-related etiologies are more common. Manifestations of esophageal rupture include pneumomediastinum and **pleural effusions. *Maternal thyroid testing in pregnancy, first trimester: Total T4 Increased, Free T4 Unchanged or mildly increased • beta-hCG stimulates thyroid hormone production in first trimester. • Estrogen stimulates TBG; thyroid Increases hormone production to maintain steady-free T4 levels TSH decreased: • Increased beta-hCG & thyroid hormone suppress TSH secretion

Persistent pneumothorax despite chest tube placement and pneumomediastinum, and presence of emphysema (palpable crepitus below the skin) on physical examination. Though rare, the most likely explanation for these radiographic and clinical findings is tracheobronchial perforation secondary to blunt thoracic trauma. The right main bronchus is most commonly injured in these cases. The. diagnosis can be confirmed with high-resolution CT scanning, bronchoscopy, or surgical exploration. Operative repair is indicated.

Diagnosis of orthostatic (postural) hypotension Within 2-5 minutes of standing from supine position: • Drop in systolic blood pressure >20 mm Hg OR • Drop in diastolic blood pressure >10 mm Hg **Ovarian cancer Is one of the leading causes of cancer mortality in the United States as the disease Is typically diagnosed in advanced stages with widespread metastasis. For average-risk patients (eg, no hereditary cancer syndromes), no screening tests exist to detect ovarian cancer In its early, more treatable stages. In women with a very strong family history of ovarian cancer, testing for the BRCA 1 and BRCA2 genes can be offered, preferably beginning with evaluation of the individual diagnosed with the disease. **Phenytoin use during pregnancy is associated with craniofacial anomalies, fingernail hypoplasia, growth deficiency, developmental delay, cardiac defects and facial clefts. *Malignant hyperthermia affects genetically susceptible individuals during anesthesia involving agents like halothane and succinylcholine. Do not confuse with heat stroke. *Pulsus paradoxus is defined as an exaggerated fall in systemic blood pressure >10 mm Hg during inspiration. It is a frequent finding in cardiac tamponade but can also occur in conditions without pericardia! effusion such as severe asthma or chronic obstructive pulmonary disease.

Prader-Willi syndrome (PWS): Clinical features • Hypotonia • Weak suck/feeding problems in infancy • Hyperphagia/obesity • Short stature • Hypogonadism • Intellectual disability • Dysmorphic facies • Narrow forehead • Almond-shaped eyes • Downturned mouth Diagnosis • Deletions on patemal 15q11-q13 • Sleep apnea (70%) Complications • Type 2 diabetes mellitus (25%) • Gastric distension/rupture • Death by choking (8%)

Clinical features of primary adrenal insufficiency: 1- Etiology: • Autoimmune • Infections** (eg, tuberculosis, HIV, disseminated fungal) • Hemorrhagic infarction (eg, meningococcemia, anticoagulants) • Metastatic cancer (eg, lung) Diagnosis: • Measure ACTH and serum cortisol with high-dose (250 micro g) ACTH stimulation test • Primary adrenal insufficiency: Low cortisol, high ACTH • Secondary/tertiary adrenal insufficiency: Low cortisol, low ACTH

Primary adrenal insufficiency (Addison's disease) is characterized by decreased cortisol, adrenal sex hormone, and aldosterone secretion. Aldosterone normally acts on the distal renal tubules to increase sodium reabsorption (saves sodium) and secrete potassium and hydrogen ions. If aldosterone is deficient, the kidney inappropriately loses sodium while retaining excessive potassium and hydrogen ions. This results in a normal anion gap and hyperkalemic and hyponatremic metabolic acidosis. **Because oxytocin is similar to antidiuretic hormone, prolonged administration of high doses of oxytocin can cause water retention, hyponatremia, and resultant seizures. Hyponatremia can present with headaches, abdominal pain, nausea, vomiting, lethargy, and tonic-clonic seizures. Management of hyponatremia involves gradual administration of hypertonic saline (eg, 3% saline) to normalize sodium levels.

In ARDS: • Lung compliance (ability to expand) is decreased (stiff lungs) due to both loss of surfactant and increased elastic recoil of edematous lungs • Pulmonary arterial pressure is increased (pulmonary hypertension) due to hypoxic vasoconstriction, destruction of lung parenchyma, and compression of vascular structures from positive airway pressure in mechanically ventilated patients Findings suggestive of ARDS include respiratory distress, diffuse crackles on lung examination, severe hypoxemia, and bilateral alveolar infiltrates on chest imaging, which occur within a week of an insult. The partial pressure of arterial oxygen (PaO2) decreases and leads to an increased fraction of inspired oxygen (FiO2) requirement. As a result, PaO2/FiO2 (P/F) is decreased (<=300 mm Hg) with lower P/F ratios indicating more severe degrees of ARDS. *New England, a Lyme endemic area. Exposure occurs primarily in wooded areas due to direct contact with leaf litter, logs, or soil. Prevention hinges on the avoidance of tick exposure and the rapid recognition of tick attachment. This is achieved with tick repellents (eg, DEET [N,N-diethyl-meta-toluamide), permethrin), long sleeve/long leg protective clothing, tick checks, and bathing (to wash away unattached ticks).

Prolactin production is stimulated by serotonin and TRH (in hypothyroidism) and inhibited by dopamine. Other causes of high prolactin levels Include dopamine antagonists (antipsychotics, tricyclic antidepressants, and MAOis), hypothalamic and pituitary tumors. *Sleep disturbance, low self-esteem, and social isolation in response to the stress of a romantic breakup is consistent with an adjustment disorder. Adjustment disorder is characterized by emotional or behavioral symptoms that develop within 3 months of exposure to an identifiable stressor and rarely last more than 6 months after the stressor ends. Diagnosis requires significant distress or impairment (as seen in this patient's social and occupational life). He lacks sufficient symptoms to meet the criteria for major depressive disorder or other mental disorder; therefore, the diagnosis of adjustment disorder is appropriate (Table). The treatment of choice for adjustment disorder is psychotherapy, which focuses on developing coping mechanisms and improving the individual's response to and attitude about the stressful situation. Helping this patient cope with his feelings of disappointment, improve his self-esteem, and eventually become open to new relationships would be appropriate.

Lacunar stroke: 1-Etiology • Small penetrating artery occlusion due to hypertensive arteriolar sclerosis 2-Affected areas • Basal ganglia • Subcortical white matter (eg, internal capsule, corona radiata) • Pons 3-Risk factors • Hypertension • Diabetes mellitus, advanced age, increased LDL, smoking Clinical features • Absence of cortical signs (eg, aphasia, agnosia, neglect, apraxia, hemianopia), seizure, or mental status changes • Common syndromes: o Pure motor hemiparesis (most frequent) o Pure sensory stroke o Ataxic hemiparesis o Dysarthria-clumsy hand

Pure motor hemiparesis due to a lacunar stroke in the posterior limb of the left internal capsule. Lacunar strokes are small (<15 mm in diameter) subcortical infarcts resulting from occlusion of deep penetrating branches of the major cerebral arteries (eg, anterior cerebral, middle cerebral, basilar). Berry aneurysms often affect the anterior and posterior communicating arteries in the circle of Willis. Anterior communicating artery aneurysms usually compress the central optic chiasm. causing bitemporal hemianopia. Posterior communicating artery aneurysms typically compress the oculomotor nerve, producing ipsilateral mydriasis, ptosis, and "down and out" deviation of the eye. Ruptured berry aneurysms cause subarachnoid hemorrhage (eg, severe headache, seizure, meningismus). which would appear on noncontrast head CT. **An epidural abscess (even without fever) is of particular concern in IV drug abuser regarding Spinal cord compression. Spinal cord compression is a medical emergency and must be evaluated immediately with an MRI of the spine.

Amyloid angiopathy is the most common cause of spontaneous lobar hemorrhage, particularly in adults age >60. It occurs as a consequence of amyloid deposition in the walls of small- to medium-size cerebral arteries, resulting in vessel wall weakening and predisposition to rupture. The disease is not associated with systemic amyloidoses; rather, the amyloidogenic proteins are usually the same as those seen in Alzheimer dementia. Hemorrhage usually occurs during routine activity and most often involves the occipital and parietal lobes (hyperdensity on head CT scan). Parietal hemorrhages can cause contralateral hemisensory loss (due to primary somatosensory cortex injury) and contralateral hemineglect if the parietal association cortex (particularly in the nondominant hemisphere) is affected. Hematoma expansion can lead to elevated intracranial pressure, resulting in impaired consciousness, confusion, headache, and nausea/vomiting. DDx:Cardioembolic stroke can occur in the setting of atrial fibrillation, especially while patients are off anticoagulants; however, they typically have sudden-onset neurologic deficits that follow a stuttering course. In addition, neuroimaging classically shows multiple ischemic infarctions at the grey-white matter junction. Carotid artery thrombosis typically leads to profound neurologic deficits (eg, contralateral homonymous hemianopsia, hemiparesis, hemisensory loss) due to ischemic infarction of the cerebral hemisphere. On CT scan, ischemic stroke typically appears as an area of hypodensity rather than a hyperdensity affecting a vascular distribution.

Subarachnoid hemorrhage: which is characterized by the abrupt onset of severe (thunderclap) headache and hyperattenuation of the sulci and basal cisterns on head CT scan. **Hodgkin lymphoma (HL) is a curable lymphoma that tends to affect young patients. Unfortunately, patients, especially those treated before age 30, can develop secondary malignancies from chemotherapy and/or radiation. There is an 18.5-fold increased risk of developing a second cancer in HL patients compared to the general population. The incidence of a second malignancy is approximately 10% within 20 years and may approach 30% by 30 years. The most common secondary solid tumor malignancies are lung (especially in smokers), breast, thyroid, bone, and gastrointestinal (eg, colorectal, esophageal, gastric tumors). In addition, HL patients treated with radiation and/or chemotherapy have an increased risk of developing subsequent acute leukemia or non-HL. Lung cancer most commonly presents with symptoms due to intrathoracic tumor (looks like a ball but no air crescent in periphery) effect such as cough, hemoptysis, chest pain (especially in younger patients), and dyspnea. DDX:A fungus ball, or aspergilloma, is composed of fungal hyphae, inflammatory cells, fibrin, and tissue debris that collect in a pre-existing lung cavity. Cavitary lung diseases complicated by aspergillomas include tuberculosis, sarcoidosis, bronchial cysts, and neoplasm. Patients can be asymptomatic or develop hemoptysis, cough, dyspnea, and fever. Imaging shows a mobile, intra-cavitary mass with an air crescent in the periphery.

A regular and narrow complex tachycardia (QRS duration < 120 ms) at a rate of approximately 160 beats per minute. This is consistent with a diagnosis of supraventricular tachycardia (SVT). SVT refers to any tachycardia originating above the His-bundle and includes sinus tachycardia, multifocal atrial tachycardia, atrial flutter, atrial fibrillation, atrioventricular (AV) nodal reentrant tachycardia (AVNRT), AV reentrant tachycardia (AVRT), and junctional tachycardia. Patients usually present with palpitations, although some may have dizziness, lightheadedness, shortness of breath, diaphoresis, chest pain, presyncope, or syncope. Paroxysmal supraventricular tachycardias (PSVTs) are SVTs with abrupt onset and offset; they include AVNRT, AVRT, atrial tachycardia, and junctional tachycardia. In patients who are hemodynamically stable, the next step in evaluation is to identify the type of SVT with the use of vagal maneuvers (eg, carotid sinus massage, Valsalva, eyeball pressure) or intravenous adenosine. Adenosine or vagal maneuvers temporarily slow conduction via the AV node and can aid in diagnosis by unmasking "hidden" P waves in patients with atrial flutter or atrial tachycardia. They can also cause a transient AV nodal block and terminate AV node-dependent arrhythmias, including AVNRT and orthodromic AVRT.

Supraventricular Arrhythmias: · Mostly narrow QRS complex tachycardia. • Usually there are no regular P waves as they are buried within the QRS complexes, but retrograde P wave can occur. • Retrograde P waves: seen in the beginning or end of a QRS complex when the atria & ventricles are not simultaneous. Can appear as spikes on QRS complexes or as Inverted P waves. Sinus Tachycardia • P waves usually before QRS complex • Ventricular rate >= 100 beats/min • P waves are usually upright in leads I, II, aVF, V3-V6 • Maximal heart rate in sinus tachycardia can be determined (beats/min = 220- age)

Disseminated gonococcal infection often presents with a triad of polyarthralgias, tenosynovitis, and vesiculopustular skin lesions. they tend to number from two to ten and may be dismissed as furuncles or pimples. Fevers and chills may be present. Prolonged hypotension from any cause can lead to ATN. The hallmark findings on urinalysis are muddy brown granular casts consisting of renal tubular epithelial cells; this is a nonspecific, but very sensitive finding for ATN. **Broad and waxy casts - Chronic renal failure **Patients with a history of colon cancer in a first- degree relative should be screened at age 40 or 10 years before the age of the relative's diagnosis. The American Cancer Society and the United States Preventive Services Task Force (USPSTF) strongly encourage routine colon cancer screening in all patients age >50. Screening can be performed using high-sensitivity fecal occult blood testing (FOBT) annually, nexlble sigmoidoscopy every 5 years combined with FOBT every 3 years, or colonoscopy every 10 years.

Sympathetic ophthalmia is also known as "spared eye injury." It is characterized by an immune-mediated inflammation of one eye (the sympathetic eye) after a penetrating injury to the other eye. The typical manifestation is anterior uveitis, but panuveitis, papillary edema, and blindness may develop. The pathophysiological mechanism is believed to be the uncovering of 'hidden' antigens. Some antigens contained within the eye are protected from immunologic recognition by natural barriers. Breaking these barriers results in the uncovering of 'hidden' antigens. An immune response against these antigens can involve autoantibodies as well as a cell-mediated reaction. *The USPSTF guidelines conclude that there is currently insufficient evidence on screen ing for thyro id disease in asymptomatic patients with a family history of thyroid disease.

Generalized anxiety disorder (GAD) is characterized by excessive, uncontrollable worry about multiple issues (eg, school, family, finances, health) for >=6 months. VS Adjustment disorder is characterized by the development of emotional or behavioral symptoms in response to an identifiable stressor that occurs within 3 months of the stressor. The diagnosis is appropriate when the patient does not meet the criteria for another mental disorder. GAD: DSM-5 criteria • Excessive worry, anxiety (multiple issues) >6 months • Difficult to control • >3 of the following symptoms: o Restlessness/feeling on edge o Fatigue o Difficulty concentrating o Irritability o Muscle tension o Sleep disturbance • Significant distress or impairment • Not due to substances, another mental disorder, or medical condition Treatment: • Cognitive behavioral therapy • SSRis or SNRis

Syncope in a young patient with a crescendo-decrescendo murmur at the lower left sternal border is most likely due to hypertrophic obstructive cardiomyopathy (HOCM). Syncope in HOCM is often multifactorial and can be due to outflow obstruction, arrhythmia, ischemia, and a ventricular baroreceptor response that inappropriately causes vasodilation. But, In large part it is due to outflow obstruction from the hypertrophied myocardium. **Evaluation of vertebral osteomyelitis: Can be due to hematogenous spread of recent urinary tract infection. Staphylococcus aureus accounts for about 50% of cases of pyogenic spinal osteomyelitis. However, other pathogens, including Gram-negative bacilli can be the culprit. Fever, back pain & focal spinal tenderness then do • Blood cultures • ESR/CRP(Leukocyte count may be normal, but ESR and CRP are usually markedly elevated.) • Plain spinal x-rays IF increased ESR/CRP but normal x-rays then do MRI CT-guided needle aspiration/biopsy needed to confirm the diagnosis.

Niemann-Pick disease: Sphingomyelinase deficiency • Autosomal recessive inheritance • Ashkenazi Jewish heritage • Onset Age 2-6 months Clinical findings: • Loss of motor milestones • Hypotonia • Feeding difficulties • "Cherry-red" macula • Hepatosplenomegaly • Areflexia There are 3 types of NPD, type A is the most severe; types B and C are milder. Types A and B are caused by sphingomyelinase deficiency. **Gaucher disease is due to glucocerebrosidase deficiency. Classic features include anemia, thrombocytopenia, and hepatosplenomegaly. *Galactocerebrosidase deficiency results in Krabbe disease, a rare autosomal recessive lysosomal storage disorder that presents early in infancy with developmental regression, hypotonia, and areflexia. **Atelectasis causes shunt, guillan barre causes hypoventilation, PE cause V-Q mismatch. Constipation, rectal bleeding, and obstruction are more seen in cancers of the left colon and sigmoid, on the other hand, virchow node, anemia, weight loss and Blumer shelf are more seen in right colon cancer.

Tay-Sachs disease: beta-hexosaminidase A deficiency • Autosomal recessive inheritance • Ashkenazi Jewish heritage • Onset Age 2-6 months Clinical findings: • Loss of motor milestones • Hypotonia • Feeding difficulties • "Cherry-red" macula • Hyperreflexia **Hurler syndrome (one of the mucopolysaccharidoses) is a lysosomal storage disorder due to lysosomal hydrolase deficiency. It presents at age 6 months-2 years with coarse facial features, inguinal or umbilical hernias, corneal clouding, and hepatosplenomegaly. **Brodie's abscess is a chronic localized bone abscess. Subacute cases ay present with fever, pain, and periosteal elevation, whereas chronic cases are often afebrile and can present with long-standing dull pain. The most common site of involvement is the distal part of the tibia. The lesion is typically single and located near the metaphysis. About 75% of the patients are younger than 25. Radiograph shows radiolucenct, irregular shaped area with no adjacent osteoblastic reaction. Surgical debridment and culture-directed antibiotics are often curative.

Acute calcium pyrophosphate dihydrate (CPPD) crystal arthritis (pseudogout): Onset at age >65, monoarticular arthritis, and chondrocalcinosis (calcification of articular cartilage). Synovial CPPD deposition can also cause a chronic **inflammatory arthritis resembling rheumatoid arthritis and a noninflammatory degenerative process resembling osteoarthritis. Pseudogout commonly affects the knees and ankles, where it may be difficult to distinguish from urate gout, but it also frequently affects the large joints of the upper extremity and may involve multiple joints concurrently. Attacks of pseudogout often occur in the setting of **trauma/overuse, surgery, or medical illness.

The finding of chondrocalcinosis in a joint with a typical acute inflammatory arthritis establishes a diagnosis of probable CPPD crystal arthritis. Synovial fluid analysis will show an inflammatory effusion (1 5,000-30,000 cells/mm3) along with rhomboid-shaped, weakly positively birefringent CPPD crystals. Arthrocentesis for synovial fluid analysis is advised to exclude urate gout (up to 50,000 cells/mm3, needle-shaped negatively birefringent urate crystals) and septic arthritis (>50,000 cells/mm3, visible organisms on Gram stain).

Passive immunization is achieved by administering high concentrations of specific antibody against a pathogen. It is an effective postexposure prophylaxis for varicella and rabies but not available for measles. Measles is characterized by a prodrome of cough, coryza, and conjunctivitis followed by a maculopapular rash that spreads in a cephalocaudal pattern. This highly contagious infection is transmitted by the airborne route. Contact precautions (ie, gown, gloves) can prevent transmission of organisms that spread by contact (eg, methicillin-resistant Staphylococcus aureus, rotavirus) but do not prevent airborne transmission. Droplet precautions (ie, surgical mask) can prevent transmission of organisms that spread via droplets (eg, influenza, respiratory syncytial virus), which are relatively large and have a short range. However, surgical masks do not block small airborne particles (eg, measles, varicella, tuberculosis).

The normal range of ALP is 44 to 147 IU/L (international units per liter) or 0.73 to 2.45 microkat/L. ESR can increase in MM (here we can have multiple lytic bone lesions and increased in total serum protein or protein in the urine) and metastasis. Total serum protein: 6.4-8.3 grams per deciliter (g/dL) or 64-83 grams per liter (g/L) **ACL injuries in sedentary patients can be treated with knee-brace immobilization and rehabilitation, whereas athletes require surgical reconstruction.

Full-term newborn: Dry, flaky, peeling skin of the hands and feet is expected as the skin adjusts to the dry extrauterine environment. The appearance of "pink stains" or "brick dust" in neonatal diapers represent uric acid crystals. Uric acid excretion is especially high at birth and decreases until adolescence, when adult levels are observed. Uric acid crystals are commonly seen during the first week as the mother's milk is coming in, or in later months with the morning void after the infant begins to sleep through the night. lose up to 7% of their birth weight in the first 5 days of life due to excretion of excess fluid acquired in utero and during labor. The weight loss is more pronounced in exclusively breastfed infants as the mother's milk supply gradually increases to meet infant demands. Frequent breastfeeding should be encouraged, and education about dehydration should be provided. Signs of dehydration include dry mucous membranes, a sunken fontanelle, and decreased urine output. As a general rule, the number of wet diapers should equal age in days for the first week of life. For example, a 4-day-old neonate should have >=4 wet diapers per day. After the first week, infants should have >=6 wet diapers per day. Birth weight should be regained by age 10-14 days.

The third heart sound (53) Is a low frequency diastolic sound heard just after 52 that is associated with left ventricular failure. Intravenous diuretics provide symptomatic benefits to patients with decompensated heart failure. The liver can normally store a 30-day supply of vitamin K, but an acutely ill person with the underlying liver disease can become vitamin K deficient in as little as 7-10 days. If a patient received no enteral nutrition postoperatively and was given a broad-spectrum antibiotic, and so both natural sources of vitamin K were compromised. Disseminated intravascular coagulation causes depletion of clotting factors and secondary fibrinolysis. This causes bleeding, acute kidney and liver injury, hypotension (hemodynamically instable), and tachycardia. Testing shows thrombocytopenia, prolonged PT and PTT, decreased fibrinogen, and schistocytes on peripheral smear.

During prenatal visists: Routine testing for toxoplasmosis is not recommended in the United States. Testing for toxoplasmosis is indicated only when patients have symptoms of potential infection (eg, fever, malaise, lymphadenopathy). **Therefore, all pregnant women should receive screening for HIV, hepatitis B virus, Chlamydia trachomatis, and syphilis.

There are 2 categories of screening tests for syphilis: nontreponemal (eg, rapid plasma reagin) and treponema! (eg, fluorescent treponema! antibody absorption) serology. Either may be used for screening, but positive results require confirmation with a test from the alternate category (as false positives are common). Patients with positive serology are treated for syphilis with intramuscular benzathine penicillin G (usually 1 dose weekly for 3 weeks). Patients who are allergic to pencillin need to be desensitized.

First-line treatments for acute mania include antipsychotics, lithium, and anticonvulsant mood stabilizers (eg, valproate). Exhibiting acute psychosis (eg. grandiose delusions) and escalating agitation (angrily shouting, threatening, banging on the door), an antipsychotic such as risperidone is preferable due to its more rapid onset of action. Both first- and second-generation antipsychotics are effective in managing mania and associated acute behavioral agitation. Administering lithium, valproate, or carbamazepine would be ineffective in managing the patient's psychosis and agitation acutely: these medications typically require gradual titration over several days to achieve therapeutic blood levels before they take effect. **Oral doxycycline is first-line treatment for Lyme disease, which can present with erythema migrans, often described as a "bull's-eye" rash. Transmission of Lyme disease requires >48 hours of tick attachment, and the rash usually appears > 7 days later.

Tinea corporis (ringworm) is a cutaneous dermatophyte infection most commonly caused by Trichophyton rubrum. Fungi thrive in humid climates and warm, moist areas (eg, shower surfaces, pools, gym mats, seats); therefore, sports involving skin-to-skin contact (eg, wrestling, gymnastics) are commonly implicated in the spread of infection. Tinea lesions initially present as scaly, erythematous, pruritic patches that spread centrifugally. Untreated individuals, such as this patient, may develop a raised annular border and eventually central clearing as the fungus grows outward. Diagnosis is usually clinical, but skin scraping and potassium hydroxide examination are confirmatory for atypical or refractory cases. First-line treatment for localized disease is a topical antifungal agent (eg, clotrimazole, terbinafine). Treatment should be continued until the lesion is resolved, which may take up to 3 weeks.

Causes of allergic contact dermatitis: • Poison oak/ivy/sumac • Nickel • Rubber/latex • Leather dyes • Medications Causes of irritant contact dermatitis: • Soaps/detergents • Chemicals • Acid/alkali

Tinea manuum is a superficial fungal infection of the hands. It typically presents as pruritic, hyperkeratotic patches on the palms or annular erythematous lesions resembling tinea corporis on the dorsum of the. hands and finger webs. Most patients have concurrent tinea pedis.

Ureteral colic can cause vagal reaction which leads to ileus and its related symptoms. Needle-shaped crystals on urinalysis indicate uric acid stones. Uric acid stones, which are radiolucent, have to be evaluated by CT of the abdomen or intravenous pyelography. Abdominal ultrasonography may also detect radiolucent stones. CT is also useful for diagnosing other pathology, such as appendicular abscess or bowel obstruction, especially in this patient with ileus. Ileus will resolve when the ureterolithiasis is treated. Stones <1 cm may pass spontaneously with hydration and analgesia; otherwise, surgical intervention is needed. Gout uric acid crystals are also needle-shaped. Yellow when aligned parallel to the slow axis of the red compensator but turn blue when aligned across the direction of polarization (ie, they exhibit negative birefringence). **Cystine crystals form hexagonal-shaped crystals that can be viewed upon microscopic analysis of the urine. Crystals are rhomboid in calcium pyrophosphate dihydrate (CPPD) crystal deposition disease, also known as pseudogout. They are positively birefringent, appearing blue when aligned parallel with the slow axis of the compensator and yellow when perpendicular.

Tumor lysis syndrome (TLS) can develop in patients with aggressive hematologic malignancies who begin cytotoxic chemotherapy. Large-scale cell death increases vascular concentrations of intracellular products, resulting in potentially life-threatening electrolyte and metabolic abnormalities. The following are often observed: • Hyperuricemia - Nucleic acids are released and metabolized into uric acid. • Hyperkalemia and hyperphosphatemia - Intracellular ions are liberated. • Hypocalcemia - Phosphate binds and precipitates calcium, reducing intravascular levels. Symptoms of TLS are primarily due to electrolyte abnormalities and include nausea, vomiting, diarrhea, muscle cramps, seizures, and tetany. Cardiac arrhythmias (hyperkalemia, hypocalcemia) and acute kidney injury (renal tubule deposition of uric acid and/or calcium phosphate) are common complications. The use of intravenous fluids to flush the kidneys and uric acid metabolism inhibitors (allopurinol, rasburicase) helps moderate the risk of uric acid-mediated renal damage; however, calcium phosphate- induced renal injury may still occur.

Hepatitis c in pregnancy: 1- Potential complications • Gestational diabetes • Cholestasis of pregnancy • Preterm delivery 2- Maternal management • Ribavirin is teratogenic & should be avoided • No indication for barrier protection in serodiscordant, monogamous couples • Hepatitis A & B vaccination 3- Prevention of vertical transmission • Vertical transmission strongly associated with maternal viral load • Cesarean delivery not protective • Scalp electrodes should be avoided • Breastfeeding should be encouraged unless maternal blood present (eg, nipple injury)

Up to 80% of patients infected with the hepatitis C virus (HCV) develop chronic hepatitis, making hepatitis C the most common cause of chronic hepatitis. HCV infection is acquired most commonly by exposure to infected blood. A combination of interferon-a and ribavirin is used for the treatment of nonpregnant patients with chronic hepatitis C and compensated liver disease. However, ribavirin is highly teratogenic, and there is insufficient data to determine the safety of interferon-a during pregnancy. *Bullous impetigo is a blistering condition caused by Staphylococcus aureus. The lesions may appear s macules, vesicles, bullae, and honey-colored crusts, which leave red denuded areas when removed. Bullous impetigo is caused by Staphylococcus aureus and presents as macules, vesicles, and bullae with honey-colored crusts. It is most common in children and is unusual in adults without underlying immune suppression or disruption of skin integrity.

Order of increased metastatic brain Incidence frequency: Lung > Breast > Unknown primary > Melanoma > Colon Primary solitary brain metastasis: • Breast • Colon • Renal cell carcinoma Multiple brain metastases • Lung cancer • Malignant melanoma **Abnormal uterine bleeding (AUB) Is defined as menstrual bleeding that is prolonged (>5 days) and heavy (>1 pad every 2 hours) with an irregular frequency. Chronic AUB can result in symptomatic iron deficiency anemia, which in tum can present as syncope, palpitations. and tachycardia.

Variable deceleration: Relationship to contraction • Can be but not necessarily associated with contractions • Abrupt (<30 sec from onset to nadir)/ Thinner • Decrease >15/min; duration >15 sec but <2 min Etiology • Cord compression • Oligohydramnios • Cord prolapse

Clinical features of primary hyperaldosteronism: Clinical presentation • Hypertension, metabolic alkalosis, hypokalemia, mild hypernatremia • No significant peripheral edema due to aldosterone escape Diagnosis • Elevated plasma aldosterone, low plasma renin • Plasma aldosterone to plasma renin activity ratio >20 suggests diagnosis • Adrenal suppression testing after oral saline load confirms diagnosis • Abdominal imaging (eg, CT) & adrenal venous sampling to distinguish between unilateral adrenal adenoma & bilateral adrenal hyperplasia Treatment for Unilateral adrenal adenoma • Surgery (preferred) • Aldosterone antagonists (eg, spironolactone, eplerenone) for poor surgical candidates or patients refusing surgery Bilateral adrenal hyperplasia: Aldosterone antagonists

Varicella is usually self-limited and mild, but serious complications include pneumonia, central nervous system disease (eg, cerebellar ataxia), and aggressive skin infections. These complications are more common in adolescents and adults, particularly those. who are immunocompromised or pregnant. Immunity to varicella is acquired by prior infection or by receiving 2 doses of VZV vaccine (at ages 1 and 4 years). Postexposure prophylaxis **with VZV vaccine is indicated for this incompletely immunized child age >1 year who was exposed within the preceding 5 days. *For susceptible individuals who cannot receive live-virus vaccines (eg, immunocompromised or pregnant patients), postexposure prophylaxis can be provided using varicella immunoglobulin. Infants (age <1 year) outside the neonatal period are not eligible for VZV vaccine and do not require immunoglobulin as they are at lower risk than neonates or older children. **Creatine kinase reference: Males > or =18 years: 52-336 U/L Females > or =18 years: 38-176 U/L

Differential diagnosis of stridor: 1- Acute A: Croup • Most common in infants/toddlers • "Barky" cough, inspiratory stridor, fever, rhinorrhea, congestion B: Foreign body aspiration Most common in infants and toddlers Acute onset of inspiratory stridor and/or wheeze without infectious symptoms 2-Chronic A: Laryngomalacia • Inspiratory stridor most prominent in infants • Stridor worse when supine, improves when prone B: Vascular ring • Presents in infants • Biphasic stridor that improves with neck extension

Vascular rings, or slings, result from abnormal development of the aortic arch, causing tracheal, bronchial, and/or esophageal compression. They can be either complete (eg, circumferential around the trachea and/or esophagus), such as a double aortic arch, or incomplete (eg, pulmonary artery sling). Up to 50% of patients also have a cardiac anomaly (eg, ventricular septal defect, tetralogy of Fallot). Vascular rings present in patients age <1, with respiratory (eg, stridor, wheezing, coughing) and/or esophageal (eg, dysphagia, vomiting, difficulty feeding) symptoms. The stridor is often biphasic, although it is more prominent during expiration, and improves with neck extension, which decreases tracheal compression. Dohle bodies are light blue-gray, oval, basophilic, leukocyte inclusions located in the peripheral cytoplasm of neutrophils. They measure 1-3 µm in diameter. Not much is known about their formation, but they are thought to be remnants of the rough endoplasmic reticulum.

**Administration of intravenous calcium chloride or gluconate (not calcium carbonate, which is used as an oral calcium supplement) helps stabilize the cardiac membrane, making it resistant to the effects of hyperkalemia. Insulin and glucose has higher administration priority than Beta-2 adrenergic agonists due to latter heart-related side effects. Wilms tumor (nephroblastoma): Epidemiology • Most common renal malignancy in childhood • Fourth most common childhood cancer • Peak age 2-5 years • Usually sporadic • Associated syndromes: • WAGR (Wilms tumor, Aniridia, Genitourinary anomalies, intellectual disability [mental Retardation]) • Beckwith-Wiedemann syndrome • Denys-Drash syndrome Clinical presentation • Asymptomatic, firm, smooth, abdominal mass that does not cross midline, we may only have hematuria. Treatment • Tumor excision or nephrectomy • Chemotherapy • +/- Radiation therapy Prognosis • 5-year survival rate with treatment: 90% DDX: Glomerulonephritis would not cause a firm abdominal mass. Treatment of septic arthritis in children: Birth to 3 months Organisms- Staphylococcus, group B streptococcus & and Gram-negative bacilli • Antibiotics - Antistaphylococcal agent (nafcillin or vancomycin), PLUS gentamicin or cefotaxime Older than 3 months Organisms - Staphylococcus, group A streptococci & Streptococcus pneumoniae • Antibiotics - Nafcillin, clindamycin, cefazolin, or vancomycin

Wilms tumor (nephroblastoma) is the most common primary renal neoplasm of childhood. It is usually diagnosed at age 2-5 years and affects a single kidney. The most common presentation is an asymptomatic abdominal mass that is found incidentally by a caretaker or physician. Some patients have abdominal pain, hypertension, hematuria, and fever. Less than 10% of patients have bilateral renal involvement (stage V disease). Although the lungs are the most common site of metastatic spread, children rarely present with pulmonary symptoms. Abdominal ultrasonography should be the first step in imaging to differentiate Wilms tumor from other causes of abdominal masses. It should be followed by contrast-enhanced computed tomography of the abdomen to evaluate the nature and extent of the mass and of the chest to identify any pulmonary metastases. Treatment includes surgery and chemotherapy with the addition of radiation therapy for high-stage disease. Survival rates are excellent especially if treated in the early stages. **High fever, right knee pain and swelling, and refusal to weight bear in the setting of leukocytosis and elevated C-reactive protein and erythrocyte sedimentation rate. These findings are concerning for septic arthritis, a bacterial joint infection that is often preceded by skin or upper respiratory tract infections. The features of septic arthritis are shown in the table. Arthrocentesis is both diagnostic and therapeutic and should be performed as soon as possible due to the risk of permanent joint destruction. Blood and synovial fluid cultures should be obtained before administering empiric antibiotics. Antibiotics preceding cultures can interfere with isolation of the offending organism and lead to false-negative results. Empiric therapy should be targeted at the most likely pathogens (Staphylococcus aureus, Group A Streptococcus, and S pneumoniae) and should be narrowed when culture data become available. Supportive therapy with bed rest and nonsteroidal anti-inflammatory drugs (NSAIDs) would be appropriate for transient synovitis, which presents with joint pain and decreased range of motion but rarely with fever or significant laboratory derangements. Acute rheumatic fever is also in the differential diagnosis for arthritis following group A streptococcal infection and would be managed with rest and NSAIDs. However, arthrocentesis is the most important next step in management due to the risk of dangerous joint damage from septic arthritis.

Clinical features of glucagonoma: Clinical presentation: Necrolytic migratory erythema • Erythematous papules/plaques on face, perineum, extremities • Lesions enlarge & coalesce over next 7-14 days with central clearing & blistering, crusting & scaling at borders Diabetes mellitus • Mild hyperglycemia easily controlled with oral agents & diet • Usually does not require insulin Gastrointestinal symptoms • Diarrhea, anorexia, abdominal pain, or occasional constipation Other findings • Weight loss • Neuropsychiatric (eg, ataxia, dementia, proximal muscle weakness) • Association with venous thrombosis Diagnosis: • Hyperglycemia with elevated glucagon >500 pg/ml • Normocytic, normochromic anemia due to likely anemia of chronic disease or glucagon directly affecting erythropoiesis • Abdominal imaging (computed tomography or magnetic resonance imaging) to localize tumor &/or metastases *Calcification of joint cartilage (chondrocalcinosis) is seen in calcium pyrophosphate dihydrate deposition (pseudogout); synovial fluid shows an inflammatory effusion with rhomboid, positively birefringent crystals. Gout causes an inflammatory effusion and needle-shaped, negatively birefringent crystals; x-rays characteristically show punched-out erosions with a rim of cortical bone.

Women with GDM are at increased risk for gestational hypertension, preeclampsia, fetal macrosomia, and cesarean delivery. Although GDM resolves after childbirth, up to half of women will develop type 2 DM later in life. All pregnant women should be screened for GDM at 24-28 weeks gestation. Patients with risk factors (eg, obesity, previous GDM, previous macrosomic infant) should be screened early in pregnancy and then rescreened at 24-28 weeks gestation if the initial screen is negative. Initial treatment includes dietary modifications composed of evenly distributed carbohydrate, protein, and fat intake over 3 meals and 2-4 snacks daily. Glucose levels should be monitored throughout the day with fasting and either 1- hour or 2-hour postprandial blood glucose levels. Fasting blood glucose levels should be <=95 mg/dl. A 1-hour level of S140 mg/dL or 2-hour level of <=120 mg/dL is an acceptable goal. Failure to achieve glycemic control with nutritional therapy warrants pharmacotherapy initiation. Insulin does not cross the placenta and has long been an accepted therapy for GDM that is unresponsive to dietary modifications and exercise. Oral medications (eg, glyburide, metformin) are equivalent in efficacy and are widely used as first-line pharmacotherapy. *Shoulder dystocia is caused by impaction of the anterior shoulder behind the pubic symphysis. Maneuvers help dislodge the anterior shoulder or reorient the infant to deliver through the widest diameter of the bony pelvis. The initial steps in relieving a shoulder dystocia are the McRoberts maneuver (eg, flexing the hips back against the abdomen) and applying suprapubic pressure. The McRoberts maneuver flattens the sacral promontory and decreases obstruction through the bony pelvis. Suprapubic pressure may dislodge the anterior shoulder and allow passage of the infant through the widest diameter of the maternal pelvis. The combination of these maneuvers relieves almost half of shoulder dystocias without further intervention.

Mild (< 250 U/L) asymptomatic elevation of serum transaminases: The first step In the evaluation of his condition should be a careful screening for ail hepatitis risk factors, including drug and alcohol intake, travel outside the United States, blood transfusions. or high-risk sexual practices. This aspect of the patient's history will provide insight as to whether the transaminase elevation could be caused by alcohol, medications (eg. NSAIDs, antibiotics, HMG-CoA reductase inhibitors. antiepileptic drugs, antituberculous drugs. herbal preparations). or viral agents. After thoroughly questioning the patient about his history and having him discontinue ail alcohol and drug use. the next step in the evaluation process would be to repeat the liver function tests. If the transaminases persist in being elevated over a six-month period, they are categorized as chronic. Testing for viral hepatitis Band C, hemochromatosis. and fatty liver should then be undertaken to further evaluate chronically elevated transaminases. If these tests prove unremarkable, a search for muscle disorders (eg, polymyositis) and thyroid disease should be made.

findings that Indicate a complicated SBO with increased risk of impending Ischemia, strangulation, and necrosis, warranting emergency abdominal exploration Include changes in the character of the pain, fever, hemodynamic Instability (hypotension, tachycardia), guarding, leukocytosis, and significant metabolic acidosis (low bicarbonate in this patient). Delay in surgery may lead to perforation and significant risk of mortality. A perforated viscus typically presents with severe abdominal pain. fever, tachycardia, and signs of peritonitis (eg, rigidity, reduced bowel sounds, rebound tenderness). It can occur in the setting of peptic ulcer disease. which is often associated with NSAID and alcohol use. The diagnosis of gastrointestinal perforation is confirmed with upright x-ray of the chest and abdomen showing free intraperitoneal air under the diaphragm.

Caustic ingestion. He is conscious and alert and of the answer choices listed, caustic ingestion is least likely to affect the patient's cognition. Caustic injury leads to damage of the tissue lining the gastrointestinal tract, manifested by necrosis, edema, scarring and severe pain. The white tongue, heavy salivation and dysphagia are results of this process. Severe esophageal and stomach ulceration may also occur and physicians should monitor for indications of peritonitis and mediastinitis. **Lateral medullary infarction typically occurs due to posterior inferior cerebellar artery occlusion. Patients develop loss of pain/temperature sense over the ipsilateral face and contralateral body (due to spinal trigeminal and spinothalamic tract injury), ipsilateral bulbar muscle weakness (nucleus ambiguus), vertigo/nystagmus (vestibular nuclei), and Horner syndrome (ascending sympathetic fibers). Embolic/thrombotic occlusion of the middle or anterior cerebral artery can result in contralateral sensory loss due to infarction of the somatosensory cortex in the post-central gyrus. However, sensory deficits are typically accompanied by hemiparesis (due to primary motor cortex injury) and cortical signs (eg, aphasia, agnosia). The underlying pathology behind lacunar stroke is a combination of microatheroma formation and lipohyalinosis that ultimately leads to thrombotic small-vessel occlusion. Due to their small size, lacunes are often not appreciated on noncontrast CT scans obtained shortly after the event. Lacunar infarcts commonly occur in the internal capsule and may lead to pure motor hemiparesis due to injury of the corticospinal (posterior limb) and corticobulbar (genu) tracts. Patients typically have weakness equally involving the contralateral face, arm, and leg. Sensory deficits, mental status changes, seizure, and cortical signs are typically absent. **Uric acid stones are often radiolucent but may be seen on ultrasound or CT scan. They are highly soluble in alkaline urine; alkalinization of the urine to pH 6.0-6.5 with oral potassium citrate is the treatment of choice. Hydrochlorothiazide decreases urinary calcium excretion and is used in the management of recurrent hypercalciuric renal stones. It increases blood urea.

lacunar stroke of the posterolateral thalamus: Which typically occurs due to atherothrombotic occlusion of the small, penetrating (thalamogeniculate) branches of the posterior cerebral artery. The ventral posterolateral and ventral posteromedial nuclei of the thalamus transmit sensory information from the contralateral side of the body and face, respectively. Consequently, patients with thalamic stroke in this region often present with sudden-onset contralateral sensory loss involving all sensory modalities (ie, pure sensory stroke). Symptoms can be accompanied by transient hemiparesis, athetosis, or ballistic movements due to disruption of neighboring basal ganglia structures and corticospinal fibers in the posterior limb of the internal capsule. Several weeks to months following the stroke, sensory deficits can improve; however, some patients develop thalamic pain syndrome (Dejerine-Roussy syndrome). This condition is characterized by severe paroxysmal burning pain over the affected area and is classically exacerbated by light touch (allodynia). Lacunar stroke: 1- Affected areas • Basal ganglia • Subcortical white matter (eg, internal capsule, corona radiata) • Pons 2- Clinical features • Absence of cortical signs (eg, aphasia, agnosia, neglect, apraxia, hemianopia), seizure, or mental status changes • Common syndromes: o Pure motor hemiparesis (most frequent) o Pure sensory stroke o Ataxic hemiparesis o Dysarthria-clumsy hand