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part 3 my notes!

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    Asclepius1 said:

    part 3 my notes!

    380.Toxoplasmosis is the most common cause of intracranial mass lesions in patients with AIDS. It typically develops subacutely over several days with the onset of fever, headache, mental status changes, and focal neurologic signs. The diagnosis of cerebral toxoplasmosis relies on a high index of clinical suspicion, neuroimaging, serologic studies, and response to a therapeutic drug trial. MRI with gadolinium is the neuroimaging test of choice to detect small lesions. Multiple lesions with ring enhancement, edema, and mass effect suggest a diagnosis of toxoplasmosis. However, no clinical or radiologic feature absolutely differentiates cerebral toxoplasmosis from a primary central nervous system lymphoma, which is the other major cause of intracranial mass lesions in patients with AIDS,put the paitent on empiric therapy with pyrimethamine, folinic acid, and sulfadiazine for 8 weeks,no response!!!do biopsy!381.Remember Premonitory symptoms in patients with syncope include a sensation of impending unconsciousness, often accompanied by nausea, a sense of warmth, and diaphoresis. Syncope often results in atonia and collapse; however, opisthotonic posturing and clonic jerks can also occur. Pallor is a characteristic feature. Syncope usually lasts 10 to 30 seconds. Recovery of cognition is relatively rapid following syncope compared with recovery following a generalized tonic-clonic seizure. 382.good example of ethics:Old Spanish lady with CHF, she doesn’t speak English, has a care-giver daughter speaking English & a clergyman visiting her for religious talks speaking both E & S? How would u discuss with her for further Mx?answer: (get a fluent translator not a friend or family member383. Giant cell arteritis (temporal arteritis) is a relatively common necrotizing granulomatous systemic arteritis t. The diagnosis should be considered in any person older than 50 years of age who has a new form of headache, abrupt loss of vision, polymyalgia rheumatica, unexplained fever or anemia, and an elevated erythrocyte sedimentation rate. Visual loss, which is preceded by amaurosis in only 15% of patients, occurs in up to 40% of those with giant cell arteritis if left untreated.384.The clinical manifestations of dermatomyositis include proximal muscle weakness that evolves over weeks or months and an erythematous, violaceous rash over the eyelids, bridge of the nose, and cheeks. About one third of patients have violaceous papules over the dorsal interphalangeal joints known as Gottron’s papules. Dermatomyositis appears to be associated with a malignancy in 6% to 45% of patients, especially patients over 40 years of age.Based on available information, there appears to be a temporal association between dermatomyositis and malignancy. In women with dermatomyositis and ovarian carcinoma, the tumor is at an advanced stage and of uniform epithelial origin. In children, dermatomyositis is often associated with vasculitis,not malignancy!!!!!!!!!!!!!!!!!!!!385. Remembber The exact pathophysiology of hepatic encephalopathy is unknown, but patients frequently respond to measures that lead to a reduction of hyperammonemia. Such measures include dietary protein restriction and lactulose administration. Gastrointestinal bleeding is an important precipitant of hepatic encephalopathy and should be ruled out by upper endoscopy.385.Keep on back of your mind Although hypoglycemia should be avoided in patients with hepatic encephalopathy,
    but if you see for example BG - 56 ,don't rush to give Glucose ,,thiamine should be administered prior to any glucose load in an alcoholic or otherwise malnourished patient to avoid precipitating Wernicke’s encephalopathy.
    386.Remember Hypertonic saline should not be administered to patients with chronic liver disease and hyponatremia because of the risk of central pontine myelinolysis in this population.
    387. weakness , dizziness, dysarthria, and dysphagia. These symptoms are highly suggestive of posterior circulation ischemia involving the brain stem. In addition, evidence of bilateral pyramidal tract findings (bilateral extensor plantar responses), oculovestibular dysfunction (unilateral nystagmus), and cranial nerve involvement (unilateral tongue weakness). The basilar artery and its branches supply most of the brain stem. 388.The posterior cerebral artery supplies the ipsilateral occipital lobe and medial temporal lobe. 389. Remember Patients with ALS generally present with muscle weakness and commonly note “muscle twitches” representing fasciculations. An electromyogram (EMG) is the most important confirmatory test for ALS.
    390.The clinical triad of Wernicke’s encephalopathy is confusion, ataxia, and abnormalities of eye movement. However, the complete triad is uncommonly noted. Although the disorder is usually associated with chronic alcoholism, Wernicke’s encephalopathy can occur in any malnourished individual. It has been described in patients with anorexia nervosa, in patients with cachexia secondary to underlying malignancy, as a complication of gastrectomy and gastric stapling, and in patients receiving chronic hemodialysis. Once the diagnosis is suspected, thiamine, 100 mg intravenously, should be administered promptly. It is important to administer thiamine prior to or during a glucose load in a malnourished patient, as exacerbations of Wernicke’s encephalopathy can occur if thiamine is not administered first. 391.Essential tremor causes a posture- or action-related tremor that usually involves the upper extremities, the head, or the voice. Other family members may have a similar disorder. A positive response to ethanol ingestion is often noted. Treatment options include beta-blocking agents such as propranolol. Primidone, an anticonvulsant medication, is also effective. Patients should be told that primidone, even at low doses, may cause an idiosyncratic reaction that is similar to an influenza syndrome. Nausea, vomiting, and significant malaise may occur for 24 to 48 hours and then rapidly dissipate. Other treatment options for essential tremor include clonazepam and gabapentin392.Remember the contrast used in catheterization procedure contains iodine!
    and iodine tends to worsen hyperthy cuased by autonomous nodules, wheres it inhibits the release of thyroid hormon in patients with autoimmune thyroid disease such as Graves.393.Middle cerebral artery (MCA) occlusion: "Difficulty with A-B-Cs in M-C-A"A-Apraxia
    B-Blindness in corresponding half of the visual field (contralateral homonymous hemianopsia)
    C-Contralateral Clumsiness of arm, face. -- Leg is somewhat spared.M-Memorization difficulties
    C-Calculation difficulties
    A-Aphasia with language-dominant hemispheral involvement394.A well-known mnemonic regarding occlusion of the vertebral-basilar circulation: 4D-Dizziness
    -Dysphagia395.Root values of reflexes are 1,2,3,4,5,6,7,8 - S1-2 ankle, L3-4 knee, C5-6 biceps/supinator, C7-8 triceps396.Argyle Robertson Pupil
    • Accomodation Reflex Present - Pupillary Reflex Absent.397.Amantadine and rimantadine are active against influenza A only. A new class of compounds, the neuraminidase inhibitors, is active against influenza A and B viruses. The neuraminidase inhibitors are also effective for prophylaxis of influenza A and B infections. 398.Remeber CA125 level is a useful parameter for assessment of the response of ovarian cancer patients to chemotherapy and for detection of relapse. not for helping in diagnose399. extensionof inflammed synovium in the popliteal space:mechanism of baker cyst400.Focal glomerulosclerosis is the most common pattern of idiopathic nephrotic syndrome in black Americans, and treatment with a prolonged course of glucocorticoids is successful in up to 50% of patients 401. Recent studies have shown that classic Bartter’s syndrome is often due to a genetic mutation in the Na-K-2Cl transporter located in the thick ascending limb of Henle. This is the transporter that is inhibited by loop diuretics. Gitelman’s syndrome has a similar clinical presentation but is due to a genetic defect in the neutral Na-Cl transporter in the distal tubule. Thiazide diuretics inhibit this transporter. These two disorders are clinically distinguished by the presence of hypercalciuria in Bartter’s syndrome and hypo-calciuria in Gitelman’s syndrome.402.Remember As with other metastatic tumors, breast cancer tends to produce multiple lesions that are most commonly located at the junction of the white matter and gray matter. These lesions are characteristically surrounded by a significant amount of edema; occasionally, the edematous area is out of proportion with the size of the metastasis403.Remember Both astrocytomas and oligodendrogliomas are tumors situated within the brain parenchyma. Both types tend to present as solitary masses without clearly defined margins. Edema, although frequently present, is less significant than the cerebral edema associated with metastatic disease. 404.Remember Meningiomas arise from the dura and the arachnoid villa of intracranial and spinal spaces. These are slow-growing tumors; patients usually present with either symptoms of a space-occupying lesion or seizures of new onset. Radiologically, these tumors are characterized by their extraparenchymal location and the fact that they have a density similar to that of surrounding brain tissue. Of interest, women with breast cancer are known to have an increased incidence of meningiomas. Prognosis of meningiomas is in general excellent; surgical excision tends to be curative. Meningiomas that are difficult to excise completely (e.g., those located at the base of the brain) or that have anaplastic features are more likely to recur. For such patients, postsurgical radiation therapy is recommended. 405.Remember Prostate cancer almost never metastasizes to the brain406.The red cell mass of less than 36 ml/kg, reduced oxygen levels, and low-normal plasma volume seen in this patient suggest a diagnosis of Gaisböck syndrome.(secendory polycytemia) Gaisböck syndrome, or relative polycythemia, is often seen at an earlier age (45 to 55 years) than polycythemia vera. In the male population in the United States, 5% to 7% have Gaisböck syndrome. Those affected are usually middle-aged, obese, hypertensive men who may also be heavy smokers. 407.Remember There are several mechanisms by which drugs can induce hemolysis; two well-recognized mechanisms are immunologic mediation (e.g., hemolysis caused by penicillin and methyldopa) and an increase in oxidative stress on red cells. Oxidative stress can occur as a result of hemoglobins becoming unstable or through a decrease in reduction capacity (as would result from G6PD deficiency).
    407.understand that patients with polycythemia vera who are older than 70 years should be treated with a myelosuppressive agent such as hydroxyurea in combination with phlebotomy ,, combination of hydroxyurea and phlebotomy has been demonstrated to be an effective therapeutic regimen in controlling the hematocrit in most patients with polycythemia vera and in lowering the risk of thrombosis that occurs with use of phlebotomy alone. 408.then remember hydroxyurea is generally used for (PV) in patients older than 70 years or for those who have previously had a thrombotic event or who require high-maintenance phlebotomy. 409.If exposed to measles, all HIV-infected infants, children, and adolescents, as well as children of unknown infectious status born to HIV-infected women, should receive 0.5 mL/kg (maximum dose, 15 mL) of immune globulin intramuscularly, regardless of their immunization status, because it is impossible to know in a timely fashion if the child has protective antibody. If the person exposed to measles is receiving intravenous immune globulin (IGIV) (400 mg/kg) and 3 weeks have elapsed since the last dose, the person should receive IG (0.5 mL/kg) or IGIV (400 mg/kg) as soon as possible. 410. Isoniazid deprees the GABA neurotransmiters R in the brane=seizure.Pyrydoxon work opposite411.Osteoarthritis of lumbar spine.:
    Referred pain from the lower lumbar facet joints or intervertebral discs is often reported by the patient as hip pain, with localization to the buttock and lateral thigh. The pain is characteristically aggravated by maneuvers that increase the force brought to bear on these joints, particularly spine extension as well as lateral bending or rotation toward the painful side. Pain over the spine may or may not be present, but even in its absence, there may be paravertebral muscle spasm contributing to reduced spine motion412.Pain resulting from hip joint pathology is usually felt in the groin and anterior thigh. Hip motion, particularly rotation, is usually painful413.Remember mitral regurgitation secondary to left ventricular dilatation(cardiomypathy dilated) and systolic dysfunction. The mechanism of mitral regurgitation in this setting appears to be lateral displacement of the papillary muscles, resulting in inadequate leaflet coaptation. Afterload reduction therapy with an angiotensin-converting enzyme inhibitor results in a decrease in ventricular dimension and improvement in papillary muscle alignment, so that many patients have a substantial reduction in regurgitant severity414. Rapid exclusion (or diagnosis) of aortic dissection is essential. Transesophageal echocardiography has a high sensitivity and specificity for aortic dissection and can be performed rapidly at the patient’s bedside. Therapy with a b-blocker to decrease blood pressure and heart rate should be initiated immediately and continued during the transesophageal examination. If an ascending aortic dissection is present, prompt surgical intervention is indicated;415. putament hemorrhage cause deviation of both eyes to the side of the lesion (away from hemiparesis), but the sizes of pupils are normal416.thalamus hemorrhage, although the sizes of the pupils are small; both eyes are deviated inward and look at nose417.patients with cerebellum hemorrhage have a normal size of pupils and they are unable to look toward the side of the lesion418.Remember Prochlorperazine (Compazine) is frequently used to treat nausea and emesis in some patients. Side effects of this medication, including extrapyramidal reactions (e.g., catatonia), are treated best by antiparkinsonian medications such as benztropine419.Remember Bupropion is the antidepressant of the choices listed that has the fewest adverse sexual side effects420. Concrete thinking is described as literal thinking that shows a lack of understanding of the nuances of meaning. These individuals lack the ability to use metaphors. for example if asks the patient what the proverb "Don't cry over spilled milk" means what??. The patient answers that if you spill what you cook, you have to do it all over again. 421.what do u find in bipsy of wilms?
    spindl shaped cell, striated muscle, anaplasia, fibrillar inclusions in histo of nephroblastoma 422.Pathophysiology: In Graves disease, B- and T-lymphocyte–mediated autoimmunity are known to be directed at 4 well-known thyroid antigens, thyroglobulin, thyroperoxidase, sodium-iodide symporter, and the TSH receptor. However, the TSH receptor itself is the primary autoantigen of Graves disease and is responsible for the manifestation of hyperthyroidism. In this disease, the antibody and cell-mediated thyroid antigen-specific immune responses are well defined. The transference of hyperthyroidism by TSH receptor antibodies in (1) healthy subjects by transfer of serum from patients with Graves disease and (2) the passive transfer of TSH receptor antibodies to the fetus in pregnant women are direct proof of an autoimmune disorder mediated by autoantibodies
    423.Physical findings that are unique to Graves disease but not associated with other causes of hyperthyroidism include ophthalmopathy, acropachy, and pretibial myxedema424.During pregnancy, both T-cell and B-cell function are diminished, and the rebound from this immunosuppression is thought to contribute to the development of postpartum thyroid syndromealsoAcute stress-induced immunosuppression may be followed by immune system hyperactivity, which could precipitate autoimmune thyroid disease.
    This may occur during the postpartum period, in which Graves disease may occur 3-9 months after delivery.
    A summary of the differential diagnosis of thyrotoxicosis is a follows:Graves disease: Special features include diffusely enlarged thyroid, thyroid bruits, ophthalmology, pretibial myxedema, and the presence of TSIs.Subacute thyroiditis: Special features include a history of antecedent respiratory tract infection, neck tenderness, elevated sedimentation rate, low or absent radioactive iodine uptake, and a self-limited course.Silent thyroiditis: Special features include painless thyroiditis, which may be seen in postpartum women (postpartum thyroiditis); a self-limited course; and low radioiodine uptake.Multinodular toxic goiter: Special features include a propensity to occur in elderly individuals and multiple nodules palpated or observed after thyroid scans.Toxic adenoma: Special features include a solitary palpable nodule and a "hot" nodule observed after a thyroid scan.Factitious thyrotoxicosis: Special features include no goiter, a low thyroglobulin level, and low radioiodine uptake.Iatrogenic thyrotoxicosis: The special feature is a history of thyroid hormone intake.Iodide-induced thyrotoxicosis: The special feature is a propensity to occur in patients with a history of nodular thyroid disease who have been exposed to iodine-containing contrast agents or drugs such as amiodarone.TSH-secreting pituitary adenoma: Special features include inappropriately elevated or normal TSH levels in the face of elevated free levothyroxine (T4) and free triiodothyronine (T3) levels, evidence of other pituitary hormone deficiencies, elevated alpha subunit level, and compressive symptoms.Beta human choriogonadotropin–induced thyrotoxicosis: Special features include a positive pregnancy test result, a history of hydatidiform mole, choriocarcinoma, and embryonal carcinoma of the testis. Also, rarely, it may be observed in normal gestation.426.How do u diff Toxic epidermal necrolysis from SSSS?
    TEN is more benign than SSSS
    biopsy diff them: in ssss: split granular TEN full thickness involvem 427.Intraoperative and postoperative hemorrhage is a significant problem in the patient with polycythemia vera. Despite thrombocytosis, these patients have a hemorrhagic tendency generally ascribed to a qualitative deficiency of the platelets. Elective surgery should be postponed until the hematocrit and platelet count reach normal levels. Alkylating agents, such as busulfan or chlorambucil, are effective in this regard. In the emergency situation, phlebectomy should
    be performed prior to operation and also an especially careful hemostatic technique should be employed428.Significant drop in estrogen leves right after delivery, can cause all changes in women mood- so called postparatum blues.
    429.remember forceps may be used in face presentation with a mentum anterior presentation(chin facing toward the maternal pubic symphysis.) ; in such a case, vacuum is contraindicated BUT opposed to forceps, the vacuum extractor does not occupy space next to the fetal head; this should lead to less trauma to maternal tissues.430.Remember When unvaccinated susceptible personnel are exposed to varicella, they are potentially infectious 10 to 21 days after exposure, and exclusion from duty is indicated from the tenth day after the first exposure through the 21st day after the last exposure, or until all lesions are dry and crusted if varicella occurs.431.if vaccinated health care personnel are exposed to varicella, they may be serotested immediately after exposure to assess the presence of antibody. If they are seronegative, they may be excluded from duty or monitored daily for development of symptoms. Exclusion from duty is indicated if symptoms (fever, upper respiratory tract symptoms, or rash) develop.432.The routine postexposure use of VZV immune globulin (VZIG) is not recommended among immunocompetent health care personnel. VZIG can be costly, does not necessarily prevent varicella, and may prolong the incubation period by a week or more, thus extending the time that personnel will be restricted from duty. The use of VZIG may be considered for immunocompromised (e.g., HIV infected) or pregnant health care personnel.433.It is essential to detect and treat chlamydial infection during pregnancy because maternal chlamydial infection is associated with several complications of pregnancy including preterm premature rupture of the membranes (PPROM) and preterm labor.434. Remember Rh isoimmunization occurs when an Rh-negative mother becomes exposed to the Rh antigen on the red blood cells of an Rh-positive fetus. This exposure may lead the mother's immune system to become sensitized to the Rh antigen such that in a future pregnancy with an Rh-positive fetus, the mother's immune system may "attack" the Rh antigen on the fetal red blood cells. This immune response may lead to the development of fetal anemia, hydrops, and death.
    435. Rh-negative women who are not Rh alloimmunized should receive RhoGAM (anti-D immune globulin):
    1. at 28 weeks of gestation,
    2.within 72 hours after the birth of an Rh-positive infant, 3.after a spontaneous abortion,
    4. after invasive procedures such as amniocentesis. 5.threatened abortion,
    6.antenatal bleeding,
    7.external cephalic version, or abdominal trauma.
    436.The amount that is usually given after the delivery of an Rh-positive fetus is 300 µg. This amount is sufficient to cover a fetal to maternal hemorrhage of 30 mL (or 15 mL of fetal cells). However, some women will have a fetal to maternal hemorrhage that is in excess of this 30 mL-especially in cases such as manual removal of the placenta or placental abruption (as this patient had). To determine the amount of fetal to maternal hemorrhage that occurred, it is necessary to perform a Kleihauer-Betke test which is an acid-dilution procedure that allows fetal red blood cells to be identified and counted. Knowing the amount of fetal to maternal hemorrhage that took place allows the correct amount of RhoGAM to be given. 437. An apt test is used to differentiate fetal from maternal blood. It can be used in the diagnosis of vasa previa or with neonatal melena. 438.Among adults with acute community-acquired bacterial meningitis, Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae, and Listeria monocytogenes are the most common pathogens. The possibilities of highly penicillin-resistant S. pneumoniae and L. monocytogenes should be considered (especially if the patient has underlying diabetes and liver disease). Although ceftriaxone is appropriate for susceptible S. pneumoniae, it would not be adequate for highly penicillin-resistant strains; thus, vancomycin should be given until definitive microbiologic results are available. The patient's advanced age and underlying medical conditions (i.e., diabetes, liver disease) predispose him to L. monocytogenes infection. Ampicillin is the antibiotic of choice for Listeria infections and should also be given empirically then Alwyes remember elderly paitent >60 years especially if with Diabet and liver disease comes with bacterial mengitis COVER HIM WITH AMPI+VANCO+CEFTRIX439.keep in your mind!! Listerial meningitis typically occurs in elderly patients, immunocompromised persons, or patients with serious underlying medical conditions (e.g., liver disease or diabetes).The CSF Gram stain is positive in only approximately 30% of patients with listerial meningitis (as compared to 60% to 90% of patients with meningitis caused by other bacteria). In addition, approximately 25% of patients with listerial meningitis have a lymphocytic predominance in the CSF (an uncommon finding in meningitis caused by other types of bacteria). The antibiotic of choice for listerial meningitis is ampicillin (or trimethoprim-sulfamethoxazole for the penicillin-allergic patient440.Spinal epidural abscess must be considered early in any patient with fever and localized back pain, because delay in diagnosis and treatment can lead to serious neurologic sequelae. Injection drug users are at increased risk .your next step?? MRI (if available) is the best choice for delineating an epidural abscess. If MRI is unavailable, CT should be performed441.Remember Although many patients with spinal epidural abscess have concomitant vertebral osteomyelitis, spinal x-rays are not sensitive enough to exclude the diagnosis. and also A bone scan would not adequately differentiate vertebral osteomyelitis from epidural abscess. 442.Remember In addition to I.V. antibiotics, the most important element of therapy for spinal epidural abscess is urgent surgery for drainage of pus and removal of granulation tissue
    443.Remember The low-probability ventilation-perfusion scan results do not alter the probability of PE. Therefore, further diagnostic workup is necessary. Lower-extremity ultrasound should be the next step before empirical anticoagulation therapy or more invasive testing such as pulmonary arteriography is administered.444.Vena cava filter placement is more effective than heparin anticoagulation in preventing recurrent VTE in the short-term
    it is best reserved for patients with recurrent VTE whose anticoagulation therapy is inadequate at the time; in patients with significant risk of bleeding; and in patients with a life expectancy of less than 2 years. 445.mechanism by which chronic disease can cause anemia :Anemia of chronic disease is generally associated with conditions that release cytokines (tumor necrosis factor-a, interleukin-1, and other inflammatory cytokines). These cytokines decrease erythropoietin production, decrease the levels of iron released from the reticuloendothelial system, and increase serum ferritin levels446.Remember Alcohol abuse can cause a reversible form of sideroblastic anemia, and stopping alcohol is an important aspect of patient care. 447.AVM is the most common subarachnoid space hemorrhage in children and history of seizure or migrain like headache is characterestic.448.keratoacanthoma, Mimics skin cancer (especially Squamous cell carcinoma) rapid onset and growth (1 month) almost never happens is SCC. Lesion spont involutes in a few months and requires no treatment449.Rhinoviruses, which cause about 50% of colds, and coronaviruses, which cause 10% to 20%, are the most important pathogens with regard to the common cold.450Adenoviruses : pharyngoconjunctival fever, which is often contracted while swimming in contaminated water. In addition to transmission by direct contact with respiratory secretions or infectious aerosols, fecal-oral transmission can occur. Infection may be acquired by pharyngeal inoculation or conjunctival inoculation from contaminated water. The incubation period for adenovirus infection of the respiratory tract is usually 4 to 7 days. Adenovirus respiratory disease typically causes moderate to severe, sometimes exudative, pharyngitis and tracheobronchitis. Fever and systemic symptoms are often prominent, and rhinitis, cervical adenitis, and follicular conjunctivitis are common. 451.Name 3 possible findings in non-REM sleep.?Sleepwalking, night terrors, and bedwetting452.Name 4 physiological actions found in REM sleep.?
    Increased/variable pulse, rapid eye movements, increased/variable blood pressure, and penile/clitoral tumescence453.Lung cancer=>think of paraneoplstic syndrome=>muslce strengh diminuished bilaterally, more proximal than distal
    -normal reflexes
    -increase in CK, (+) EMG
    -pathology is located in the muscle membrane.454.Disseminated gonococcal infection-rash, tenosynovitis, polyarthralgia (migratory)
    -mediated by immune complexes from gonococcemia.455.)Pneumonia post bone marrow transplant=>think CMV
    -not immediate, comes in about 2 weeks to 2 years post-transplant456.To detect the benefit of lung resection=>do PFT, especially FEV1457.)Status epilepticus=> treat by general anesthesia+intubation458.when u have P value > .1 means u r power ( p value ) is LOW!
    mean ur number of samples r LOW !
    cause ur power is low!!459.HSP is an IgA-mediated autoimmune vasculitis, which can cause tissue damage as a result of immune complex formation. Deposition of these immune complexes in the kidneys can lead to nephritis, which is the leading cause of permanent sequelae from HSP. End-stage renal disease is an uncommon but possible outcome. It is important to perform frequent urinalyses for early detection of kidney involvement.460.Pathogenes of A Zencker's diverticulum is a pharyngoesophageal pulsion diverticulum that occurs at the point of transition between the oblique fibers of the thyropharyngeus muscle and the horizontal fibers of the cricopharyngeus muscle. A hypertrophied cricopharyngeus muscle is thought to predispose the development of the diverticulum at this transition point. 461.cardiac output = 3-7 liters/ minCO in cardiogenic shock is decreased; whereas CO in overload (eg. bld transfusion) will increase by increasing the mean circulatory filling pressure but it does not cause enhanced performance of heart.
    Ref : Kaplan Q bank462.Remember Some antibiotics should not be used during pregnancy :. These include tetracyclines (adverse effects on fetal teeth and bones, congenital defects), quinolones (various congenital defects), trimethoprim in the first trimester (facial defects, cardiac abnormalities), and chloramphenicol and sulfonamides in the last trimester (Gray syndrome; hemolytic anemia in mothers with glucose-6-phosphate dehydrogenase [G-6-PD] deficiency, jaundice, and kernicterus, respectively). should we manage truma to neck zone!
    be careful about 2 things!
    first is it gunshot or stab wound?
    odes he stabe or unstable!?
    NOW RULE!.if you have a penetrating truma to neck(can be gun shot or stab wound) + UNSATBLE paitent go for surgery without any doubt and forget any ZONE!2,if you have a GUNSHOT to middle ZONE don't think the paitent is stable or not send him for surgery!3.If you have a STAB WOUND to MIDDLE ZONE!first look the paitent is stable or not!
    if stable just observe for 12 hours no need for surgery or any expensive workup!ok middle Zone is clear?:-)!we talked about both gunshot and stab wound in middle ZONE!now let's go to upper zone!
    GUN shot to upper zone first do arterigraphic diagnosis and managment! if paitent is stable!
    if paitent is not stable you know the rule!now stab wound to upper zone paitent stable and asymptomatic!just observe!
    if unsatble surgery!now move to base of the neck!
    GUNSHOT and stable! do arterography,esophagogram,esophagoscopy,broncoscop y ,then surgery!if unstable you know ,surgery!
    stab wound in neck of zone I have no idea becuause kaplan didn't mention!464.Remember TSH levels are very helpful in confirming the diagnosis of the hyperthyroid state, but are not the best parameter to follow in patients undergoing treatment for thyrotoxicosis.Serum T4 levels are the best parameter to follow; they are readily available and relatively inexpensive, and allow for careful monitoring of the effects of antithyroid drug therapy.465.The appropriate evaluation of the hypothalamic–pituitary–adrenal axis is a post-cosyntropin measurement of serum cortisol; cortisol levels fluctuate widely due to the pulsatility of this hormone, and therefore random measurements are not useful. The appropriate evaluation of the hypothalamic–pituitary–thyroid axis is a free thyroxine index (or dialysis free T4) because the TSH concentration is often normal in central hypothyroidism. The hypothalamic–pituitary–gonadal axis in men is best evaluated by measuring serum total testosterone466.Alwyes remember There is significant variation in sperm counts on semen analysis, and a single abnormal test should never be used to document infertility.Repeat it again!!!!before you say he is infertile!!!!!!467.Treatment for Gonococcal conjunctivitis =>>> Ceftriaxone
    Prevention =>>> erythro topical 468.Adrenal Leukodystrophy (ALD)
    USMLE LOVE TO ASK!!!!!!!Clinical Sx:
    The disease usually presents in males age 5-10 years old with a gradual disturbance in gait and slight intellectual impairment. There is usually rapid progression with hypotension, seizures, visual complaints, and difficulty in swallowing appearing with time. Abnormal skin pigmentation or other signs and symptoms of adrenal insufficiency may become apparent before CNS symptoms. In some cases, adrenal symptoms never appear. Etiology/Pathophysiology:
    Classic ALD and the adult variant adrenomyeloneuropathy (AMN) are X-linked diseases in which there is deficiency of lignoceroyl-CoA ligase, a perioxisomal enxyme needed for the degradation of very long chain fatty acids (VLCFA). Pathology:
    White matter diseases are usually classified as demyelinating or dysmyelinating diseases. Dysmyelinating diseases such as ALD are inherited enzymatic deficiencies that cause abnormal formation or increased breakdown of myelin. Demyelinating diseases result in the loss of normally formed myelin by processes such as infection, chemotherapy, radiation, and autoimmune disorders such as multiple sclerosis. The diagnosis of ALD is made by the assay of plasma, red cells, or cultured fibroblasts for increased amounts of VLCFA. Imaging:The classic presentation on CT is low attenuation in the central occipital white matter that extends into the splenium of the corpus callosum.
  2. DoolePege's Avatar

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  3. zs.vatan said:
    thanks, very nice notes
  4. oompaloompa said:
    Thanks so much
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