Clinical Knowledge Notes

Clinical Knowledge Notes . . . 1. Motility agents used to treat gastroparesis: Metaclopramide, Cisapride, Erythromycine, Donperidone 2. New Diabetic Agents: Exenataide, Sitagliptin, Pramlintide 3. SSRI: Fluvoxetine Fluvoxamine, Sertaline, Paroxetine, Escitalopram, Citalopram 4. TCA: Clomipramine, Amitryptaline, Nortriptyline, Desipramine, Imipramine, Doxepin 5. MAOI: Phenylzine, Tranylcypromine, Selegiline 6. NDRI: Buproprion 7. SNRI: Duloxetine, Milnacipran, Nefazodone, Venlefaxine 8. Tetracyclic: Mertazepine, Trazadone 9. Seratonin Antagoinist used to treat benzo resistant agitation: Cyproheptadine 10. Ramsay Hunt Syndrome: herpes zoster oticus 11. Lab Abnormalities that necessitate obtaining thyroid function test: Hyperlipidemia, unexplained hyponatremia, elevated serum CK

Clinical Knowledge Notes

12. Feltys Syndrome: Rheumatoid Arthritis + Splenomegaly + Neutropenia 13. Hypothyroidism + elevated anti-TPO = Hashimotos Thyroidities >> @ increased risk for Thyroid Lymphoma 14. 15. Thyroid abnormalities at Pregnancy and OCP use: increased TBG, increased total-T4, with normal FreeT4 16. When to do Parathyroidectomy: @ pt with parathyroid adenoma or parathyroid hyperplasia that is symptomatic with sotnes, groans, bones, and psychic moans; @ Serum Ca+ > 1.o mg/dL above the upper limit of normal;@ 24 H Urine Ca > 400 mg; @Creatine Clearance reduced by 30%; @Bone Mineral Density T-Score <-2.5 at any site; @Age < 50. 17. MCC increased PTH (hyperparathyroidism) : Adenoma, Hyperplasia 18. MEN1: Pancreas (gastrinoma/ZES, Insulinoa, VIP-oma) + Parathyroid + Pituitary 19. MEN2A: Parathyroid + Adrenal/pheo + Thyroid/Medullary 20. MEN2B: Pheo/Adrenal + Thyroid/Medullary + Neuromas + Marfan Habitus 21. Treat Hyperphosphatemia (Po43-): dietary restriction of phosphate (protein); Oral phosphate binders (calcium
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Clinical Knowledge Notes

carbonate/Tums, calcium Acetate); sevelamer; Lanthanum; Aluminum hydroxide 22. Treat Prolactinoma (1) Cabergoline>Bromocriptine or pergolide (DA-agonists) (2) switch to 2nd DA-agonist (3) Transsphenoidal surgery + radiation therapy 23. Acromegaly: Screen = IGF-1; Confirm = OGTT; Positive OGTT = Pituitary MRI 24. Cabergoline DA-agonist that inhibits GH secretion; used as first-line in Prolactinoma and second-line in Acromegaly 25. Increased PAC + Decreased PRA = Conns primary hyperaldosteronism (Incr ALd)- look for high aldosterone to renin ration 26. Increased PAC + Increased PRA = 2HyperALd 27. Decreased PAC + Decreased PRA = Hypercortisolism (Cushings) or chronic Licorice ingestion 28. Lactotroph Adenoma = Prolactin producing pituitary adenoma 29. Somatotroph Adenoma = GH secreting tumor 30. MCC Cushings syndrome: (1) exogenous steroid use = low serum cortisol (2) pituitary adenoma (cushings disease) = dexamethasone suppression test w/ high dose dexamethasone will suppress cortisol
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Clinical Knowledge Notes

31. Drugs that elevate PRL: Phenothiazines, antipsychotics, methyldopa, verapamil [decrease DA = increase PRL] 32. Pagets disease = increase ALP all else normal 33. Primary Hypoparathyroidism = increased ALP, PTH, and Ca with low PO 34. Treatment for Black Widow Spider Bite: Wash wound with soap and water >> Ice to reduce inflammation >> 24 h observation for signs of systemic involvement >> pressure and immobilization to slow the systemic spread of venom >> tetanus toxoid prophylaxis >> Analgesia as needed >> if necrotic center > 2cm >> 5-7 days corticorsteroid >> if ulceration >> would care w/ dressing changes and debridement :: @ signs of infection, cellulitis, abscess = PO Erythromycin :: @ latrodectism (muscle spasms) = calcium gluconate, BZD, steroids, nitrates, methocarbamol, analgesia with acetaminophen +/- opiods >> give antivenum @< 30 s/p bite. 35. Treatment for dog/cat bite: Clean with iodine, copious pressure irrigation with NS >> plain film to look for foreign matter >> @ Hand = NO sutures :: @ Face = sutures ok >> Antibiotics (unasyn/clindamycin/moxifloxacin/clindamycin) 36. What causes a high A-a gradient? (nl 5-15 mmHg) Hard time getting oxygen from alveoli to the artery. Pulmonary Edema/ARDS; PE; R-L vascular shunt; high inspired O2 content
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Clinical Knowledge Notes

37. Treatment for PAD: Cilostazol - makes RBC more flexible so can squeeze through clogged arteries by selectively inhibiting PDE3 38. Hepatitis B Rx: Interferon-alpha (standard or pegylated) or Antiviral (Lamivudine, Adefovir, Entecavier, or Telbivudine) 39. Hepatitis C Rx: Pegylated interferon + Ribavarin 40. c/o dysphagia = w/u Barium Swallow 41. Treatment for Gastric Cancer: @ distal 1/3 = subtotal gastroectomy + chemo/rad; @ middle or upper stomach = total gastrectomy + chemo/rad 42. Tx pancreatic cancer at the head of the pancreas = whipple procedure (removal of pancreatic head, duodenum, proximal jejunum, common bile duct, GB, & distal stomach) + Chemo 43. Treatment for managing Crohns disease: 5-ASA (Mesalamine, Sulfasalazine); Azathioprine or Mercaptopurine > MTX; Anti-TNF alpha (Infliximab, Adalimumap, Etanercept & Enbrel); Steroids +/- Antibiotics for exacerbations 44. MC benign small bowel tumor = Leiomyoma 45. MC malignant small bowel tumor = Adenocarcinoma 46. Meperidine = Demerol
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Clinical Knowledge Notes

47. Hartmanns procedure = proximal colostomy + stapling but not removal of the distal segment = prevention of volvulus 48. Elderly pt presents to the ER w/ vomiting and abd pain and distention. Abd-XR= two distinct but sequential portions of bowel in the sigmoid colon that are distended with air. What is the TX? DX= Volvulus ; TX = Colonoscopy try to de-torsion (untwist) the volvulus 49. What tumors cause secretory diarrhea? VIPoma, Carcinoid tumor, Gastranoma, Medullary Thyroid Cancer 50. Malabsorption in a patient with a (+) sudan stain in the stool sample and normal D-xylose test? Pancreatic Insuficiency 51. Anti-endomysial antibody and Anti-gliadin antibody = celiac sprue 52. Crohns = (+) ASCA [antiyeast saccharomyces cervisiae Ab] 53. Ulcerative colitis = (+) PANCA 54. What type of pt is at high risk of acalculous cholecystitis? Pt on TPN or in ICU 55. Charcots Triad = RUQ pain + Jaundice + Fever 56. Reynolds Pentad = Charcots + AMS + Hypotension
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Clinical Knowledge Notes

57. Calcified GB >> next step = biopsy 58. Mgmt Cholecystitis = Go straight to Cholecystectomy 59. Mgmt Cholangitis = Drain bile ducts w/ ERCP then >> go do cholecystectomy 60. Outpatient Rx Diverticulitis (GN + Anaerobes) = TMP-SMX + Metronidazole, Fluoroquinalone + Metronidazole, or Augmentin (Amoxicillin + clavulonate) 61. Volume status assessment in trauma or GI bleed: HR/BP/UO 62. Antibiotics to reduce toxins formed by gut bacteria = Neomycin or Rifaximin (used to tx hepatic encephalopathy) 63. The presence of EBV DNA in the CSF = Primary CNS lymphoma. MRI reveals a weakly ring-enhancing mass that is usually solitary and periventricular 64. Three treatment options for codyloma acuminate: (A) Chemical or physical agents [trichloroacetic acid, 5florouracil epinephrine gel, and podophyllin]; (B) Immune therapy [imiquimod, interferon alpha]; (C) Surgery [cryosurgery, excisional procedures, laser treatment] 65. Exudates = increased capillary permeability

Clinical Knowledge Notes

66. Transudates = increased hydrostatic or decreased oncotic pressure 67. Medium-chain triglycerides do not need bile for absorption. Can use them as a supplement for weight loss in patients with primary biliary cirrhosis 68. Budd-Chiari syndrome: ascites + Hepatomegaly + jaundice + RUQ pain 69. Screening test for hemochromatosis? Ferritin level 70. PBC = (+) Anti-mitochondrial antibody; (+) ANA; MC@F; a/w other autoimmune d/o looks like vanishing bile duct b/c PBC is mcc of ductopenia in adults 71. PSC = (+) P-ANCA; MC@M; a/w UC; ERCP = beads on a string. Periductal portal tract fibrosis and segmental stenosis of the extrahepatic and intrahepatic ducts. 72. Vanishing bile duct syndrome , a rare disease involving progressive destruction of the intrahepatic bile ducts = ductopenia. Causes of ductopenia: PBC*, failing liver transplantation, Hodgkins disease, graft-versus-host disease, sarcoid, CMV infection, HIV, and medication toxicity. 73. Isolated MCP arthropathy (squared-off bone ends and hook-like osteophytes of the MCPs) = Hemochromatosis 74. Anticyclic citrinullated peptide (anti-CCP) = RA

Clinical Knowledge Notes

75. DMARDs: Sulfasalzine, Hydorxychloroquine, MTX, Leflunomide, cyclosporine, anti-TNF agents, anakinra 76. Anti-Jo-1 antibody = Dermatomyositis: heliotropic rash, shawl sign, grottons papules, polymyositis (symmetrical proximal muscle weakness occurs at legs first) 77. Treatment for Fibromyalgia: Nortriptyline, Tylenol, pregabalin, duloxetine, milnacipran 78. Anti-Scl-70, anti-RNA, anti-U1 RNP, anti-centromere = Scleroderma (CREST) 79. Osgood-Schlatter disease: inflammation of the bonecartilage interface of the tibial tubercle. MC sx is anterior knee pain that increases over time and is worsened by quadriceps contraction (running, jumping) b/c insertion of patellar ligament is inferior on tibia. Signs at the tibial tuberosity = tissue swelling, a palpable bony mass, and/or pain upon quadriceps flexion. Typically resolves in 618months. TX: continue sports, stretch, protective pad over tibial tuberosity, ice, nsaid 80. Nursmaids elbow [forced supination and flexion closed reduction ] reduce by gently flexing and supinating the arm with one hand while supporting the elbow and applying gentle pressure to the radial head with the other give the child a popsicle that they can eat only by using the recently reduced arm to encourage movement and confirm successful treatment (no need to immobilize)

Clinical Knowledge Notes

81. Legg-Calve-Perthes disease = AVN of capital femoral epiphysis mc btwn 3-8 yo 82. Forward (anterior) slip of vertebrae resulting in a palpable step-off on PE usually L5 over S1 = childhood Spondylolisthesis. Subacute bak pain exacerbated by heperextension of the spine. Knee-flexed, hip-flexed gait in cases where the sacrum becomes relatively more vertical and hip extension is impaired. Possible neurological dysfunction including urinary incontinence (very rare). 83. XR reveals femoral head sclerosis = Legg-Calve-Perthes 84. XR reveals ice-cream scoop (femoral head) falling off cone (femur) = Slipped Capital Femoral Epiphysis 85. Obese, male adolescent with dull hip pain and an inability to bear weight = SCFE 86. Acute onset of tibial pain, fever, malaise, elevated ESR, no joint pain = Osteomyelitis 87. Acute onset of knee pain fever, elevated ESR, Leukocytosis = Septic Arthritis 88. 7-year-old with growth delay and inner thigh pain = LPCP 89. 6-year-old with unilateral hip pain for 5 days, low-grade fever, spontaneous resolution = toxic synovitis

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Clinical Knowledge Notes

90. 13-year-old male with pain and swelling at the tibial tuberosity = Osgood-Schlatter 91. tx for SCFE = non wt bearing + surgical pinning. If @ hypothyroidism pin B/L 92. anti-RNP = mixed connective tissue disease 93. proximal muscle weakness and facial rash = dermatomyocytis 94. pain and stiffness in the hips and shoulders = polymyalgia rheumatic 95. jaw claudication and difficulty standing from a chair = polymyalgia rheumatica + temporal arteritis 96. pencil in cup defomitis of DIP and PIP joints = psoriatic arthritis 97. arthritis + oral ulcers + proteinuria = SLE 98. fixed DIP and hyperextended PIP = Swann- neck /RA 99. never give Rifampin (RIF) alone because of increased risk for developing resistance 100. Community Acquired MRSA: [Bactrim + RIF] or [Clindamycin + RIF] or [Mino/Doxycycline + RIF] or Linezolid

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Clinical Knowledge Notes

101. General empiric polymicrobial coverage = imipenem (or meropenem_ +/- vancomycin; if streptococci = PCN G +/Clindamycin; if clostridia = PCN + clindamycin 102. HPV 1-4 = skin & HPV 6&11= genital not a risk for cervical ca. 103. condyloma acuminata (genital warts / HPV 6 & 11) tx: spontaneous regression of small asymptomatic warts within 3 months occurs ~25% ; Podophyllotoxin, Podophyllin, Trichloroacetic acid (TCA); Imiquimod; Cryoablation 104. Tinea versicolr = salmon-colored pale, velvety pink, lightbrown or whitish hypopigmented macules usually limited to the upper trunk and extremities. Lesions Do Not tan. Scale when scraped. spaghetti and meatballs on KOH, blue green scales w/ woods lamp 105. Pediculosis capitis (lice) = permethrin cream 106. Antibiotics used for skin abscesses >5cm or if pt at high risk for complications (DM,IC) 107. Necrotizing Fasciitis: unexplained excrutiating pain in the absence of or beyond the area of cellulits; erythema with blister and bullae +/- crepitus; DM pt w/ foot cellulitis + signs of systemic toxicity; perineal cellulitis with abrupt onwet & rapid spread (Fourniers Gangrene) 108. Never uses Tetracycline with isoretinoin because vit A analogs = increased risk of pseudotumor cerebri
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Clinical Knowledge Notes

109. Tx rosacea: sulfacetamide(topical), metronidazole (topical), rhinophyma laser therapy. PO tetracycline, doxycycline, acutane 110. Diseases a/w increased incidence of seborrheic dermatitis: Parkinsons, HIV, psoriasis, IC 111. Homeless HepC alcoholic pt with blistering lesion on face and hyperpigmented face and dorsum of hand with hypertrichosis everywhere= porphyria cutanea tarda. Elevated LFTs, common to have h/o HepC, elevated total plasma porphyrin. Tx: phlebotomy, low dose chloroquin/hydroxychloroquine, avoid alcohol, estrogens, iron supplements and use susnscreen 112. Mc type of melanoma = superficial spreading 113. nonpigmented melanoma = amelanotic melanoma 114. dark papule on the legs or trunk that bleeds with minor trauma = nodular melanoma 115. occurs on palms, soles, or beneath nail plate in patients with dark skin = acral lentiginous 116. dark lesion larger than 6mm with irregular asymmetric borders = superficial spreading

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Clinical Knowledge Notes

117. @ vitiligo can use a woods lamp to see better = will florescence at hypopigmented spots but may need to ddx with tinea versicolor 118. comorbidities a/w vitiligo: Autoimmune d/os : Graves, Autoimmune thryroiditis, pernicious anemia, type 1 DM, Primary adrenal insufficiency, hypopituitarism, alopecia areata, autoimmune hepaititis 119. most important prognostic indicator in cases of melanoma = depth of lesion (thickness) 120. pigmented plaques that appear to be stuck onto the skin = seborrheic keratosis 121. rough lesions on sun exposed skin that are easier to feel than see = actinic keratoisis 122. circular rash with central clearing on the trunk or arms = tinea corporis 123. pearly papule with telangiectasias +/- ulcer with rolled edges = basal cell cancer 124. papule or ulcer +/- scaling or keratinization with irregular/distorted look +/- pain = squamous cell cancer 125. Pemphigus vulgaris = + nikolsky sign and anti-desmosome 126. Bullous pemphigoid = -Nikolsky , tense/hard bullae that is difficult to rub off. Anti hemidesmosome
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Clinical Knowledge Notes

127. Tx actinic keratosis w/ 5-FU, cyotherapy, imiquimod 128. Adrogenic alopecia in men tx w/ finasteride +/- minoxidil 129. Androgenic alopecia in women tx w/ minoxidil +/spironolactone 130. Underlying causes of alopecia areata(asymptomatic, noninflamatory, non-scarring areas of good old fashion hairl loss) : syphilis, perniciaous anemia, lupus, chronic hepatitis, thyroid disease, addisons disease 131. Menopause : decr E (ovaries shut down and no more aromatase activity) = incr FSH, incr LH, incr GnRH. Menopause = 12 months of amenorrhea at >45 YOF 132. Anorexic: decr LH, decr FSH, decr GnRH = no period 133. Turners (45XO) = decr E, incr LH, incr FSH 134. Premature Ovarian Failure : decr E, incr LH, incr FSH [elevated FSH>>LH d/t slower clearance of FSH from circulation] = FSH:LH ratio > 1.0 ; POF = absence of menses 6 mo @ <40 YOF 135. PCOS: incr E, incr LH, incr androgen, incr T, decr FSH, and incr DHEA [ LH:FSH ratio > 3:1] 136. Amenorrhea + 46,XY ; elevated T = androgen insensitivity syndrome
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Clinical Knowledge Notes

137. amenorrhea + 46,XX; normal female T levels = abn mullerian development 138. amenorrhea + uterus present, not pregnant, and FSH low cranial MRI for hypothalamic or pituitary disease 139. amenorrhea + uterus present, not pregnant, and FSH normal serum PRL and thyrotropin 140. amenorrhea + uterus present, not pregnant, and FSH high karyotype for 45XO 141. amenorrhea + signs of hyper androgenism serum T and DHEAS to assess for androgen-secreting tumor; incr T + nl DHEAS = PCOS; incr T + incr DHEAS = Androgen-secreting tumor (adrenals) 142. ovaries = DHEA; adrenals = DHEAS 143. true precocious puberty = incr LH, incr FSH give dose GnRH = incr LH & incr FSH 144. Pseudoprecocious puberty = decr LH, decr FSH (b/c have exogenous hormone suppressing them) give dose GnRH = no response from LH or FSH 145. MCC of pseudoprecocious puberty: (1) exogenous hormone supplementation (heterosexual) (2) adrenal tumor (DHEAS^) (3) CAH (MC 17-OH) (4)hormone secreting tumor

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Clinical Knowledge Notes

(sertoli-leydig, granulosa cell) (5) McCune-Albright syndrome (Female) 146. Primary amenorrhea = (1) absence of menses by 16 with nl secondary sexual characteristics (2) absence of menses + absence of secondary sexual characteristics by 13 147. Primary amenorrha + absent secondary sex characteristics + anosmia = Kallmans syndrome (congenital absence of GnRH secretion) 148. MCC abnormal uterine bleeding (AUB) = anovulatory bleeding/DUB 149. +hCG + interauterine pregnancy + closed os = threatened abortion 150. enlarged uterus + menometorrhagia for months = uterine fibroid/ leiomyoma 151. bleeding a/w severe menstrual pelvic pain = endometriosis 152. menorrhagia + perimenopausal = endometrial hyperplasia 153. AUB started with menarche = hereditary bleeding d/o (vWB dz) 154. + hCG + severe pain + no fetus in uterus on US = Ectopic

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Clinical Knowledge Notes

155. metorrhagia esp s/p intercourse + no pain + normal sized uterus = endometrial/cervical polyp 156. depression + constipation + AUB = hypothyroidism 157. out pt TX PID: ceftriaxone + metronidazole + doxycycline + f/u in 2-3 days 158. Inpatint tx PID: IV Cefoxitin/cefotetan + doxycycline or Clinda + Gent or Amp/sulbactam + doxy 159. Tx PMS and PMDD: exercise, vit B6, NSAID, OCP, Progestins = regulate cycle & SSRI +/- alprazolam = regulate mood 160. Bacterial vaginosis = clue cells, pH > 4.5, greenish d/c 161. Trichomonas = pH >4.5, motile wet mount, strawberry cervix, greenish d/c 162. Candida = pseudohyphae on KOH, cottage-cheese like d/c, nl vaginal pH 3.5-4.5 163. Which STD can be mistaken for IBD d/t a/w fistula formation = lymphogranuloma venerum c/b L-1, L-2, L-3 serotype of C. Trachomatis 164. Prognosis endometrial cancer histological grade>depth of myometrial invasion

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Clinical Knowledge Notes

165. Lichen Sclerosis = chronic inflammatory condition of the anogenital region, most commonly affecting postmenopausal woman = ivory or porcelain-white macules and plaques with pruritus. TX: low threshold for punch biopsy to r/o SCC; Clobetasol (a steroid w/ s/e thin skin) or Primecrolimus 166. Mcc Bloody nipple discharge = intraductal papilloma 167. Mc breast cancer = invasive ductal carcinoma 168. Often presents with serous or bloody nipple discharge = intraductal papilloma 169. Mc mass in pt 35-50 = fibrocystic changes of breast 170. Mc tumor in teen and young women = fibroadenoma 171. Breast mass accompanied by redness, pain and heat = inflammatory carcinoma 172. Next step in mgmt. of CIN2 cervical lesion identified on biopsy = excise effected part of cervix by (1) LEEP (2) conization (3) laser ablation 173. Next step in mgmt. of ASCUS pap smear = rpt PAP Q3-6 mo until get 3x successive negative PAP (if get 2 neg in a row next step is colposcopy) 174. Next step in mgmt. of AGUS pap = colposcopy + endocervical curettage + if > 35 or have risk factors then endometrial biopsy
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Clinical Knowledge Notes

175. Psammoma bodies = serous cystaendoma carcinoma of the ovaries 176. Estrogen excess = Granulosa-theca-cell tumor of the ovaries 177. Androgen secretion = Sertoli-Leydig cell tumor of the ovaries 178. Tx ductal carcinoma in situ of the breast = Lumpectomy +/- radiation 179. Tx lobular carcinoma in situ = life long observation +/tamoxifen or raloxifene +/- excisional biopsy 180. Iron supplementation in pregnancgy: @ first trimester if Hgb<11 or @ third trimester Hgb <10.5 181. Painless bleeding at 3rd trimester = abruption placentae 182. massive bleeding s/p delivery = placenta acreta 183. painless bleeding at any trimester = placenta previa 184. Increased nuchal translucency @ Downs, Turners, and CHD 185. Quad screen shows decr AFP, decr unconjugated estriol, elevated inhibin A, and elevated hCG = Downs or Turners

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Clinical Knowledge Notes

186. What additional supplements should be given to complete vegitarians during pregnancy = iron, vit D, B12 187. Quad screen @ 16-18w & OGTT @ 24-28 w, Amniocentesis for karyotype @ >16w & chorionic villous sampling >9w 188. Lab changes in pregnancy: TSH nl (incr TBP = incr tT3 & tT4), decr BP at 1st and 2nd TM nater @ 24w nl @term, serum pH increases respiratory alkalosis with metabolic compensation, CO increases by 40% (incr SBP), Incr ventilation 189. Hyperemesis gravidarum = wt loss > 5% pre-preg + detection of keonuria d/t starvation. Tx: vit B6, ginger, doxylamine, promethazine, ondansetron,granisetron, metoclopramide, IVF +/- MVT+thiamine 190. Tocolytics: (MINT-R), Magnesium Sulfate, Indomthacin, Nifedapine, Terbutaline, Ritodrine 191. Magnesium toxicity : Sx= loss of DTR, Respiratory paralysis, Cardiac arrest. TX= calcium gluconate 192. Sinusoidal heart rate baseline 120-160 bpm with oscillating amplitude of 5-15bpm = fetal anemia 193. Normal variability of fetal HR is 6-25bpm 194. Normal fetal HR is 110-160bpm

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Clinical Knowledge Notes

195. Normal , reactive nonstress test = 2, 15bpm accelerations of Fetal HR lating 15 s within 20 minutes (15x15x20)x2 196. Ss of chorioamnionitis = fever + 1: maternal tachycardia, fetal tachycardia, maternal leukocytosis (WBC>15,000), uterine tenderness, or foul smelling d/c next step abx 197. BPP = fetal (tone + breathing + movement) + AFI + NST 198. Oligo = AFI <5 and Poly = AFI > 25 199. Prolonged latent phase of labor = does not progress from latent to active phase for > 20 hours in nulliparous pts or >14hours in multiparous 200. Prolonged active phase of labor: Active phase >12h or nulliparous <1.2 cm/hr dilation or multiparous < 1.5 cm/hr dilation 201. Contraction pattern necessary for cervical dilation to occur is > 3 contractions in 10m 202. Arrest of descent = cervix does not continue to dilate during the active phase for >2h in multips and >3 hours in primips reassess 3Ps (power,passage, passanger), place IUPC, agument w/ oxytocin, +/- c section 203. Bisphosphonates = DOC for mild to moderate hypercalcemia. They may also pevent skeletal complications (Reduce bone pain, fracture risk), and perhaps improve survival in patients with multiple myeloma and breast
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Clinical Knowledge Notes

cancer. >> IV Zolendronic Acid = recommended for all women who have metastatic breast cancer and radiographic lytic bone disease, and are receiving either hormone therapy or chemotherapy. 204. AV nicking = hypertensive retinopathy 205. Marfans = aortic insuficiency 206. Gallstone illeus : XR film of the abdomen shows air-fluid levels throughout the small bowel and air in the liver; there is no gas in the colon or free air and increase small bowel sound due to obstruction stone obs the ileocecal wall. 207. Monitor respiratory function = measure vital capacity at the bedside >>>>> the riks for ventilatory failure increass significantly whne the VC < 15mL/kg 208. Cerebral palsy = low APGAR scores, hypotonia, hypereactive DTR, learning disabilities and h/o prolonged labor = mcc cerebral anoxia 209. Hereditary Telangiectasia ( Osler-Weber-Renu Syndrome) = AD d/o charcterized by diffuse telangiectasias, recurrent epsistaxis, and widespread AVMs. AVMs tend to occur in the mucous membranes, skin, and GIT, +/- liver, brain and lung. 210. Folic Acid Supplementation is encouraged in patients with high risk for developing aplastic crisis ( hereditary spherocytosis, Sickl cell)

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Clinical Knowledge Notes

211. Sca++mous cell carcinoma of the lung = hilar mass on CXR of smoker, Hypercalcemia d/t PTHrP 212. Prophyria Cutanea Tarda = deficiency of uroporphyrinogen decarboxylase, an enzyme in the heme synthesis pathway. Sx: painless blisters, increased skin fragility on the dorsal surfaces of the hands, facial hypertrichosis and hyperpigmentations. It can be triggered by the ingesition of certain substances (ethanol, estrogens) TX: phlebotomy or hydroxychloroquine +/- interferon-alpha at pt simultaneously infected with Hep c virus 213. Mechanical ventilation improves oxygen by providing an increased fraction of inspired oxygen (FiO2) and by providing PEEP to prevent alveolar collapse. In the hospital setting, the arterial pO2 provides an important measure of oxygenation. It is influenced mainly by the FiO2 and PEEP level. The arterial pCO2 , a measure of ventilation, is affected mainly by the respiratory rate and tidal volume. >>> The normal FiO2 @ sea level is 0.21, or 21%. Patients are often provided a high FiO2 (>80% or 0.8) initially in mechanical ventilation, pending the results of the first blood gas analysis.The ventilator settings can subsequently be adjusted based upon these results. The GOAL is to maintain paO2>60). An important early goal in initial ventilator management should be to decrease the FiO2 to non-toxic values. There is no strict cut-off FiO2 value for oxygen toxicity, but levels below 50-60% are desirable. In this case, the patients initial ABG values indicate appropriate ventilation and excessive oxygenation. Thus, the FiO2 should be slowly decreased to below 60% to prevent toxicity to the lungs.
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Clinical Knowledge Notes

214. Diabetes, oculomotor nerve (CN3) neuropathy =

215. Prinzmetals angina

216.

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