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Upper gastrointestinal endoscopy is the diagnostic study of choice when a patient presents
with acute alkali ingestion.
2. Quantitative CT of the spine is the most sensitive diagnostic test for osteopenia but it is not a
gold standard because of its poor reproducibility. The test of choice in most settings is dual-
energy X-ray absorptiometry of spine
3. Despite of other risks, HRT is still the best form of therapy for osteoporosis in postmenopausal
4. Pap smear: If 3 consecutive pap smears are normal, screening may be performed less
frequently (every three years) in a low-risk patient. Screening is usually started at 18 and stopped
at 60-75 years.
5. If a woman has undergone a hysterectomy for cancer or cervical dysplasia she needs yearly
Pap smear screening of the vaginal epithelium and inspection of the vulvar and perianal
6. Learn the Hepatitis-B prevention. Know when to give vaccine and when to give HBIG. If
someone is exposed to HBV and has a documented response to HBV vaccination, he does not
need anything else but reassurance
7. Human studies have demonstrated a significant association between type A personality and
exaggerated cardiovascular response.
8. Pneumococcal vaccine contains capsular polysaccharides and it produces T cell independent B
cell response
9. Racemic epinephrine decreases the need for intubation in patients with croup and should
always be tried before any invasive procedure
10. Adolescent onset of hirsutism and virilism, with normal menstruations and elevated 17-
hydroxyprogesterone, are diagnostic of congenital adrenal hyperplasia

11. Spontaneous hemarthrosis raises the suspicion for hemophilia for which factor VIII assay is
12. Decreased tympanic membrane mobility is specific for the diagnosis of acute otitis media.
13. Tetralogy of Fallot, the most common cyanotic congenital disease in children of less than 4
years of age, presents with cyanotic spells and pansystolic murmur on examination.
14. Neonatal sepsis is suspected when a baby develops jaundice after the 3rd day and within the
first week, especially if he is feeding poorly and lethargic; work-up with blood cultures and
lumbar puncture is the next step.
15. Rubella is characterized by low-grade fever, lymphadenopathy (sub-occipital and posterior
auricular) and rash
16. The prodrome of measles may show Koplik sign, a pathognomonic finding, which appears as
bluish white lesions on the erythematous buccal mucosa opposite to the first and second upper
molars, and sometimes on the inner conjunctivae and vaginal mucosa.
17. An epiglottis rolling in from side to side is the diagnostic finding of laryngomalacia, and all
such babies should be fed in the upright position.
18. Bedwetting is a normal phenomenon until the age of 5.
19. Severe dehydration in a neonate in the presence of hyponatremia, hyperkalemia,
hypoglycemia and metabolic acidosis suggests the diagnosis of congenital adrenal hyperplasia.

20. First step in the management of an infant with suspected congenital diaphragmatic hernia is
the placement of orogastric tube.
21. Kawasaki’s disease is a disease of blood vessel walls leading to aneurysm formation. It is
usually self-limited though it can be fatal because of aneurysm formation, thrombosis or rupture
of the coronary arteries, leading to myocardial infarction.
22. Moderate to severe degree of slipped capital femoral epiphysis requires surgery
23. Ileo-ileal intussusceptions, which may be caused by Henoch-Schonlein purpura, require
surgical reduction.
24. Friedreich Ataxia is an autosomal recessive condition and genetic counseling is
recommended for prenatal diagnosis for parents with one affected child.
25. Displaced anterior fat pad is a radiographic sign of supracondylar fracture, which may be
complicated by Volkmann’s ischemic contracture
26. Fragile X syndrome is characterized by low to normal IQ with learning disabilities,
generalized language disability, short attention span, autism, large head, prominent jaw, large
low set ears and macroorchidism.
27. Meningitis may be complicated by regression of developmental milestones
28. Cerebral anoxia is the most common cause of cerebral palsy
29. Fetal alcohol syndrome is characterized by irritability, mild to moderate mental retardation,
hypoplastic maxilla, long philtrum, thin upper lip border, and microcephaly
30. Deficiency of sphingomyelinase causes Niemann-Pick's disease, which is characterized by
cherry red macula, protruding abdomen, hepatosplenomegaly, lymphadenopathy, and regression
of developmental milestones.

31. Bed rest with hip joint in the position of comfort is the treatment of choice for transient
synovitis of the hip
32. Arthrocentesis and empiric treatment with IV nafcillin are the most appropriate measures for
the management of suspected septic arthritis in a child
33. Aspirin therapy with monitoring of liver enzymes are the mainstay of the treatment of
systemic juvenile rheumatoid arthritis
34. Presence of dermatitis herpetiformis and chronic non-bloody diarrhea in a child of 12-15
months, suggests the diagnosis of celiac disease
35. Positive anti-Smith antibodies and/or anti-double stranded DNA antibodies is specific and
confirmatory for the diagnosis of systemic lupus erythematosus
36. Duodenal atresia presents with bilious vomiting, and its typical radiographic finding is the
‘double bubble sign’
37. Sudden onset of respiratory distress may be caused by foreign body aspiration, and rigid
bronchoscopy is the procedure of choice, both for diagnostic and therapeutic purposes
38. Recurrent self-limiting episodes of vomiting and nausea in children, in the absence of any
apparent cause, suggest the diagnosis of cyclical vomiting.
39. The 24-hour esophageal pH monitoring is the gold standard for the diagnosis of
gastroesophageal reflux disease
40. Mast cell stabilizers are the drugs of choice for asthmatic patients who also have evidence of
other allergic disorders

41. Increased gastric residues in a preterm neonate are highly suspicious for necrotizing
42. Unilateral flank mass in a child more than 3 years is most likely due to Wilm’s tumor, which
arises from the metanephros.
43. Nodular swellings in the irises of patients with neurofibromatosis are hamartomas.
44. The investigation of choice, for the diagnosis as well as the follow-up, in cases of Sturge-
Weber syndrome is CT scan of the head. The cerebral lesions in Sturge-Weber syndrome are
histologically similar to the facial lesions.
45. Turner's syndrome with 46 XY karyotype is associated with a higher incidence of
gonadoblastoma, and hence, prophylactic bilateral gonadectomy is indicated.
46. Revise the management of hyponatremia from SIADH.
Mild (asymptomatic with sodium 120-130 meq/L) = Fluid restriction
Moderate (asymptomatic with sodium 110-120 meq/L) = Loop diuretic + normal saline
Severe (symptomatic) = hypertonic saline
47. NSAIDs can cause SIADH, which results in euvolemic, hypotonic, hyponatremia
48. Radioactive Iodine is the treatment of choice for Grave’s disease
49. Propylthiouracil can cause agranulocytosis, which should be suspected in patients presenting
with sore throat and fever while on the drug
50. Hashimoto’s may rarely cause hyperthyroidism but the radioactive Iodine uptake is low thus
distinguishing it from Grave’s disease

51. Indication for parathyroidectomy in asymptomatic patients with hyperparathyroidism are S.

calcium 1 mg/dL above upper limit with urine calcium excretion over 50mg/24hr, urine calcium
excretion over 400mg/24hr, cortical bone density more than 2SD below normal, under age 50-
60, pregnancy, follow up difficulty.
52. Primary adrenocortical deficiency is associated with hyperpigmentation of the skin due to
increased levels of ACTH that helps to differentiate from secondary adrenal insufficiency, which
is due to pituitary failure.
When Addison’ s disease is suspected clinically, the short cosyntropin (ACTH) stimulation test
is performed to make a diagnosis
54. Failure to suppress 24-hour urine cortisol level following high dose dexamethasone
suppression test suggests ectopic ACTH production rather than Cushing’s syndrome.

55. Know how to differentiate between primary and secondary hyperaldosteronism. Plasma
rennin activity is low in primary hyperaldosteronism and is high in secondary
56. Suspect DKA in stuperous patients with rapid breathing and history of weight loss,
polydypsia and polyuria.
57. The single best screening test for virilizing neoplasm is to obtain serum testosterone and
58. Know the importance of fluid replacement in the treatment of acute hypercalcemia. Loop
diuretics are indicated only after adequate rehydration.
59. Dehydration in Diabetes insipidus is managed with isotonic saline until the volume deficit is
60. Know that detection of microalbuminuria is the best screening test for diabetic nephropathy
61. Management of DKA includes restoration of intravascular volume with normal saline and
correction of ketosis with regular insulin
62. In non-ketotic hyperglycemic hyperosmolar coma: ketones are not found in the serum; blood
glucose levels are very high (greater than 600 mg/dl); there is no acidosis; anion gap is not
elevated and serum bicarbonate level is either normal or mildly decreased; neurological
manifestations including coma are often present; serum osmolality is greater than 310 mOsm/kg
63. Fluid replacement is the most important step in the management of non-ketotic
hyperglycemic coma
64. Waning of insulin dose results in hyperglycemia at 3 AM and 7 AM whereas in Dawn
phenomena the hyperglycemia occurs only at 7 AM.
65. Insulinomas secrete excessive amounts of insulin, C peptide, and pro insulin
66. Arterial pH or anion gap is the most reliable indicator of metabolic recovery in patients with
diabetic ketoacidosis
67. Know the management of diabetic nephropathy. Protein restriction to 0.8 g/kg of body
weight has a beneficial effect on the course of diabetic nephropathy.
Thyroiditis is associated with hyperthyroidism and low radioactive Iodine uptake
69. In the management of type 2 diabetes mellitus, if one oral hypoglycemic agent becomes
ineffective then often another agent from a different group is added to achieve better glycemic

70. Treatment of choice for streptococcal pharyngitis is single injection of IM Benzathine

penicillin G.

71. TMJ syndrome often presents with unilateral and chronic pain in the muscles of mastication.
Pain is described as a dull ache worsened by chewing. Recognise the radiation to the ear, jaw,
and posterior cervical region.

72. Know the clinical features and management of peritonsillar abscess or quinsy, which is a
suppurative complication of acute tonsillitis
• Contralateral deviation of the uvula
• Throat pain markedly more severe on the affected side and occasionally referred to the
ipsilateral ear.
• Exudates on the tonsil AND Erythema of the tonsil

73. Fibreoptic laryngoscopy establishes the diagnosis of epiglottitis but it must be performed in
the operating room with preparations already made to perform endotracheal intubation
74. While breaking bad news, physicians have to begin with an appropriate initial sentence,
which would help the patient feel at ease
75. D-xylose absorption is abnormal both in bacterial overgrowth and Whipple’s disease.
However, with bacterial overgrowth, the test becomes normal after antibiotic treatment.
76. When a motility disorder of esophagus is suggested by contrast studies, the next step is
usually esophagoscopy to exclude mechanical causes of dysphagia like stricture or esophageal
Esophagoscopy is indicated when a patient with gastroesophageal reflux disease (GERD) fails to
respond to empiric treatment or when patient has features of complicated disease.

78. Hepatitis B virus immune globulin plus lamivudine treatment is the most effective treatment
to prevent recurrent HBV infection after liver transplantation.
79. When diarrhea caused by clostridium difficile is severe, administration of metronidazole is
also needed along with discontinuation of the offending antibiotic
80. Increased intragastric pressure during vomiting could cause tears in the mucosa of the cardia
and sometimes of the distal esophagus- called Mallory-Weiss tears.
81. CT scan is the best test for the diagnosis of diverticulitis in acute setting
82. Fulminant colitis is a serious complication of ulcerative colitis and plain radiography shows
distended colon. Proctosigmoidoscopy with biopsy establishes the diagnosis of ulcerative colitis
and it can be performed in acute settings.
83. Always suspect Crohn’s disease as a cause for chronic diarrhea in a young patient
84. Migratory thrombophlebitis and atypical venous thromboses are suggestive for chronic DIC,
most probably due to some visceral malignancy.
85. Abdominal CT scan is the next diagnostic test when abdominal ultrasound does not explain
cholestatic jaundice
86. Gastro-intestinal (GI) blood loss without GI complaints in an elderly patient is most probably
caused by colon cancer and needs a colonloscopy
87. Recurrent peptic ulcers with hypercalcemia are best explained by MEN type 1
88. Barium swallow is the initial test of choice for all patients with dysphagia
89. Manometry establishes the diagnosis of diffuse esophageal spasm
90. Recognize Zenker’s diverticulum. Barium esophagogram is the investigation of choice for

91. Know how to manage severe

symptomatic bradycardia. IV atropine is usually the first step.

92. Recognize the hemodynamic features of mediastinal hemorrhage and know how to
differentiate it from pericardial tamponade
93. Recognize mesenteric arterial stenosis in a patient that presents with abdominal angina
94. Recognize the clinical presentation of mesenteric thrombosis. Severe abdominal pain out of
proportion to the physical findings along with bloody diarrhea should make you think about this.
95. Think of PE in a postoperative patient with JVD and new onset RBBB.
. Recognize the classic presentation of a tension pneumothorax. Remember the hypotension
shortness of breath jugular venous distension and decreased breath sounds

97. Recognize the clinical presentation of pulmonary edema. Iatrogenic fluid overload is one of
the common causes of pulmonary edema in perioperative patients
98. MI is one of the differential diagnoses of acute abdominal pain and should be ruled out in
patients with risk factors.
Learn the clinical presentation of mesenteric artery thrombosis.Always consider abdominal
angina in a patient with risk factors for atherosclerotic vascular disease. Postprandial pain
typically shortly after 20-30 mins Pain Last 60- 90 mins. Wt loss because fear of food might
cause pain. Abdo pain and blood in stool. Sudden onset. Tx. Laparotomy and prophylaxis

100. Antihypertensive management should be the first step in patients with aortic dissection with
101. Thiazide diuretics are the initial antihypertensive of choice in patients with osteoporosis.
102. Learn how to differentiate ischemic angina from aortic stenosis angina. Echocardiogram
should be the next step in suspected AS.
103. Know the natural history and complications of Marfan's syndrome in pregnancy. Every
woman with Marfan’s syndrome who is contemplating pregnancy must be screened by
echocardiography to determine the size of her aortic root.
104. Know how to recognize and treat right ventricular infarction. IV NS to increase the outflow
from right ventricle should be considered in these patients
105. Sudden onset of shortness of breath (SOB), bibasilar rales, and an 'apical' murmur radiating
to the axilla are quite characteristic of new onset mitral regurgitation. Papillary muscle
dysfunction, or rupture, is the most common cause of MR in this setting
106. Choose the appropriate initial antihypertensive therapy in a patient with asthma. HCTZ is
the initial drug of choice in patients with chronic persistent asthma
107. IV adenosine is the drug of choice for paroxysmal SVT. Know how to recognize the rhythm
on ECG
108. Any patient who presents with sudden onset of chest pain, SOB, and has evidence of
hypoxia and the new onset right bundle branch block should be considered as having a PE until
proven otherwise. Therefore, the next best step from the choices offered is to get a V/Q scan
109. IV nafcillin is the treatment of choice for cellulitis with systemic signs.
110. Lithium precipitates and exacerbates psoriasis which is characterized by sharply defined
erythematous areas with whitish, silvery and scaly plaques
111. Look for electrolyte abnormalities and correct them in patients with arrhythmias
112. Know how to differentiate between primary hyperparathyroidism and familial hypocalciuric
hypercalcemia in a patient with increased serum calcium, decreased serum phosphorus, and
increased PTH levels. Calcium excretion is decreased in familial hypocalciuric hypercalcemia
and is normal or elevated in primary hyperparathyroidism
113. In a patient with hypochloremic metabolic alkalosis due to gastric outlet obstruction,
potassium is usually low and needs to be supplemented
114. Parathyroidectomy is the only effective treatment for primary hyperparathyroidism
115. Plummer-Vinson syndrome is characterized by atrophic glossitis, stomatitis, and upper
esophageal webs associated with iron-deficiency anemia. Usually these webs don’t regress with
conservative treatment and require dilatation
116. Paracentesis provides useful diagnostic information in patients with ascites
117. Slow tapping of ascitic fluid balanced with infusion of albumin per liter tapped, is the final
conservative measure for the treatment of acsites secondary to cirrhosis that has to be attempted
before surgery.
118. Hypotension, hyponatremia, azotemia, and oliguria with normal urinalysis in a patient with
severe liver disease are suggestive of hepato-renal syndrome. Measures are taken to withhold all
possible precipitating factors and initial management includes careful volume load.
119. Patients with carcinoid syndrome are at risk of developing niacin deficiency owing to
increased formation of serotonin from tryptophan.
120. Varicoceles that fails to empty when the patient is recumbent raises the suspicion for renal
cell carcinoma for which abdominal CT scan is the investigation of choice.

121. Suspect medullary cystic disease in adults with recurrent UTI or renal stones and contrast
filled cysts demonstrated by IVP
122. Know the different causes of nephrotic syndrome and their likelihood in a given patient.
Focal segmental glomerulosclerosis (FSGS) is the most common cause of nephrotic syndrome in
African American adults. It also occurs in patients with HIV and IV drug abuse.
123. Indications for dialysis includes uremic symptoms such as pericarditis, encephalopathy,
coagulopathy, and fluid overload unresponsive to diuresis, hyperkalemia not amenable to
standard therapy, and pH less than 7.20
124. Know the factors that have been shown to delay the progression of chronic renal disease.
Protein restriction and use of ACE inhibitors are two such factors.
125. Acute pyelonephritis presents with fever, chills, flank pain, pyuria, and bacteriuria. CVA
tenderness may be present. Sometimes WBC casts may be seen.
126. Hydration is the cornerstone of therapy for renal stone disease. A detailed metabolic
evaluation is not needed when a patient presents with their first renal stone.
127. Colicky flank pain with radiation to groin indicates renal colic. Small bowel disease such as
surgical resection or chronic diarrhea, leading to the malabsorption of fatty acids and bile salts
can predispose calcium oxalate stones
128. Know the differential diagnosis of microscopic hematuria, and know to differentiate
myoglobinuria from hematuria. Alcoholism can cause rhabdomyolysis; the resulting
myoglobinuria causes a positive dipstick analysis for blood and a negative microscopic
examination for RBC‘s.
129. IgA nephropathy is the most common cause of glomerulonephritis in adults. Suspect IgA
nephropathy in patients with gross hematuria associated with upper respiratory infection, GI
symptoms, or flu-like illness
130. Any patient with recurrent sinusitis, cavitary lung lesions, pulmonary hemorrhages and
glomerulonephritis will most likely have Wegener’s glomerulonephritis
131. The common presentation of cryoglobulinemia includes palpable purpura,
glomerulonephritis, non-specific systemic symptoms, arthralgias, hepatosplenomegaly,
peripheral neuropathy, and hypocomplementemia. Most of these patients have evidence of
Hepatitis C.
132. Suspect Alport’s syndrome in patients with recurrent episodes of hematuria, sensorineural
deafness and family history of renal failure.
133. Oral trimethoprim-sulfamethoxazole is the preferred empiric treatment for acute
uncomplicated cystitis.
134. When isolated proteinuria occurs, the evaluation of the patient should begin by testing the
urine on at least two other occasions
135. Chlamydial urethritis is suggested by the presence of mucopurulent urethral discharge,
sexual history with multiple partners, and absence of bacteriuria on urinalysis
136. Patients with prostatodynia are afebrile and have irritative voiding symptoms. Expressed
prostatic secretions show normal number of leukocytes and culture of these secretions is negative
for bacteria.
137. Ultrasound or other imaging techniques should be done in patients with pyelonephritis
whose symptoms do not respond 48 -72 hours after appropriate antibiotics
138. Acute epididymitis in younger patients is usually caused by sexually transmitted organisms
such as C. trachomatis or N. gonorrhea. In older men it is usually non-sexually transmitted and is
caused by gram-negative rods.
139. Know how to recognize and treat nonbacterial prostatitis. Rule out bladder cancer in all
elderly patients with irritative voiding symptoms and have negative urine culture.
140. Acute post streptococcal glomerulonephritis occurs 10-20 days after streptococcal throat or
skin infection. It presents with hematuria, hypertension, red cell casts, and mild proteinuria.
141. Renal vein thrombosis is an important complication of nephrotic syndrome, which is the
most commonly caused by membranous glomerulonephritis in adults.
142. 70% of cases with interstitial nephritis are caused by drugs such as cephalosporins,
penicillins, sulfonamides, sulfonamide containing diuretics, NSAID’s, Rifampin, phenytoin, and
allopurinol. Discontinuing the offending drug is the treatment of drug-induced interstitial
143. Patients with nephrotic syndrome are at increased risk for developing hypercholesterolemia,
hypertriglyceridemia, and hypercoagulable state.
144. Acalculous cholecystitis occurs in critically ill patients and imaging studies show diagnostic
findings of thickening of the gall bladder wall and presence of pericholecystic fluid.
145. Primary Polydypsia (psychogenic polydypsia) is characterized by primary increase in water
intake. Patients taking phenothiazines have this problem due to dry mouth caused by
anticholinergic action of phenothiazines
146. Accidental ingestion of battery into esophagus warrants its immediate removal.
147. Warfarin induced skin necrosis is a complication seen in patients with protein C or S
deficiency especially when it is started in high doses without heparin coverage
148. Gentamicin causes vestibular toxicity
149. Spherocytosis is due to RBC membrane defect mostly from spectrin deficiency
150. Aortic dissection is an acute emergency and its medical management includes prompt blood
pressure lowering with IV nitroprusside and short-acting beta-blocker.
151. Vitamin A and its derivatives taken in large doses can lead to pseudotumor cerebri as a
complication. The presentaion includes headache, nausea, vomiting, papilledema, and elevated
CSF opening pressures, which is characteristic of pseudotumor cerebri.
152. Patients who are on high doses of vitamin D and calcium should have a close eye on serum
calcium levels. Signs of toxicity include nause, vomiting, constipation, polyuria, and mental
status changes.
153. Wernicke’s encephalopathy is a syndrome characterized by ataxia, ophthalmoplegia,
nystagmus and altered mental status. Wernicke’s encephalopathy is seen in chronic alcoholics
with thiamine deficiency
154. Hypercarotenemia is commonly seen in patients with anorexia, diabetes & hypothyroidism.
155. Excessive use of vitamin C in patients with renal insuffiency can cause oxalate stones
156. Pellagra, a niacin deficiency syndrome is characterized by a triad of 3 Ds of Diarrhea,
Dermatitis, and Dementia and if untreated eventually leading to Death (4th D).
157. Patients who eat heated food all the time, such as toast and tea are more likley to develop
folic acid deficiency.
158. Vitamin K deficiency is usually manifested by prolonged PT, normal platelet count and
normal bleeding time. PTT is variable.
159. Vitamin B 12 deficiency: Subacute combined degeneration of the dorsal and lateral spinal
columns is the classic neurologic manifestation. Symmetrical neuropathy, ataxia with loss of
vibration and position sense is the clinical clues.
160. Penile fracture is a medical emergency and needs prompt surgical repair, but it should
always be preceded by retrograde urethrogram to rule out urethral injury which is very common
with penile fracture
161. Removal of impacted esophageal foreign body is mandatory
162. Pressure sores are common over the sacrum, heels and hips. Frequent turning of the patient
is the only best method to prevent these
163. Heat stroke is a life threatening catastrophic medical emergency due to failure of
thermoregulatory center leading to severe hyperthermia with body temperature generally greater
than 105 F. Patients will have CNS symptoms
164. Heat exhaustion, also known as heat prostration is a syndrome characterized by volume
depletion under the conditions of heat stress. It can be distinguished from heat stroke by T< 40 C
and lack of severe CNS symptoms.
165. Rapid cooling of the patent is the cornerstone of management of heat stroke and should be
done in adjunction of stabilizing treatment. Evaporation cooling is the preferred modality.
166. Think of Conversion disorder in a female patient with sudden onset neurological symptoms
preceded by an obvious stressor. The treatment of choice would be Psychotherapy
167. Zinc deficiency is associated with alopecia, mental changes, diarrhea, and dysgeusia, smell
abnormalities, maculopapular rash around the mouth and eyes, and impaired wound healing.
168. Severe, excruciating pain should be treated with IV opioids even if the patient has a history
of drug abuse
169. Lithium toxicity presents with tremulousness, headache, confusion, GI distress, fatigue and,
in extreme cases, with seizures, coma, hyperreflexia and opisthotonus
170. Hypothyroidism should always be considered in patients with an unexplained elevation of
serum CK concentration and myopathy.
171. For frostbite injuries, the best treatment is rapid re-warming with warm water. Whenever
frostbite or cold injuries are diagnosed, no attempt should be made to débride any tissue initially.
Rapid re-warming with dry heat (like a fan) is not effective for frostbite.
172. Beta blockers decrease the risk of perioperative myocardial infarction, and thus do decrease
mortality in perioperative patients with vascular disease undergoing noncardiac surgery. Beta 1
selective agents are the drugs of choice for this purpose.
173. Wiskott Aldrich syndrome is one of the immunodeficiency syndromes, characterized by
recurrent pyogenic infections, atopic eczema and thrombocytopenia. IgM levels will be
decreased, but IgA, & IgG will be within normal limits
174. In a HIV patient, bilateral interstitial pneumonia is most likley due to Pneumocystis carinii
175. Flumazenil, a benzodiazepine antagonist, is antidote for acute benzodiazepine intoxication.
176. Glucagon is used to treat beta-blocker toxicity
177. Mucormycosis requires aggressive surgical debridement plus early systemic chemotherapy
with amphotericin B.
178. Association of diabetes mellitus and Mucor-mycosis is frequently tested in the examination.

179. Empiric antibiotic therapy with either ceftazidime or cefepime should be started in febrile
neutropenic patients
180. Invasive aspergillosis occurs in immunocompromised patients like those with neutropenia,
those who are taking cytotoxic drugs like cyclosporine or those who are taking very high doses
of glucocorticoids. Invasive pulmonary disease presents with fever, cough, dyspnea or
hemoptysis. Chest x-ray may show cavitary lesion. CT scan shows pulmonary nodules with halo
sign or lesions with air crescent.
181. Treatment of disseminated Histoplasmosis in HIV patients is IV amphotericin B followed
by lifelong treatment with itraconazole
182. Lymphocutaneous Sporotrichosis is the most common form and presents with painless
papule at the site of inoculation which later on ulcerates.
183. Always remember Blastomycosis is big-based budding yeast. Blastomycosis is endemic in
south central and north central USA.
184. Know the epidemiology of the fungal infections. Patient from Arizona should make you
think of Coccidioidomycosis
185. Whenever there is suspicion of HSV encephalitis, IV acyclovir should be started without
186. Always suspect Infectious mononucleosis in a young patient presenting with sore throat and
nonspecific spectrum of symptoms. Recognise the role of steroids in treating complications.
187. In both infants and children, Staphylococcus aureus is the most common organism
responsible for osteomyelitis.
188. S. Epidermidis is a frequent cause of osteomyelitis associated with prosthetic devices.
189. Gram-negative rods like Klebsiella or Pseudomonas cause osteomyelitis when patients have
a history of urinary tract infection (UTI) or urinary instrumentation
190. Three phase technetium scan is the test of choice for acute osteomyelitis and it is very
191. Learn the clinical presentation, pattern of organ involvement and the complications in a case
of mumps. Orchitis is one of the most frequent complications of mumps in adults.
192. Always consider the risk of splenic rupture in case of infectious mononucleosis and advise
the patient to avoid contact sports to prevent this hazard.
193. Amoxicillin-clavulanate is the antibiotic of choice for prophylaxis against infections caused
by human bite
194. Cat-scratch disease that usually occurs after scratch or bite by a cat and is caused by
195. Strep viridans is a frequent case of infective endocarditis in patients with damaged heart
196. Failure to respond to herpes simplex with acyclovir indicates resistance. The patient most
likely requires foscarnet.
197. Babesiosis should be suspected in any patient from an endemic area who presents with a
tick bite. Remember 'splenectomized patient'
198. The herpes simplex virus (HSV) esophagitis ulcers are usually multiple, well circumscribed
and have a "volcano" (small and deep) like appearance, whereas the ulcers seen in CMV
infection tend to be large, shallow and superficial.
199. Skin lesions of Kaposi sarcoma usually occur on the trunk, face and the extremities. Usually
these lesions are papules that later on become plaques or nodules. The color changes from light
brown to pink to dark violet.
200. So far there has been no case reports of congenital rubella syndrome in women
inadvertently vaccinated during early pregnancy.
201. Pyridoxine (Vitamin B6) is an antidote for isoniazid
202. Duration of QRS complex is the best measure for assessment of severity of tricyclic
antidepressant toxicity.
203. All chemical injuries to eyes should be immediately washed with plain water or saline.
204. Impaired concentration and conjunctival injection are important features of marijuana use.
205. Calcium is useful in reversing cardiac effect of calcium channel blocker.
206. Tyramine contained in aged cheese reacts with monoamine oxidase inhibitors to produce
hypertensive crisis
207. Dextromethorphan interacts with monoamine oxidase inhibitors and can produce severe
208. Decision of use of N acetyl cysteine as an antidote for acetaminophen overdose is generally
based on 4 hour post-ingestion acetaminophen levels
209. Bromocriptine is used in the treatment of neuroleptic malignant syndrome, which is
characterized by marked hyperthermia, muscular rigidity, tremors, altered mental status, and
210. First step in the management of pesticide poisoning is to remove the source of poison.
211. Phenothiazines cause hypothermia by causing vasodilatation and by inhibition of shivering
212. Sodium bicarbonate prevents the development of arrhythmia in patients with tricyclic
antidepressant toxicity by alleviating cardio-depressant action on sodium channels
213. Recognize the affect of alcohol intake on acetaminophen induced hepatic injury
214. In case of suspected osteomyelitis, blood cultures and x-rays should be taken and the patient
should be started on intravenous antibiotics. If the x-rays are negative three-phase technetium
bone scan should be considered. Needle biopsy can be done to identify the organism if the blood
cultures are negative.
215. Cervicofacial actinomycosis classically presents as slowly progressive, non-tender,
indurated mass, which evolves into multiple abscesses, fistulae, and draining sinus tracts with
sulfur granules, which appear yellow. Treatment is high dose penicillin for 6-12 weeks.
216. Cauda equina is an acute compression syndrome presenting with acute motor and sensory
loss, loss of rectal tone and urinary retention. It has to be treated urgently
217. Neurofibromatosis is a neurocutaneous syndrome, which has a tendency to form tumors of
the central nervous system (CNS), peripheral nervous system, skin and viscera
218. CT scan showing hyperdense (White) area suggests hemorrhage. The infarcts on CT are
seen as hypodense (Black) parenchymal areas.
219. Asymptomatic patients with carotid artery stenoses of 60 to 99 percent are considered to
have a proven indication for CEA. Complete occlusion (100 percent stenosis) of the carotid
artery is a contraindication to surgery
220. When a patient presents with painless visual loss lasting a few seconds, a duplex ultrasound
of the carotids should be the first test of choice.
221. Petit mal seizures may present with a sudden cessation of mental activity, which occur
repeatedly. There are not associated with complex automatisms or tonic clonic activity.
Diagnosis can be best confirmed by EEG studies
222. Primidone is an anticonvulsant agent, which can be used to treat benign essential tremor.
However, it can also precipitate acute intermittent porphyria. Diagnosis of porphyria is made by
assessing urine for porphobilinogen.
223. Itch, redness and fissuring in swimmers is typical of athlete’s foot. The condition is best
treated with antifungal creams such as tolnaftate.
224. In a child who has been to the ER several times and has bruises of unknown origin on
his/her body, child abuse should always be suspected and reported to the appropriate authorities.
225. Gonorrhea is a common organism, which causes sexually transmitted disease. It is also a
common cause of pharyngitis, generally acquired from oral sex.
226. Postherpetic neuralgia can cause significant pain along the nerve dermatomal distribution.
The best treatment is with the anti viral agent, acyclovir
227. Urethral cultures have higher yield than synovial or blood culture in cases of suspected
gonococcal purulent arthritis.
228. Always suspect endocarditis whenever a patient is febrile and has other constitutional
features in the presence of a new heart murmur.
229. Patients with trichinosis, presents with gastrointestinal (GI) complaints followed by muscle
pain, swelling, and weakness. Presence of subungual splinter hemorrhages, conjunctival and
retinal hemorrhages, periorbital edema and chemosis should make you think about trichinosis.
230. Always suspect rubella when a febrile patient with rash has occipital or posterior cervical
lymphadenopathy and arthritis.
231. Vibrio parahaemolyticus is usually transmitted by ingestion of seafood. Patients having
symptoms of food poisoning after intake of seafood should be suspected for this.
232. Group A beta-hemolytic streptococcus is the most frequent cause of erysipelas and
233. Proteus is the most likely cause of urinary tract infection in patients with alkaline urine.
234. Facial nerve palsy and classical Erythema migrans (EM) indicate Lyme disease, which is a
tick borne disease.
235. Pseudomonas aeruginosa is the most frequent cause for malignant otitis externa.
236. Mefloquine is the drug of choice for chemoprophylaxis of chloroquine resistant malaria
237. Amoxicillin is used for treatment of pregnant/lactating patients with early-localized Lyme
238. Doxycycline is used to treat primary syphilis in penicillin allergic patients
239. Pneumococcal vaccine is recommended in all HIV infected patients whose CD4 count is >
200 cells/micro-L.
240. IV amphotericin plus flucytosine is the antibiotic regimen of choice for central nervous
system cryptococcal infection in AIDS patients.
241. Bacillary angiomatosis, a great mimicker of Kaposi sarcoma, is caused by gram-negative
rod Bartonella and is successfully cured with antibiotic treatment. They are highly vascular,
initially are smooth and in the form of small papules that gradually become enlarged and
pedunculated or nodular.
242. Azithromycin or clarithromycin is the drug of choice for MAC prophylaxis in HIV patients
with CD4 cell count below 50/microL.
243. Whenever a health care worker is exposed to HIV, baseline HIV testing should be
performed immediately and postexposure prophylaxis with combination of two or three
antiretroviral drugs should be started without any delay.
244. Any patient from southwestern region with history of tick bite developing systemic
symptoms along with leukopenia and thrombocytopenia should make you think about
245. HIV patients are at a high risk for tuberculosis and require prophylactic treatment to prevent
an active disease. PPD is done to verify this. Skin induration of greater than 5 mm with PPD
testing in HIV patients requires prophylaxis with isoniazid for 9 months
246. Listeria monocytogenes is a frequent cause of meningitis in patients older than 55 and
therefore in such patients ampicillin should be added to the empiric antibiotic regimen.
247. Presence of erythema chronicum migrans in a patient with tick bite history warrants
immediate treatment without waiting for serology of Lyme's disease.
248. Lyme disease prophylaxis is given in pregnant patients who have history of tick bite and
have anxiety about acquiring disease.
249. Methanol intoxication is associated with visual loss.
250. Patients with hemochromatosis are vulnerable to listeria monocytogenes infections and
some other bacterial infections. Know the various bugs that are likely to jeopardize such patients.
251. Pinpoint pupils and respiratory depression are the hallmark features of acute opioid toxicity
for which naloxone is the drug of choice
252. Heterophil antibody test is sensitive and specific for diagnosis of IM. EBV specific antibody
test is used in patients with high suspicion for IM and have negative heterophil antibody test.
253. Albendazole or mebendazole is the first line of treatment for E. vermicularis infection.
Pyrantel palmate is an alternative.
254. Consider CMV pneumonitis as a late complication in post BMT recipients with dyspnea
and cough.
255. Serotonin agonists (triptans) are the drugs of choice to abort acute attacks of migraine when
simple analgesics or NSAIDs fail.
256. Pregnancy testing should be considered in patients with high risk of being pregnant prior to
starting treatment with sumatriptan
257. The choice of prophylactic agent for migraine depends upon any associated medical
condition. In patients with coexistent depression, antidepressants should be used for prophylaxis
of migraine.
258. Rupture of saccular aneurysm is the most frequent cause of non-traumatic subarachnoid
hemorrhage (SAH). Know the CT appearance of SAH.
259. Campylobacter jejuni is the most frequent precipitant of Guillain-Barré Syndrome (GBS).
260. Atrophy of the caudate nucleus is a characteristic feature of Huntington’s chorea. Recognize
the classic clinical presentation of Huntington’s chorea.
261. Acetazolamide is the first line medical treatment for idiopathic benign intracranial
262. Acute exacerbations of MS are treated with corticosteroids. Beta-interferon or Glatiramer
acetate is used to decrease the frequency of exacerbations in patients with relapsing-remitting or
secondary progressive form of MS.
263. Oligoclonal bands are present in 85-90% of cases of multiple sclerosis. CSF pressure,
protein and cell count is grossly normal in patients with MS.
264. Initial presentation of multiple sclerosis with optic neuritis or sensory symptoms carries a
good prognosis.
265. Cutaneous larva migrans is a common cause of dermatological disease in travelers from
tropical regions, and is characterized by pruritic elevated serpiginous lesion on the skin.
266. Always consider malaria in patients from endemic areas with high-grade periodic fever and
chills. Anemia and splenomegaly are the clinical clues.
267. Condyloma Lata and bilaterally symmetrical maculopapular rash involving the entire trunk
and extremities are characteristic of second stage of syphilis. Remember the rash is present on
palms and soles. Serological tests are positive in secondary syphilis.
268. It is recommended that all patients with atherothrombotic TIA should receive an antiplatelet
agent if there is no contraindication to its use and antiplatelet agent of initial choice for this
purpose is aspirin.
269. Anticoagulation is considered when TIA is due to emboli arising from the heart.
270. Anticholinergics are useful treatment for Parkinsonism patients who are younger than 70
with disturbing tremor and minimal bradykinesia. Parkinsonism tremor is a resting tremor.
271. Oral anticholinesterase is usually the initial treatment of choice for myasthenia gravis and
all patients should have evaluation for thymectomy
272. First step in all patients suspected of having stroke is CT scan without contrast. If they have
evidence of ischemic stroke, then carotid Doppler and TEE are performed to evaluate the
possible source of embolism.
273. Presence of cord cavity is the most characteristic feature of syringomyelia that typically
presents with areflexic weakness in the upper extremities and dissociated anesthesia in a "cape"
distribution. Other features like caudal displacement of fourth ventricle or cerebellar tonsils or
focal cord enlargement may or may not be present.
274. CT/MRI picture of heterogenous and serpiginous contrast enhancement is typical of high-
grade astrocytoma. Recognize the classic butterfly appearance.
275. Patient with cerebellar hemorrhage presents with ataxia, vomiting, occipital headache, gaze
palsy, and facial weakness. There is no hemiparesis. It is crucial to make early and correct
diagnosis, as urgent surgical decompression may be life saving in such cases.
276. Treatment of myasthenia crisis consists of endotracheal intubation and withdrawal of
anticholinesterases for many days.
277. The most common site of hypertensive hemorrhage is putamen (35%). Internal capsule that
lies adjacent to putamen is almost always involved leading to hemiparesis.
278. All those patients who are on warfarin treatment and develop serious bleeding need rapid
reversal of anticoagulation and fresh-frozen plasma is the most appropriate first choice for this
279. Untreated LGV may progress to a severe and chronic disease causing ulceration,
proctocolitis, rectal stricture, rectovaginal fistulas and elephantiasis.
280. Riluzole is a glutamate inhibitor and is currently approved for its use in amyotrophic lateral
281. Intravenous cefotetan, ampicillin/sulbactam, or the combination of clindamycin and a
fluoroquinolone is the appropriate empirical treatment for limb-threatening infections in
diabetics, whereas mild, or non-limb-threatening, infections can be treated with oral antibiotics
like cephalosporin, clindamycin, amoxicillin/clavulanate and fluoroquinolones.
282. The majority of human infections with E. granulosus are asymptomatic. Hydatid cysts can
be found in almost any part of the body but liver (MC) is involved in two-thirds of patients and
the lungs are involved in 25 percent of patients. It is most commonly seen in areas where sheep
are raised.
283. Neurocysticercosis is the most common parasitic infection of the brain and highest
prevalence seen in rural areas where pigs are raised and there are poor sanitary conditions
284. Streptococcus bovis endocarditis is associated with colorectal cancer and colonoscopy is
advisable in such patients.
285. Condylomata acuminata are skin colored or pink, verrucous and papilliform skin lesions
present around the anus and podophyllin is one of the available treatment options.
286. Eaton–Lambert syndrome is associated with small cell carcinoma of the lung and results
from autoantibodies directed against the voltage-gated calcium channels in the presynaptic motor
nerve terminal.
287. Immunocomplex disease is primarily responsible for glomerulonephritis, Roth spots and
Osler’s nodes. Janeway lesions result from septic embolism.
288. MRI is the test of choice to support the clinical diagnosis of multiple sclerosis
289. Multiple observational studies have demonstrated that patients with hypertension have
about four times the risk of stroke when compared to non-hypertensive subjects
290. Understand the concept of lead-time bias in screening tests. The concept of lead-time bias
includes prolongation of apparent survival in patients to whom this test was applied, without
changing prognosis for the disease.
291. Confounding is referred to the bias that can result when the exposure-disease relationship is
mixed up with the effect of extraneous factors called confounders.
292. Know the concept of positive predictive value; positive predictive value depends on the
prevalence of the disease of interest in the population to which the test is applied. PPV increases
with an increase in prevelance of disease in the study population. For NPV, the inverse is true.
293. Thymectomy may induce remission in patients with myasthenia gravis and should be
considered in all patients who are between puberty and 60 and whose disease is not confined
only to the extraocular muscles.
294. Incidence is the measure of new cases, the rapidity with which they are diagnosed.
Prevalence is the measure of the total number of cases at a particular point of time.
295. 68% - within 1 standard deviation from the mean
95% - within 2 standard deviations from the mean
296. 99.7% - within 3 standard deviation from the mean
297. Observer bias occurs when the decision as to whether outcome is present is adversely
affected by the knowledge of the exposure status.
298. Any HIV-positive patient with bloody diarrhea and normal stool examination should have a
colonoscopy and biopsy done to look for CMV colitis. CMV colitis is characterized by bloody
diarrhea with abdominal pain, multiple ulcers and mucosal erosions on colonoscopy; biopsy
shows characteristic cytomegalic cells with inclusion bodies.
299. Dihydropyridine Ca-channel antagonists can cause peripheral edema and should always be
considered in the differential diagnosis of this condition, along with other causes, such as heart
failure, renal disease and venous insufficiency.
300. Elderly patients with depression often present with memory loss (Pseudodementia.), which
can mimic other causes of dementia, including Alzheimer’s dementia, while the CT will be
normal in these patients, the DST may be of value.
301. In cross-sectional study, exposure and outcome are measured simultaneously at a particular
point of time (you can remember it as a ‘snapshot’ study). In other study designs, a certain time
period separates exposure and outcome.
302. Situational syncope should be considered in the differential diagnosis of syncopal episodes.
The typical scenario would include a middle age or older male, who loses his consciousness
immediately after urination, or a man who loses his consciousness during coughing fits.
303. Recognize normal pressure hydrocephalus by the triad of gait disturbance, dementia and
urinary incontinence. Other features are normal CSF pressures on lumbar puncture and enlarged
ventricles on MRI
304. VDRL testing, PPD skin testing, Hepatitis A and B serology and antibody titer for
Toxoplasma are indicated as a part of initial work-up in all newly diagnosed HIV-positive
305. Primary polydypsia is a disorder in which the patient drinks fluids in excess of 5 L per day
and both plasma and urine are diluted.
306. SIADH results in hyponatremia, low serum osmolality and inappropriately high urine
307. Diabetes insipidus presents with polyuria and polydypsia and urine osmolality is less than
serum osmolality.
308. Several well-organized and well-controlled clinical trials demonstrated that ACE inhibitors
could slow the progression of diabetic nephropathy and reduce albuminuria
309. Somogyi effect refers to early morning hyperglycemia caused by counter regulatory
hormones following nocturnal hypoglycemia
310. Acute respiratory alkalosis (increase in extracellular pH) causes a fall in ionized plasma
calcium by increasing the affinity of albumin to calcium
311. There are various mechanisms by which malignancy produces hypercalcemia. These are:
the production of cytokines, parathyroid hormone related peptide, calcitriol and ectopic PTH
312. Remember when albumin is low, serum calcium concentration falls in the ratio of 0.8-1 mg
of calcium to 1 g of albumin.
313. Always suspect surreptitious vomiting as a cause of hypokalemic alkalosis in a
normotensive patient and distinguish it from other entities like diuretic abuse and Bartter’s
syndrome on the basis of urine chloride concentration
314. Distinguish primary hyperaldosteronism from renovascular hypertension based on low
plasma renin activity in the former and high plasma renin activity in the later.
315. Patients with Bartter’s syndrome have hypokalemia, metabolic alkalosis, normal blood
pressure and elevated urine chloride concentration.
316. Patients with primary hyperaldosteronism show persistent elevation of BP, hypokalemia,
metabolic alkalosis, mild hypernatremia, very low plasma renin activity and absence of edema
317. Measurement of glycosylated hemoglobin provides good evidence of how well the glucose
has been controlled over the past 100-120 days (RBC survival time)
318. Hypercholesterolemia is the most frequent lipid abnormality in patients with
319. Hyperlipidemia, unexplained hyponatremia and elevated serum muscle enzymes are
indications for thyroid function tests
320. Whenever a patient presents with thyroid nodule, first step is assessment of thyroid
321. Hyperplastic colloid nodule is the most frequent cause of thyroid nodule. Majority of
thyroid nodules are benign, not malignant.
322. Patients with generalized resistance to thyroid hormones have high serum free T4 and T3
and normal or high serum TSH. Patients typically have features of hypothyroidism despite of
having elevated free thyroid hormones
323. Agranulocytosis is a serious side effect of propylthiouracil
324. Radioiodine is more likely to cause permanent hypothyroidism in patients with Graves’
disease than multinodular goiter or toxic adenoma
325. Patients with osteomalacia have low or low-normal serum calcium, low serum phosphate
and increased serum parathyroid hormone.
326. Osteomalacia is characterized by defective mineralization of bone
327. Always suspect hypophosphatemic rickets in patients of rickets who has normal serum
calcium, normal serum alkaline phosphatase and normal 25-OH vitamin D.
328. Dopamine agonists like bromocriptine or cabergoline are the mainstay of treatment for
patients with prolactinoma
329. Mucosal neuromas are the most distinctive feature of multiple endocrine neoplasia type 2b
and are present in more than 90% of cases
330. Prolactinoma is the most common pituitary tumor
331. The most common thyroid hormone pattern in sick euthyroid patients is a fall in total and
free T3 levels and normal levels of T4 and TSH. Remember ‘low T3 syndrome’
332. Antiperoxidase antibodies are the most prevalent antibodies in patients with Hashimoto’s
333. Patients with Hashimoto’s thyroiditis are at an increased risk for developing lymphoma of
334. Papillary carcinoma of thyroid is the most common thyroid malignancy. Invasion of tumor
capsule and blood vessels is the hallmark feature of follicular carcinoma of thyroid.
335. Subacute lymphocytic thyroiditis presents with painless enlargement of thyroid gland and
hyperthyroidism. Duration is less than 2 months, goiter is small, no ophthalmopathy, and
radioactive iodine uptake is low in such patients.
336. Asymptomatic patients with Paget’s disease generally don’t require any treatment.
Symptomatic patients are best treated with bisphosphonates
337. MEN II consists of a medullary carcinoma of the thyroid, hyperparathyroidism and
338. In Leydig cell tumors, the estrogen production can be increased with secondary inhibition of
LH and FSH
339. Male secondary hypogonadism is characterized by low levels of testosterone and low
normal gonadotropins
340. DHEA and DHEA-S are produced by the adrenal glands and are used as markers for the
adrenal tissue
341. 21-hydroxylase deficiency is the most common form of CAH. It presents with virilism, salt
wasting, and increased 17-alpha-hydroxyprogesterone levels.
342. Most significant clinical impact of GH excess in acromegaly occurs on cardiovascular
system, which accounts for 38-62 percent of deaths in acromegaly patients, CHF being the most
343. In central DI, urine osmolality becomes greater than that of serum on arginine vasopressin
administration while it remains lower than that of plasma when etiology is nephrogenic in origin.
Treatment of choice for central DI is desmopressin, which is usually administered intranasally.
344. Fasting blood glucose measurement is now the recommended test for screening high-risk
individuals for diabetes mellitus
345. Know the risk factors for development of foot ulcers in diabetics. Neuropathy is found in
about 80% of diabetics with foot ulcers
346. Symmetric distal sensorimotor polyneuropathy is the most commonly seen neuropathy in
diabetes and is characterized by classic "stocking glove" pattern sensory loss. The most common
cranial nerve involved in diabetes is cranial nerve III. The most commonly involved peripheral
mononeuropathy is the median nerve.
347. Diabetic cystopathy manifests as overflow incontinence. The pathology involves weak
detrusor contraction secondary to autonomic neuropathy. Treatment is usually started with strict
voluntary urinary scheduling and bethanechol; if no response, then the use of intermittent
catheterization is advised.
348. GI manifestations of diabetic neuropathy include gastroparesis, constipation and diarrhea.
Metoclopramide (drug of choice), bethanechol and erythromycin are useful in the management
of gastroparesis
349. Diabetic neuropathy can be accompanied by acute or chronic pain. Treatment options for
chronic diabetic neuropathic pain are gabapentine and TCAs (amitriptyline or desipramine).
350. Know the management of diabetic ulcers. Good wound care and debridement is key to the
management. Antibiotics alone do not cure diabetic ulcers
351. Fasting blood glucose measurement is now the recommended test for screening high-risk
individuals for diabetes mellitus. When fasting plasma glucose is 126 mg/dL or greater, repeat it,
and if it is still elevated, diagnosis of diabetes mellitus is established and treatment is started.
352. The first test in all patients with unexplained hypertension and hypokalemia is measurement
of plasma renin activity and plasma aldosterone concentration. If it is consistent with primary
hyperaldosteronism, do an aldosterone suppression test for confirmation; once confirmed,
perform a CT scan of the adrenals to look for a mass; but, if there is no mass on CT scan, do
adrenal vein sampling
353. Nocturnal penile tumescence helps differentiate psychogenic causes of male erectile
dysfunction from organic causes. It is positive in psychogenic causes and negative in organic
354. Glasgow coma scale is used to assess the severity of head injury but it does not indicate the
presence or absence of increased intracranial pressure (ICP).
355. Patients with mild head injury can be discharged with a “head sheet” if they have a normal
CT scan.
356. Pain relief should be the prime objective in management of rib fracture in elderly
357. In reference to neck trauma, neck can be divided into three zones and the treatment depends
on the zone involved
358. Any gunshot wound of the abdomen requires exploratory laparotomy. Any gunshot wound
below the 4th intercostal space (level of nipple) is considered to involve the abdomen.
359. Hypotension not responsive to fluid administration is suggestive of ongoing blood loss and
such patients with abdominal trauma need an exploratory laparotomy.
360. All the patients with acute carbon monoxide poisoning should be treated with 100% oxygen
via a facemask.
361. Delayed emergency from anesthesia is characterized by hypoventilation, which is evident
by decrease in respiratory rate, hypertension progressing to hypotension, tachycardia progressing
to bradycardia, restlessness and pallor/cyanosis.
362. It is important to rule out a fracture or dislocation of cervical spine as the first priority
because of grave consequences of missing a cervical spine injury.
363. Hyperventilation helps to prevent and treat intracranial hypertension by causing cerebral
vasoconstriction and thus decreasing cerebral blood flow.
364. Orotracheal intubation and surgical cricothyroidectomy are preferred way to establish an
airway in apneic patient with head injury
365. Nasoethmoidal fractures may be associated with injuries to ethmoidal roof, lacrimal system,
medial canthal tendons, cribriform plate and vasculature of nose. Associated injuries of these
structures can give rise to cerebrospinal fluid rhinorrhea, epistaxis, anosmia, epiphoria or
366. Beck's triad of hyotension, elevated JVP, and muffled heart sounds confirms the diagnosis
of pericardial tamponade
367. Primary resuscitation of any trauma patient is based on establishing airway, breathing and
circulation (ABC of resuscitation).
368. An airway is needed in all unconscious patients and in emergency room an orotracheal
intubation is the best option. Hemodynamically unstable trauma patients should be started on IV
crystalloids immediately.
369. Aortic rupture should be ruled out in all the chest trauma patients with hypotension.
Screening for aortic trauma can best be done with a chest x-ray. Confirmatory test is angiography
or spiral CT scan.
370. Saphenous vein cut down or percutaneous femoral vein catheterization are alternatives to
have an intravenous access in trauma patients with collapsed veins.
371. Expectant therapy is a rule for all patients with uncomplicated basilar skull fracture. Clinical
signs of basilar skull fracture includes rhinorrhea, raccoon eyes (black eyes), and ecchymosis
behind the ears and otorrhea.
372. Acute subdural hematoma has a classic presentation of unconsciousness followed by a lucid
interval followed by gradual deterioration of consciousness. CT scan is diagnostic and it shows a
biconvex hematoma.
373. Treatment of acute subdural hematoma is essentially conservative if no midline shift is
present on CT scan.
374. CT scan of a diffuse axonal injury shows numerous minute punctuate hemorrhages with
blurring of grey-white interface.
375. Hemothorax is most commonly managed by a tube thoracotomy in lower part of chest.
Surgery is seldom necessary
376. Anterior cord syndrome is commonly associated with burst fracture of the vertebra and is
characterized by total loss of motor function below the level of lesion with loss of pain and
temperature on both sides below the lesion and with intact proprioception.
377. Fat embolism presents with dyspnea, confusion and petechiae in the upper part of the body
and occurs after multiple fractures of long bones
378. Know the tetanus immunization.
379. An exploratory laparotomy is needed in all the patients with blunt trauma to abdomen with
signs of peritoneal irritation.
380. Patient with head injury can never have hemorrhagic shock due to intracranial bleeding
381. USG or DPL are the procedures of choice to diagnose intra abdominal bleeding in an
unstable trauma patient.
382. Posterior urethral injury is associated with pelvic fractures and presents with blood at
meatus, high riding prostrate, scrotal hematoma and inability to void in spite of sensation to void.
383. Retrograde urethrogram should be the first step in management of suspected posterior
urethral injury
384. Intraperitoneal bladder rupture can occur in trauma patient with full bladder
385. Retrograde cystogram with post void film is the investigation of choice for patients with
suspected bladder trauma
386. Penile fracture is a medical emergency and needs prompt surgical repair
387. Rule out vascular injuries in case of penetrating wound near the site of important vessels
388. The usual sequence of management of injury to bone, artery and nerve is to stabilize the
bone followed by repair of vasculature followed by the nerve repair
389. All the patients with traumatic wound should be assessed for need of Tetanus toxoid and/or
tetanus immunoglobulin
390. Pelvic X ray should be routinely done in all patients with trauma to screen for pelvic injury.
391. Vital signs, hemodynamic stability, and need for blood transfusion are important
determinant for surgical v/s non-surgical management of patient with splenic trauma.
392. Rhabdomyolysis can occur with severe crush injuries and should be managed with IV
fluids, osmotic diuretics and alkalinization of urine
393. Infection is the most common cause of death in burns patients
394. Body surface involved in burn injury is calculated with the help of “Rule of Nines.
395. Burns patients need 4 ml / kg / % of the body area involved of fluids in first 24 hours, half
of which is given in the first 8 hours
396. Inhalation injury is common in burns patients and may take several days to manifest.
Diagnosis is best done with a bronchoscopy.
397. When circumferential full-thickness burns involving the extremities or chest are present,
escharotomy may be necessary
398. Know the injuries suggestive of child abuse and report such cases to child safety services
399. Superficial and erythematous burns while painful do not require any special wound care.
Topical or oral analgesics agents can be prescribed.
400. Early excision therapy is indicated for extensive partial-thickness and full-thickness burns,
as they do not heal spontaneously. Also, it allows for early skin grafting and lesser complications
401. Know the type of burn injuries and difference between burns and scalds. Scalds are the burn
injuries secondary to contact with liquids. The type of burn injury in case of scalds depends on
the type of liquid and duration of contact.
402. Psoriatic arthritis (PA) is asymmetrical and oligo-articular and such patients usually have
typical features (silvery scales on erythematous plaques over flexural surfaces) of psoriasis
present for years. Think of PA when pitting nails is present in the history. Skin rash may not be
present all the time.
403. Chronic renal failure is the most common cause of death in systemic lupus erythematosus
404. Inflammatory myopathies are best treated with corticosteroids
405. Presence of fever, inflammatory signs, no crepitus or bullae and signs of overlying skin
necrosis all suggest that the patient has cellulitis. This patient also had toe web tinea pedis, which
is one of the most common portals of entry for the microorganisms, causing cellulitis.
406. Osteoarthritis is a degenerative bone disease involving mainly the weight bearing joints.
Know the pattern of joint involvement, x-ray findings and the differentiating features of this
407. The demonstration of negatively birefringent needle shaped urate crystals in the synovial
fluid is suggestive of gout.
408. Prophylactic allopurinol is the most effective method to prevent gout in patients at risk for
tumor lysis syndrome.
409. Acute inflammatory monoarticular arthritis in a previously damaged joint suggests septic
arthritis. Leukocyte counts in synovial fluid exceeding 50,000 or even 100,000/ul should make
you think of septic arthritis
410. Hyperparathyroidism and hemochromatosis patients are more prone for pseudogout. Joint
fluid aspirates reveal rhomboid shaped calcium pyrophosphate crystals, with positive
411. Asymmetric migratory polyarthralgia, followed by monoar
ticular arthritis, in a sexually active patient with a characteristic skin rash suggests gonococcal
412. In patients with frequent attacks of acute gouty arthritis not controlled by colchicine, a 24-
hour uric acid levels in urine is determined. This evaluates whether hyperuricemia is due to over
production or under secretion of uric acid
413. Obesity is a major risk factor for osteoarthritis. Hence weight loss is the most effective
measure in osteoarthritis management.
414. Leriche syndrome occurs as a result of atherosclerotic vascular disease and is characterized
by impotence and intermittent claudication.
415. The cauda equina syndrome occurs as a result of compression of lumbosacral nerve roots by
infection or tumor. Usual presentation is with urinary retention or overflow incontinence.
416. Thoracic aortic aneurysm is a serious complication of giant cell arteritis, which can be fatal
so such patient must be monitored continuously
417. Regular exercise/physiotherapy is the only beneficial treatment that halts the disease
progression in ankylosing spondylitis
418. Giant cell arteritis must be treated immediately with glucocorticoids once the clinical
diagnosis is made. Temporal artery biopsy can be done within several days after treatment, for
confirmation of the disease.
419. Anterior uveitis is the most common cause of red eye in patients with ankylosing
420. Plain X-ray of the Sacroiliac joint is the next best step in a suspected patient of ankylosing
421. Frozen shoulder should be suspected when a patient presents with stiffness and limited
range of motion
422. Bladder carcinoma is a recognized complication of long-term use of cyclophosphamide
423. MRI is the definitive diagnostic study for rotator cuff tear
424. Joint involvement in Parvovirus infection is symmetrical. Hands, wrists, knees and feet are
the most frequently involved joints. Rash may or may not be present. Patient may have
arthralgias or arthritis. Joint involvement most frequently occurs in adult females.
425. Eye examinations at 6 months to 1 year intervals should be performed in all patients who
are taking hydroxychloroquine
426. Anti-B19 IgM is the diagnostic study of choice when Parvovirus infection is clinically
427. Diffuse proliferative glomerulonephritis is the severest form of glomerular disease in
patients of systemic lupus erythematosus
428. Lofgren’s syndrome is an acute form of sarcoidosis and consists of triad of bilateral ankle
arthritis (some times knees, wrists or elbows), erythema nodosum and bilateral hilar adenopathy
429. Systemic steroids are the drugs of choice in sarcoidosis
430. Thoracic outlet syndrome occurs with signs and symptoms of neurovascular bundle
431. Fibromyalgia is a chronic widespread pain disorder associated with fatigue, poor sleep, and
depression. Patients have multiple trigger points of tenderness
432. Nerve conduction studies are very useful in diagnosing the carpal tunnel syndrome
433. Dupuytren’s contracture manifests as nodular thickening of the third and the fourth fingers
with inability to extend completely
434. Amitriptyline and cyclobenzaprine have been shown to be effective in the treatment of
435. Arthritis in systemic lupus erythematosus (SLE) is non-erosive and arthritis in rheumatoid
arthritis is erosive.
436. Anti-DsDNA antibodies are primarily involved in the pathogenesis of lupus nephritis
437. Heliotrope rash, Gottron’s sign, and proximal muscle weakness are the classical features of
438. Muscle biopsy is the best diagnostic study for polymyositis
439. Total knee replacement is indicated in patients with severe restriction of walking and
nocturnal and rest pain
440. Low back pain in patients with history of malignancy should always raise the suspicion of
bone metastasis
441. Reflex sympathetic dystrophy is a syndrome of pain and swelling associated with
vasomotor instability.
442. Anserine bursitis presents with medial knee pain just below the joint line.
443. The most common cause of asymptomatic elevation of alkaline phosphatase in an elderly
patient is Paget’s disease.
444. Hemochromatosis is an important condition that has been found to be associated with
445. Young patients with high spiking fevers associated with characteristic salmon colored
evanescent rash, arthralgias, and leukocytosis most likely have adult stills disease.
446. Keratoderma blennorrhagicum is a typical skin manifestation of Reiter’s syndrome
447. Relapsing polychondritis is an idiopathic disorder characterized by recurrent inflammation
of cartilaginous structures and other internal organs.
448. Whipple disease presents with joint pain, abdominal pain, diarrhea, and weight loss.
Periodic Acid-Schiff positive material on small intestinal biopsy establishes the diagnosis.
449. Bucket handle tear of medial meniscus is the most common meniscus injury at knee and
leads to locking of the knee joint during terminal extension.
450. Lachman's test is the most sensitive physical test for diagnosis of anterior cruciate ligament
injury. Recognize the clinical presentation of ACL tear.
451. MRI is now the investigation of choice for ligamentous injuries of the knee with an
accuracy rate of 95%. Surgery is rarely necessary for MCL tear.
452. Most of the fractures of shaft of femur can be managed with closed intramedullary fixation
of fracture.
453. 10% of calcaneal fractures secondary to fall from height is associated with compression
fracture of thoracic or lumber vertebra.
454. Stress fracture or March fracture or insufficiency fracture is commonly seen in young active
adults involved in vigorous and excessive exercises.
455. Elderly patients with displaced femoral neck fractures should be treated with primary
456. Internal fixation with sliding screw and plate and early mobilization is the treatment of
choice for intertrochanteric fractures.
457. Nonunion and avascular necroses are common complications seen in scaphoid fracture.
458. If a scaphoid fracture is suspected, even without a visible fracture on x-ray, it must be
treated as if there was a fracture.
459. When clavicle injuries occur and a bruit is present, an arterial injury must be ruled out with
an angiogram.
460. When a patient presents with a pulsatile abdominal mass and hypotension, a presumptive
diagnosis of ruptured abdominal aortic aneurysm must be entertained and the patients should be
taken straight to the operating room
461. Ludwig’s angina is infection of the submaxillary and sublingual glands. The source of the
infection is from an infected tooth.
462. For carcinoid tumors locate at the tip of the appendix, appendectomy is sufficient treatment
463. The treatment of a tension pneumothorax is immediate chest tube placement
464. After placement of a central line, a chest x-ray must be obtained to ensure proper line
465. Cardiac contusion can be associated with various arrhythmias and is best monitored by
continuous ECG monitoring
466. Once an esophageal perforation has been diagnosed, primary repair of the esophagus should
be done immediately
467. Nasopharyngeal cancer usually presents initially as a painless neck mass.
468. Fever occurring in the first 1-2 days after surgery is usually due to atelectasis
469. The presence of pulses does not rule out compartment syndrome and suspicion should be
high for this diagnosis. Fasciotomy is the treatment and must be done urgently
470. Whenever an open wound fails to heal after a prolonged period, biopsies have to be
obtained to ensure that the ulcer has not degenerated into a squamous cell carcinoma. These
ulcers are known as Marjolin’s ulcers.
471. Ulcers on the medial aspect of the leg are generally from venous disease. Venous
hypertension may be due to vein varicosities and incompetent perforators.
472. In patients who present with ulcers on the soles of the foot, neuropathic ulcers from diabetes
should be suspected
473. In a patient who undergoes bowel resection and then develops kidney stones, one should
always suspect oxalate as the culprit
474. After rhinoplasty, if there is a whistling noise during respiration, one should suspect nasal
septal perforation.
475. In a young individual who present with a fleshy immobile mass on his hard palate, the most
likely diagnosis is torus palatinus. No medical or surgical therapy is required
476. Diagnostic peritoneal lavage, CT scan, ultrasound or local wound exploration has no role in
the management of patients with a direct gunshot wound to the abdomen; laparotomy should be
477. When there is an intimal flap of the carotid artery, surgery is recommended to repair the
vessel. Intimal flap injury can lead to vessel occlusion and symptoms and signs of ischemia.
Today, with the availability of stenting, this may be an alternative option to surgery
478. Subluxation of radial head is a common condition in preschool children and needs closed
reduction by flexion and supination of forearm
479. Cast immobilization is recommended in the treatment of all non-displaced scaphoid
fractures (fractures < 2 mm displacement and no angulation).
480. Volkmann’s ischemic contracture is the final sequel of compartment syndrome in which the
dead muscle has been replaced with fibrous tissue.
481. Radial nerve is the most commonly injured nerve in association with fracture of midshaft
482. The treatment of choice for isolated diaphyseal humeral fracture is by closed methods
483. Monteggia and Galeazzi fractures need open reduction and internal fixation
484. Colles fracture is the most common fracture of distal radius characterized by dorsal
displacement and dorsal angulation
485. Axillary nerve is the most commonly injured nerve in anterior dislocation of shoulder
486. Clavicle is one of the most commonly fractured bones and is treated with figure of eight
487. Pain on passive extension of fingers is the most sensitive physical sign of compartment
488. Adolescent onset idiopathic scoliosis is the most common type of scoliosis and is
commonly seen in adolescent girls. (< 20 degree-Observe; >30-Bracing; >40-Surgery)
489. Osgood Schlatter disease is an apophysitis of tibial tubercle seen in young teenagers due to
490. Legg Calve Perthes disease is serious but self-limiting condition of young children
characterized by avascular necrosis of femoral head.
491. Slipped femoral capitis is an emergency condition and should be promptly corrected with
external screws.
492. USG is the most sensitive investigation for the diagnosis of DDH for infants less than 6
months of age.
493. Most of the snakes are not poisonous and even when bitten by a poisonous snake it does not
necessarily mean that envenomation has occurred (Only 1/3 rd of the patients bitten with
poisonous snakes develop envenomation). Antivenom should be given to all patients with
significant symptoms.
494. Bee and Hymenoptera stings account for more deaths in the United States than any other
envenomation. Anaphylactic shock should be promptly treated with subcutaneous epinephrine.
495. Brown recluse spider bite causes deep necrotic ulcer at the bite site.
496. Unique fracture patterns like green stick fracture, torus fracture and plastic deformation are
seen in children because their bones are more porous and less brittle.
497. In case of amputation injury, amputated parts should be retrieved and brought to the
emergency department. The amputated part should be wrapped in a saline-moistened gauze
sponge placed in a plastic bag. The plastic bag should be sealed and placed on ice.
498. Atelectasis on chest-x ray can be confused with pneumonia and pleural effusion. However,
it is more common after surgery in smokers and requires bronchoscopy to remove the mucus
499. After blunt trauma to the chest, if an x-ray shows a deviated mediastinum with a mass in the
left lower chest, one should suspect a diaphragmatic perforation.
500. Patients treated with high-dose methylprednisolone within eight hours of spinal cord injury
have significant and sustained neurological improvement, thus its use is warranted as the first
priority after stabilizing the patient
501. Isolated duodenal hematoma is treated conservatively with nasogastric tube and parenteral
502. Duodenal injuries are best diagnosed with CT scan of the abdomen with oral contrast or an
upper GI study with gastrograffin, followed by barium, if necessary.
503. The second part of the duodenum is the most commonly injured portion of the duodenum
and needs a high degree of suspicion for diagnosis, especially in the presence of retroperitoneal
air or blunting of the right psoas shadow on x-ray.
504. After an AAA repair, diarrhea with blood in the stools should raise the suspicion of
ischemic colitis. If the CT scan is inconclusive a sigmoidoscopy/colonoscopy is recommended.
505. Diphenhydramine toxicity produces seizures as well as anti-cholinergic effects.
506. In patients with fever and cough after upper GI endoscopy suspect anaerobic lung infection.
Clindamycin and ampicillin plus metronidazole are the commonly used agents for this infection.
507. Know the different kind of bias, which can decrease the validity of study results. Hawthorne
effect is the tendency of the study population to affect the outcome, due to the fact that they are
being studied.
508. Know how to interpret odds ratio. To be clinically significant, odds ratio should be greater
than or less than 1. OR > 1 means that the factor under study is a risk factor for the outcomes,
whereas the OR < 1 means that the factor under study is a protective factor in respect to the
outcome. OR = 1 means there is no significant difference in outcomes in either the exposed or
the unexposed.
509. Contrast studies with gastrograffin are indicated in addition to upper gastrointestinal
endoscopy when a patient with acute alkali ingestion is suspected of having esophageal
510. Toxicity with tricyclic antidepressants is characterized by anticholinergic effects and QRS
widening on EKG
511. Calcium gluconate is used to treat black widow spider bite
512. Phencyclidine (PCP) is an hallucinogenic drug and its intoxication is characterized by
disorientation, agitation, dizziness, ataxia, combativeness, sensory dissociation and nystagmus
513. Phencyclidine causes psychotic symptoms.
514. Deferoxamine is an antidote for iron toxicity that causes hemorrhagic gastroenteritis with
acidosis and hypotension
515. Magnesium is an effective treatment for torsade de pointes.
516. Sodium bicarbonate is effective for the treatment of cardiac dysfunction induced by
thioridazine toxicity
517. Chlordiazepoxide is the treatment of choice for delirium tremens that is characterized by
disorientation, hallucination, tachycardia, hypertension, and agitation.
518. Tuberculosis is the most common cause of constrictive pericarditis, in immigrant
population. It should be considered in patients with unexplained elevation of JVP and history of
predisposing condition
519. In a patient with an MI who develops a cold leg, one has to get an ECHO to rule out a
thrombus in the left ventricle.
520. Dressler syndrome typically occurs two-to-four weeks after an MI and presents with a low-
grade fever, malaise and pleuritic chest pain. ECG will reveal 'non specific' ST elevations and
there may be a pericardial effusion. NSAIDs are the agents of choice.
521. Amiodarone has the potential to cause lung fibrosis and should be avoided in patients with
history of pulmonary fibrosis
522. Digoxin-specific antibody Fab fragments are indicated when adults ingest more than 10 mg
of digoxin or when serum digoxin level is greater than 10 ng/ml.
523. . Statin intolerance should be suspected if the patient develops myalgias and elevated serum
transaminases. Symptoms usually develop within few weeks to few months of starting statin
524. Beta blockers are the initial drugs of choice for the treatment of isolated left ventricular
diastolic dysfunction as they improve diastolic filling by lowering the heart rate and increasing
the diastolic filling time
525. Recognize the clinical features of cardiogenic shock. Elevated PCWP is the most important
finding to concentrate.
526. ST segment depression, T wave inversion and first degree AV block can occur at
therapeutic levels of digoxin and they do not represent digitalis toxicity and therefore there is no
need for discontinuation of the drug.
527. Whenever a patient of chronic aortic regurgitation develops symptoms of LV dysfunction,
he should undergo aortic valve replacement after his congestive symptoms are relieved by
intense medical treatment with digoxin, diuretics, and vasodilators
528. Infective endocarditis prophylaxis and repeated regular follow-ups are recommended for all
patients of aortic stenosis even if they are asymptomatic
529. The majority of patients who have a mild degree of mitral stenosis can tolerate pregnancy
without any complications.
530. Procainamide or disopyramide are the drugs of choice for atrial fibrillation in the context of
WPW syndrome. Remember digoxin and calcium channel blockers should not be used.
531. Any patient, who has undergone genitourinary instrumentation, has a history of IV drug
abuse, or a history of prosthetic valves should be suspected for infective endocarditis if they have
fever, chills, weakness, and/or a new onset murmur.
532. Any patient who comes from South America and have findings suggestive of
cardiomyopathy should make you think about Chaga’s disease.
533. The classic findings of pericarditis on EKG are:
a. Diffuse ST segment elevation with upward concavity at ‘J’ point.
b. No new ‘Q’ waves
c.'PR’ segment elevation in aVR with ‘PR’ depression in other leads
534. Once sick sinus node syndrome has been diagnosed, the best treatment is placement of a
permanent pacemaker.
535. Wenckebach or Mobitz type I heart block is characterized by a narrow QRS, progressive
increase in PR interval until a ventricular beat is dropped, and then the sequence is repeated. It is
a benign arrhythmia and is transient. Unless the patient is symptomatic, it requires no treatment.
536. First-degree heart block is a completely benign arrhythmia and requires no treatment
537. Torsades de pointes is an arrhythmia of gradually changing QRS morphology and most
often caused by Quinidine
538. Ventricular tachycardia in the presence of a stable blood pressure does not warrant
cardioversion. The best treatment is loading with lidocaine or amiodarone
539. Coarctation can present with rib notching on the chest-x ray. A “3” sign is typically seen
with coarctation of longer duration, implying proximal aortic dilation, constriction and
descending aorta dilatation
540. Mobitz type 2 block is a dangerous arrhythmia which can progress to complete heart block
and requires a permanent pacemaker
541. Atrial flutter with unstable hemodynamics is best treated with cardioversion. Acute atrial
flutter with stable hemodynamics can be treated with cardioversion or can be managed with rate
control. Chronic stable atrial flutter is best treated with rate control, which is best achieved with
either calcium channel blockers or beta-blockers.
542. Premature atrial beats are benign and neither requires any follow up nor treatment.
543. When atrial fibrillation is associated with hemodynamic compromise, cardioversion is the
treatment of choice.
544. The treatment of ventricular fibrillation is STAT defibrillation with 200-360 joules. If
defibrillation fails, lidocaine or amiodarone (drug of choice) can be loaded and the patient
shocked again. Epinephrine can sensitize the heart and lower the threshold for conversion.
545. Anytime if the patient is hemodynamically unstable, treatment of choice is electrical
cardioversion. If the patient is hemodynamically stable, then you have to think whether it is an
acute process? or a chronic process?. If it is an acute process then you can choose to convert the
patient to sinus rhythm by either cardioversion or you can keep the patient under rate control. If
it is a chronic process then it is best managed with rate control along with anticoagulation. Rate
control is best achieved with diltiazem or metoprolol.
546. Complete heart block is a dangerous condition, which can cause sudden cardiac death. It
requires immediate placement of permanent pacemaker.
547. Amiodarone is a class III antiarrhythmic agent and is well known to cause lung fibrosis.
Also, remember thyroid dysfunction (both hypo and hyper), hepatotoxicity, cornel deposits and
bluish-slate gray discoloration of the skin.
548. Bluish discoloration and cool fingers in the ICU are a common finding after use of
norepinephrine for hypotension
549. Amoxicillin is the drug of choice for prophylaxis of infective endocarditis in dental and
respiratory procedures. In patients who are allergic to penicillin, alternatives include cefazolin,
clarithromycin or clindamycin.
550. For genitourinary and GI procedures, other than esophageal procedures, the regimen of
choice is ampicillin plus gentamicin in high-risk patients. If the patient is allergic to penicillin, a
combination of vancomycin plus gentamycin is used in high-risk patients
551. GI endoscopy is a low-risk procedure for infective endocarditis. For GI endoscopy,
prophylaxis is optional in high-risk patients and not recommended in moderate-risk patients.
552. Patients with artificial pacemakers and defibrillators do not require prophylaxis for infective
553. Aspirin, beta-blockers, ACE inhibitors and spiranolactone improve survival in patients with
heart failure, while digoxin and loop diuretics does not provide any survival benefit
554. A patient who develops a cold leg after an MI should be suspected of throwing an embolus.
An angiogram is diagnostic and an embolectomy is required.
555. Isolated premature ventricular arrhythmias generally do not require any medical treatment;
observation is usually the treatment of choice.
556. It is better to keep systolic pressure < 130 mmHg to slow end-organ damage in patients with
diabetes and chronic renal failure
557. Syncopal episode without following disorientation (post-episode confusion is more
characteristic for a seizure), hearing impairment, normal physical exam, and family history of
sudden cardiac death should make you think of congenital long ‘QT’ syndrome. Beta-blockers
are the drugs of choice
558. It is important to recognize that oral contraceptives can be a potential cause of hypertension,
and simply discontinuing its use can correct the problem
559. In all cases of ST elevation MI, reperfusion therapy with thrombolytics or PTCA(PCI) with
or without stenting must be performed as soon as possible. PTCA(PCI) is preferred over
560. Presence of hypotension, pulsus paradoxus, and pulseless electrical activity in a patient with
a recent acute MI should make you think of free ventricular wall rupture.
561. Suspect aortic dissection as a cause of tearing chest pain in the setting of HTN and BP
difference in the 2 arms.
562. Recognize the high risk of arterial thromboembolism associated with anterior wall MIs
563. The most common cause of aortic dissection is systemic HTN
564. CK-MB fraction has a high specificity for an acute MI (slightly lower than cardiac
troponins). It begins to rise within 4-6 hours after MI and returns to baseline within 48-72 hours.
It’s high specificity and rapid return to the baseline makes it the biomarker of choice for the
diagnosis of a recurrent MI.
565. Thrombolytic therapy is not indicated for unstable angina or non-ST elevation (non ‘Q’
wave) MI. The treatment of unstable angina primarily includes aspirin, beta-blockers, heparin
and nitroglycerin
566. Electrical alternans is an important EKG finding for the diagnosis of pericardial tamponade.
Other findings include sinus tachycardia and low voltage QRS complexes.
567. Viral infection is the most common cause of myocarditis that results in idiopathic dilated
cardiomyopathy. The most frequently implicated virus is Coxsackie’s B virus.
568. Exercise testing is indicated in the risk stratification of patients with coronary artery disease.
Understand the indications of other non-invasive tests for the diagnosis of coronary artery
569. Know how to treat acute pulmonary edema in the setting of acute MI. Loop diuretics should
be given to treat pulmonary edema.
570. Tobacco and alcohol are reversible risk factors for the development of atrial premature
571. A detailed medical history and physical examination is the most effective way to screen a
low risk population for the presence of underlying cardiac disease
572. Hypertrophic cardiomyopathy is the most common cause of sudden cardiac death in young
573. HCM follows autosomal dominant inheritance
574. Know how to manage symptomatic HCM. Beta-blockers are usually the first line of
575. Total abstinence from alcohol is the mainstay of alcoholic cardiomyopathy management
and it may reverse this condition if it is employed earlier in the course of the disease
576. Know the physiology of HCM and be able to correctly identify the factors that increase or
decrease the intensity of the murmur in HCM. Valsalva maneuver and standing-Increase;
Handgrip, Phenylephrine and Leg elevation; Decrease the murmur.
577. Screening should be done in all first-degree relatives of the patients of hypertrophic
cardiomyopathy and the most effective way of screening these people is echocardiography
578. Mitral valve prolapse is the most common cause of mitral regurgitation in USA
579. Restrictive cardiomyopathy is characterized by severe diastolic dysfunction due to a stiff
ventricular wall.
580. Beta blockers are used to treat chest pain, palpitations, and autonomic symptoms of MVP.
581. Know how to diagnose mitral valve prolapse based on clinical findings. Remember the
‘systolic click’
582. . The presence of a tapping apex beat, a loud first heart sound, and a mid-diastolic rumble at
the apex suggest the diagnosis of mitral stenosis in this patient.
583. Atrial fibrillation in MS is due to left atrial dilatation.
584. It is important to look for and treat hemochromatosis early in patients who present with
restrictive cardiomyopathy, because this intervention significantly improves prognosis in these
585. Know how to manage a case of CHF exacerbation due to atrial fibrillation with a rapid
ventricular response. Digoxin is the drug of first choice in this situation
586. S. Aureus is the most frequent cause of IE in IV drug abusers
587. Transesophageal echocardiography or computed tomographies are the diagnostic studies of
choice for suspected aortic dissection.
588. The typical radiographic abnormalities and PaO2/FiO2 ratio of 91.6 (which is less than 200)
in the setting of absent clinical evidence of elevated left atrial pressures (or PCWP 50, do yearly
digital rectal plus PSA (Prostate Specific Antigen)
749. In Waldenström’s Macroglobulinemia, IgM is produced in excess amounts which causes
hyperviscosity of the blood. IgM spike on electrophoresis and hyperviscosity are two important
diagnostic clues for this disorder.
750. Eradication of H. pylori by antibiotics is the most accepted and recommended next best step
in the management of gastric mucosa-associated lymphoid tissue lymphoma without any
751. Adenocarcinoma of lung has the least association with smoking. It is usually located
peripherally and consists of columnar cells growing along the septa. It presents as a solitary
nodule and may be detected incidentally.
752. Squamous cell carcinoma of mucosa of head and neck may present with palpable cervical
lymph node. The best test for such patients is panendoscopy to detect the primary tumor.
753. There is no evidence that ultrasound of abdomen can help in decreasing mortality from
ovarian cancer.
754. For a breast mass that disappears completely with FNA and fluid aspirated is clear, next
step is to observe for 4 weeks.
755. Tamoxifen reduces the risk of breast cancer in patients who are at an increased risk of
developing breast cancer.
756. Paget’s disease presents as a persistent dermatitis of the nipple. There is a red, oozing,
crusted lesion, which is often unresponsive to topical steroid and antibiotics. Biopsy shows
malignant cells that invade the epidermis and have abundant pale staining cytoplasm surrounding
a hyper-chromatic nucleus, with prominent nucleoli.
757. Tamoxifen increases the risk of two types of cancer that can develop in the uterus:
endometrial cancer, which arises in the lining of the uterus, and uterine sarcoma, which arises in
the muscular wall of the uterus.
758. Recognize migratory thrombophlebitis and consider appropriate investigation to find out the
possible occult malignancy.
759. Ondansetron is the drug of choice for chemotherapy-induced emesis.
760. Melanoma should be on the top of the list if a metastatic mass bleeds inside brain.
761. In low risk patients (i.e. < 40 years and non smokers) a solitary pulmonary nodule is not a
sign of immediate alarm. The best approach is to ask for an old x-ray.
762. The best way to handle bone tumor is to recognize it and leave it for experts.
763. Amphotericin should be started in febrile neutropenic patients if they are persistently febrile
despite of 5-7 days of ceftazidime/cefepime plus vancomycin.
764. Febrile neutropenia is a medical emergency; patient should be admitted in hospital and
started on broad-spectrum antibiotics preferably 3rd generation cephalosporins after obtaining
blood cultures.
765. Radiologically, Ewing's sarcoma is associated with a lamellated or "onion skin" periosteal
reaction. The lesion is usually lytic and central. Endosteal scalloping is often present.
766. Any contrast enhancing, heterogeneous, irregular mass on kidney is a malignancy until
proven otherwise. Through workup by an urologist is recommended
767. Hypercalcemia and hilar mass in a smoker of more than 45 years is most likely from a
squamous cell carcinoma of the lungs.
768. Hypercalcemia and intractable ulceration can be due to MEN syndromes.
769. Syndrome of inappropriate antidiuretic hormone secretion is often seen with small cell
carcinoma of the lung.
770. CT chest should be done to look for thymoma in all newly diagnosed myasthenia gravis
771. IV normal saline is the first step in managing acute hypercalcemic crisis.
772. An increase in serum levels of both insulin and C-peptide and hypoglycemia is diagnostic of
773. Acanthosis nigricans might be a manifestation of occult gastrointestinal malignancy.
774. Water restriction is the first step in managing hyponatremia in patients with syndrome of
inappropriate antidiuretic hormone secretion.
775. Hypocalcemia is an important component of Tumor Lysis Syndrome. It is believed to be
due to the release of intracellular products by cell lysis. There are a number of metabolic
abnormalities associated that include hyperphosphatemia, hypocalcemia, hyperkalemia, and
776. Any adolescent boy who presents with epistaxis and has localized mass with bony erosion
on the back of the nose has an angiofibroma until proven otherwise.
777. Patients with Peutz-Jeghers syndrome have a high risk of developing ovarian tumors.
778. Hyperglycemia, necrolytic migratory erythema and diarrhea should make you think about
779. Know how to diagnose osteosarcoma. Codman’s triangle and sunburst appearance are the
two classic radiologic features of this entity.
780. Spironolactone is the diuretic of choice for managements of ascites.
781. The drug of first choice for cancer-associated anorexia is Megestrol acetate.
782. Recognize acute monocytic (FAB M5) leukemia based on the smear and positive ‘alpha-
naphthyl esterase’
783. Chronic lymphocytic leukemia is almost always seen in elderly patients; presence of
marked leukocytosis with predominant lymphocytosis and smudge cells are the diagnostic
784. Multiple myeloma is a plasma cell disorder and often presents with lytic lesions,
hypercalcemia, and renal failure.
785. Know about the typical presentation of infectios mononucleosis and always keep in mind
that heterophil antibody test is usually positive after 3 weeks of infection.
786. Recognize the importance of tartrate resistant acid phosphatase stain in the diagnostic of
hairy cell leukemia.
787. Acute lymphoblastic leukemia is predominantly a disease of children and recognize the
importance of periodic acid schiff positive staining in diagnosis.
788. Know the blood indices in various types of anemias. Megaloblastic anemias are
characterized by elevated MCV, 90% of the times elevated MCH, and normal MCHC.
789. Patients with high MCV should be tested for vitamin B12 and folic acid levels. Know how
to differentiate between various causes of megaloblastic anemia.
790. In a patient with increased reticulocyte count, increased bilirubin, negative Coombs test and
spherocytes on peripheral blood films, the diagnosis of Hereditary Spherocytosis (HS) is top on
the list
791. PA is the most common megaloblastic anemia and is the prototype of the group. In PA,
Vitamin B12 deficiency is caused by reduced Intrinsic factor (IF) secondary to gastric atrophy.
In majority of the cases antibodies to parietal cells have been reported.
792. Microcytic anemia and basophilic stippling in a child should make you think about lead
793. In Paroxysmal Nocturnal Hemoglobinuria , a red cell membrane defect causes increased
binding of complement to the red cell leading to increased intravascular hemolysis.
794. Know the iron studies in various types of microcytic anemias. Low serum iron, ferritin, and
increased TIBC indicates iron deficiency anemia.
795. Polycythemia can present with hypertension. Know various presentations of polycythemia
vera and try to identify it from other causes of hypervolemia.
796. Presence of antibodies to ds-DNA is specific for the diagnosis of systemic lupus
797. New onset diabetes, arthropathy, and hepatomegaly should alert you about the possibility of
798. In P. Vera urinary erythropoetin assay reveals the absence of measurable erythropoetin in
the urine.
799. In CLL, presence of thrombocytopenia is a poor prognostic factor.
800. Try to identify chronic lymhpocytic leukemia from clinical picture and hematological
findings. Lymph node biopsy not bone marrow biopsy confirms the diagnosis.
801. Know that leukocyte alkaline phosphatase score is high in leukemoid reactions and usually
low in chronic myeloid leukemia.
802. The hallmark of Bernard –Soulier syndrome is the Giant platelets. There is mild
thrombocytopenia but the major defect is of membrane glycoprotein Ib. This defective platelet
membrane lacks the receptor site for vWF so the platelets can’t adhere to vascular
803. Glazmann’s Thrombasthenia is a qualitative platelet defect with normal platelet count but
prolonged bleeding time and abnormal aggregation test with ADP.
804. Elderly patient with anemia, renal failure, and hypercalcemic should make you think of
multiple myeloma
805. Imatinib has changed the prognosis in patients with chronic myelogenous leukemia.
806. Know the diagnostic features of Hairy Cell Leukemia and that Cladribine is the drug of
choice for it.
807. Know the presentation of thrombotic thrombocytopenic purpura and its differentiating
features from disseminated intravascular coagulation, idiopathic thrombocytopenic purpura and
hemolytic uremic syndrome.
808. Folic acid supplementation is encouraged in patients with high risk for developing aplastic
809. Bone marrow iron stain is the most definite way to diagnose iron deficiency anemia.
810. Recognize the pathology of B12 deficiency anemia. B12 stores are available for 3-4 years.
811. Supplementation with folic acid may correct anemia but will not correct neurological
complications in patients with vitamin B12 deficiency.
812. Consider macro vascular hemolysis as a cause of microcytic anemia in patients with
artificial heart valves or severely calcified aortic valves.
813. Always consider G6PD deficiency in patients who develop acute hemolysis following
ingestion of primaquine or sulfa drugs. Also, G6PD levels are often normal during the hemolytic
814. Acute cord compression in cancer patient is a medical emergency and needs prompt
administration of intravenous steroids as the first step.
815. Radiation therapy is useful in managing bone pain in patients with prostate cancer who have
undergone orchiectomy.
816. Vitamin K deficiency can occur following chronic diarrhea or broad-spectrum antibiotic
use, manifesting with bleeding disorders in the form of easy bruisability, mucosal bleeding, etc.
PT is prolonged. If the PT is not corrected with administration of vitamin K, it should make you
think that this is not the result of vitamin K deficiency and liver disease should be suspected.
817. Recognize HUS in a child who has recently recovered from a diarrheal illness and presents
with acute renal failure, microangiopathic hemolytic anemia, fever, thrombocytopenia and
characteristic peripheral smear finding of schistocytes.
818. Chronic liver disease or cirrhosis from almost any cause is a risk factor for hepatocellular
cancer. Hepatocellular cancer is responsible for 30% of deaths in patients with hemochromatosis.
819. Chronic liver disease or cirrhosis from almost any cause is a risk factor for hepatocellular
cancer. Hepatocellular cancer is responsible for 30% of deaths in patients with hemochromatosis.
820. Reye’s syndrome or acute fatty liver with encephalopathy can lead to fulminant hepatic
failure in children.
821. Pancreatic pseudocyst is a complication of both acute and chronic pancreatitis and is
diagnosed by ultrasound.
822. Anti mitochondrial antibodies are present in 90% of patients with primary biliary cirrhosis.
823. Liver disease should be evaluated on the basis of tests to assess both the function and the
structural integrity of the liver.
824. Hyperestronism in cirrhosis leads to gynecomastia, testicular atrophy, decrease bodily hair,
spider nevi and palmar erythema.
825. Suspect spontaneous bacterial peritonitis (SBP) in cirrhotic patients with fever and ascites.
826. High serum AFP (>500 ng/ml) in an adult with liver disease and without an obvious G.I.
malignancy is strongly suggestive of hepatocellular carcinoma.
827. Abdominal ultrasound is the best initial investigation for gallbladder pathology.
828. The triad of sudden onset right upper abdominal pain, fever, and leucocytosis is highly
suggestive of acute cholecystitis.
829. Newborns of mothers with active hepatitis B should be passively immunized at birth with
hepatitis B immunoglobulin followed by active immunization with recombinant HBV vaccine.
830. Risk factors for non alcoholic hepatic steatosis are obesity, diabetes mellitus,
hyperlipidemia, total parental nutrition and bypass surgery for obesity.
831. Hemochromatosis is an autosomal recessive disorder characterized by increased skin
pigmentation, diabetes, cirrhosis and arthralgia.
832. Checking for anti HBcAg and HBsAg is the best screening of the acute hepatitis B.
833. HCV RNA is the single most sensitive serological marker to screen for HCV infection.
834. Hepatitis E has a very high rate of progression to fulminant hepatitis in pregnant women.
835. Acute liver failure or fulminant hepatitis is most commonly due to acetaminophen toxicity.
836. Persons who received blood transfusions before 1992 should be screened for Hepatitis C
and those with blood transfusions before 1986 should also be screened for hepatitis B.
837. Isoniazid causes idiosyncratic liver injury with histology similar to viral hepatitis.
838. Primary sclerosing cholangitis is caused by inflammatory destruction of both the
intrahepatic and extrahepatic biliary channels. It is often associated with ulcerative colitis.
839. Alpha-1 Antitrypsin deficiency can cause panlobular emphysema and cirrhosis.
840. Non-selective B blockers are used in primary and secondary prevention of variceal bleeding
in cirrhotic patients who have portal hypertension with varices.
841. The first step in the treatment of acute variceal bleeding is to get vascular access with two
large bore intravenous needles.
842. C-J 1 is characterized by:

1. Unconjugated hyperbilirubinemia of 8-30mg/dl.

2. Normal liver enzymes and histology.
3. High rates of kernicterus
4. No response to Phenobarbital

C-J 2 is characterized by:

1. Unconjugated hyperbilirubinemia of 1000mg/dl can cause acute pancreatitis.

878. Endoscopic retrograde cholangiopancreatography is the investigation of choice for patients
with recurrent pancreatitis with no obvious cause.
879. Paracentesis can be used for both diagnostic and therapeutic purposes in patients with
880. Hydatid cysts in the liver are due to infection with Echinococcus granulosus.
881. Transjugular intrahepatic portosystemic shunt procedure is used in cirrhotic patient for
refractory ascites, refractory hydrothorax, and surgical management of acute recurrent variceal
882. Entamoeba histolytica is a protozoan, which can cause amebic liver abscess. Remember the
Mexico trip.
883. Factors independently associated with high rates of liver fibrosis in chronic hepatitis C
patients are:
1. Male gender.
2. Acquiring infection after age of 40.
3. Alcohol intake: alcohol intake in any amount can hasten the progression of fibrosis in patients
with chronic hepatitis C.
884. ERCP with sphincterotomy is the treatment of choice for sphincter of oddi dysfunction
885. The treatment of acute cholangitis is to give supportive care, broad-spectrum antibiotics,
and biliary drainage with an endoscopic retrograde cholangiopancreatography.
886. Checking for urinary excretion of bilirubin is an easy and effective way of determining
whether the cause of jaundice is conjugated or unconjugated bilirubin. So the presence of
bilirubin in urine is indicative of conjugated hyperbilirubinemia.
887. Conjugated hyperbilirubinemia is mainly because of intrahepatic or extrahepatic obstruction
or congenital impaired hepatic excretion of bilirubin.
888. Acute pancreatitis is one of the conditions causing acute abdomen, which is managed
889. About 10% of patients on isoniazid develop a mild elevation of aminotransferases within
first few weeks of the treatment. However, this elevation of aminotransferases returns to normal
despite continued use of isoniazid in most of the patients.
890. Orthotopic liver transplantation remains the only effective mode of treatment of fulminant
hepatic failure and should be considered in any patient presenting with fulminant hepatic failure,
regardless of the etiology.
891. Liver biopsy is the most reliable way to distinguish chronic active from chronic persistent
892. Benign intrahepatic cholestasis can develop after a major surgery in which hypotension,
extensive blood loss into tissues and massive blood replacement are notable.
893. Hepatic venogram or a liver biopsy is the diagnostic test of choice for the evaluation of
congestive hepatomegaly secondary to hepatic vein occlusion (Budd Chiari syndrome).
894. Porcelain gall bladder is an entity usually diagnosed on an abdominal x- ray. The condition
predisposes individuals to gall bladder carcinoma and requires resection.
895. In a patient with primary amenorrhoea and no breasts, estrogen is low and FSH
measurement should be ordered: if it is decreased, GnRH stimulation test is the next step; if it is
increased, karyotype is the next step.
896. In any woman of childbearing age with amenorrhea, first rule out pregnancy.
897. DUB is the most common cause of abnormal uterine bleeding, but owing to its benign
nature, it is a diagnosis of exclusion. About 70% of cases are caused by anovulatory cycles. After
menarche and before menopause it is considered physiologic. IV estrogen is the drug of choice
for uncontroled bleeding.
898. When to perform endometrial biopsy to rule out endometrial carcinoma in patients with
DUB? If the patient is older than 35 years, obese, diabetic or with chronic hypertension.
899. OCPs have been shown to decrease the risk of ovarian and endometrial carcinoma. As for
breast cancer, the risk does not seem to change with their use. Beside hypertension, OCPs expose
to other complications such as thromboembolism, cerebrovascular disease, MI, gallblader
disease and benign hepatic tumors.
900. Postcoital or emergency contraception has become necessary because it is estimated that
around 60% of pregnancies in the US are unplanned. It can be given upto 72 hours.
901. Presence of dysmenorrhea, heavy menses, and enlarge uterus is almost diagnostic of either
adenomyosis or fibroid uterus.
902. Primary dysmenorrhea usually appears 6 to 12-months after menarche. NSAIDs are highly
effective for treatment; oral contraceptive pills inhibit ovulation and are also effective.
903. Patients with polycystic ovarian disease (PCOD) usually have elevated DHEA levels.
Although ACTH levels are normal in these women, ACTH stimulation test produces an
exaggerated response of DHEA because of increased sensitivity of the adrenal gland to ACTH.
904. Treatment for overflow incontinence includes cholinergic agents and intermittent self-
905. External hordeolum or stye is a common staphylococcal abscess of eyelid, which is treated
with warm compresses and if the resolution doesn’t begin in next 48hrs, with incision and
906. Age related macular degeneration is usually seen in patients above 50yrs of age, presents
with progressive and bilateral loss of central vision with preservation of navigational vision.
907. Congenital cataract is the most common cause of white reflex in pediatric population.
908. Allergic conjunctivitis is an acute hypersensitivity reaction caused by environmental
exposure to allergens and characterized by intense itching, hyperemia, tearing, conjunctival
edema and eyelid edema.
909. Cataract is a vision-impairing disease, due to progressive thickening of lens and
characterized by blurred vision and glare.
910. Angle Closure Glaucoma occurs predominantly in people aged 55-70 yrs and presents with
acute onset of severe eye pain and blurred vision associated with nausea and vomiting.
911. Open Angle Glaucoma is more common in African Americans, is generally asymptomatic
in intial stages and characterized by gradual loss of peripheral vision over a period of years
resulting into tunnel vision.
912. Postoperative endophthalmitis is the most common form of endophthalmitis, usually occurs
within six weeks of surgery.
913. Vesicular rash in the terminal distribution with dendriform corneal ulcers is suggestive of
Herpes zoster opthalmicus.
914. CMV retinitis occurs when CD4 count is less than 50/ul; may be asymptomatic and is
diagnosed by the characteristic fundoscopic findings of yellow white patches of retinal
opacification and hemorrhages.
915. Optic neuritis presents with changes in color perception and decreased visual acuity.
Afferent pupillary defect and central scotoma should make you think of optic neuritis.
Remember the association between optic neuritis and multiple sclerosis.
916. Trachoma presents as follicles in the conjunctiva and signs of nasopharyngeal infection.
917. Dacryocystitis presents with inflammatory changes in the medial canthal region of the eye.
918. Hordeolum is a painful, tender swelling localized to the eyelid.
919. Corneal vesicles and dendritic ulcers characterize Herpes simplex keratitis.
920. Amaurosis fugax is transient loss of vision due to embolic phenomena
921. Recognize the clinical presentation of retinal detachment; it usually presents with sudden
onset of photopsia and floaters.
922. Vitreous hemorrhage occurs in patients with diabetic retinopathy and the fundus is hard to
923. When an individual with acute glaucoma is diagnosed, all agents, which can dilate the
pupil, like atropine, should be avoided.
924. Spontaneous subconjunctival hemorrhage is a benign finding and does not require any
925. In any patient less than 3 years old and presenting with impairment in social interactions
and communication, delayed language development, and stereotypical behaviors, always thinks
of autism.
926. Thus, in any patient with symptoms of short attention span, impulsivity, and hyperactivity,
for more than 6 months in more than one setting, ADHD should be considered as the most
probable diagnosis.
927. Infant botulism is transmitted by ingestion of food contaminated with C. botulinum. The
germ grows in the gut and produces a toxin, which is responsible for the clinical signs.
928. Ventricular septal defects are common in patients with Edward’s syndrome, which is
characterized by micrognathia, microcephaly, rocker bottom feet, overlapping fingers, and absent
palmar creases.
929. Hirschsprung’s disease occurs with increased frequency in patients with Down’s syndrome.
930. Cystic fibrosis may presents with meconium ileus, which is characterized by bilious
vomiting, failure to pass meconium at birth, and ground glass appearance on abdominal X-rays.
931. Midgut volvulus usually presents in a child less than one month with bilious vomiting,
abdominal distension and bloodstained stools.
932. In a neonate who presents with bloody diarrhea, the presence of eosinophils in the stools
and positive family history of atopy suggest the diagnosis of milk protein intolerance.
933. Painless melena in a 2 to 3-year-old child is most likely due to Meckel's diverticulum.
934. Fiberoptic laryngoscopy in the operating room is the most appropriate next step when
diagnosis of acute epiglottitis is suspected.
935. Pyloric stenosis presents with non-bilious vomiting in a 4 to 8-week-old child, and
abdominal ultrasound confirms the diagnosis.
936. Gaucher’s disease is diagnosed based on the radiological appearance of Erlenmeyer flask
deformity of the distal femur, and characteristic Gaucher cells with their wrinkled paper
appearance in bone marrow examination.
937. Children with a parental history of elevated total cholesterol levels (>240 mg/dL), or risk
factors for coronary artery disease should get a screening test for total cholesterol level.
938. Peroxisomal disorders such as Zellweger's syndrome should be considered in neonatal
seizures, especially if the neonate presents with typical facial dysmorphism.
939. Patients with classic phenylketonuria present with fair skin, blue eyes, musty body odor and
eczema, and labs show elevated plasma phenylalanine levels.
940. Cri-du-chat syndrome is due to 5p deletion and it presents with features of hypotonia, short
stature, and a characteristic cat-like cry.
941. Edwards' syndrome commonly presents with microcephaly, prominent occiput,
micrognathia, closed fists with index finger overlapping the 3rd digit and the 5th digit
overlapping the 4th, and rocker bottom feet.
942. Down’s syndrome, or trisomy 21, presents with flat face, upward and slanted palpebral
fissures, epicanthal folds, simian crease, short and broad hands, hypoplasia of the middle phalanx
of the 5th fingers, and high arched palate.
943. Vitamin D deficiency rickets is more common in dark skinned infants who are less exposed
to sunlight and are 1-2 years of age. It presents with craniotabes, rachitic rosary, and thickening
of the lower end of long bones, all due to defective mineralization.
944. Birth injuries such as clavicular fracture are common complications in mothers with GDM
and large babies.
945. Mongolian spots are flat blue or gray lesions, characteristically well demarcated, seen more
commonly in the sacral or presacral areas, and disappear by the first few years of life.
946. Conduct disorder is characterized by disruptive behavioral patterns that violate basic social
norms present for more than one year, in patients less than 18 years old.
947. Suspect Vitamin A deficiency in any child 2 to 3 years of age presenting with dry eyes and
skin, photophobia, and impaired dark adaptation.
948. Iron supplementation in the form of iron-fortified milk formula or medicinal iron, should be
started at 6 weeks in all premature and low birth weight babies.
949. Maternal HIV infection is an absolute contraindication to breast-feeding.
950. Heroin withdrawal usually presents within the first 48 hours of life, with tremors and
hyperirritability as the most prominent symptoms.
951. Surgery is advised in umbilical hernia if the hernia persists to the age of 3-4 years, exceeds
2 cm in diameter, causes symptoms, becomes strangulated, or if it enlarges progressively after
the age of 1 to 2 years.
952. Physiological jaundice usually presents after 24 hours of birth. Any jaundice in the first 24
hours of birth, or a direct hyperbilirubinemia, needs detailed evaluation for the cause of jaundice.
953. Neonatal necrotizing enterocolitis should be suspected in any preterm or low birth weight
infant with fever, vomiting, abdominal distension, and roentgenographic finding of pneumatosis
954. Hyaline membrane disease should be suspected in preterm infants with respiratory distress
and hypoxia not responding to oxygen therapy, and is treated early with mechanical ventilation
and surfactant
955. Cephalohematoma is a subperiosteal hemorrhage, presents few hours after birth as scalp
swelling limited to one cranial bone.
956. Absence seizure is a generalized seizure of childhood and is characterized by sudden and
brief lapses of consciousness without loss of postural control. It usually presents with multiple
'daydreaming' episodes and decline in school performance.
957. Intussusception, the most common cause of intestinal obstruction in the first two years of
life, presents with intestinal obstruction and red currant jelly stools containing blood and mucus.
958. Calcified lesion above the sella requires an evaluation for craniopharyngioma.
959. Sturge-Weber syndrome is a neurocutaneous syndrome and is characterized by congenital
unilateral cavernous hemangioma along the trigeminal nerve distribution; radiography shows
characteristic intra-cranial calcifications that resemble a tramline.
960. Supportive care is the mainstay of treatment in cases of infant botulism.
961. The treatment of Kawasaki's disease consists of aspirin and IV immunoglobulins.
962. Always suspect pyloric stenosis in a neonate who presents with non-bilious, projectile and
persistent vomiting, and order abdominal ultrasound to establish the diagnosis.
963. Osgood-Schlatter disease is generally a disease of children age around 10-17 years, which
presents with knee pain at the tibial tuberosity, that is, at the site of insertion of the quadriceps
964. Recognize fetal alcohol syndrome and know that it is the most common cause of mental
retardation in children. Remember the midfacial abnormalities.
965. Guthrie test is a qualitative (coloration) test which can detect the presence of metabolic
products of phenylalanine in the urine.
966. The healthy appearance of the neonate, the evanescent nature of the rash, and the distinctive
red halo surrounding the lesions support the diagnosis of erythema toxicum. The presence of
eosinophils in the skin lesions is diagnostic.
967. Galactosemia should be considered for the newborn or young infant who has failure to
thrive, bilateral cataract, jaundice and hypoglycemia. Early diagnosis and treatment by
elimination of galactose from the diet are mandatory.
968. Aplastic anemia should be suspected in any patient with pancytopenia following drug
intake, exposure to toxins or viral infections.
969. American Academy of Pediatrics advises against the use of cow's milk in the first year of
life. Infants should receive breast milk or iron fortified formulas for the first year of life, and
iron-fortified cereal should be added at the age of 4-6 months.
970. Any patient with recurrent or unusual lymphadenitis, hepatic abscesses, osteomyelitis at
multiple sites, or unusual infections with catalase-positive organisms (e.g., S. aureus) requires
clinical evaluation for chronic granulomatous disease.
971. Severe combined immune deficiency is a life-threatening syndrome presenting with
recurrent bacterial, viral and fungal infections, and diagnosed by absence of lymph nodes and
tonsils, lymphopenia, and absence of a thymic shadow on chest X-rays.
972. Hyper-IgM syndrome (HIM) is characterized by high levels of IgM with deficiency of IgG,
IgA and poor specific antibody response to immunizations.
973. Bruton’s agammaglobulinemia classically presents in a male infant of 6-9 months of age
with recurrent pneumonia and otitis media. Level of all classes of immunoglobulins and
circulating B-lymphocytes are decreased.
974. Salicylates are contraindicated in young children with viral infections. Recognize the
clinical presentation of Reye’s syndrome.
975. Hypoglycemia, lactic acidosis, hyperuricemia, and hyperlipidemia, in the presence of liver
and kidney enlargement, are hallmarks of Type I glycogen storage disease (deficiency of
976. Kawasaki's disease is characterized by fever, conjunctival vascular injection, cracked lips,
polymorphous erythematous rash, diffuse erythema of palms and soles and unilateral
977. In patients suspected of epiglottitis, visualization of the epiglottis should not be attempted.
Securing the airways as soon as possible is the first and foremost step in management of these
978. Croup is caused by Parainfluenza virus and commonly presents in children younger than 3
years with hoarseness, a barking cough, and varying degrees of respiratory distress.
979. Myotonic dystrophy, a slowly progressive, dominantly inherited disorder, usually manifests
itself in the third or fourth decade but occasionally appears early in childhood. The genetic defect
has been localized to the long arm of chromosome 19 in the type 1 disorder. Myotonia leads to
complaints of muscle stiffness and is evidenced by the marked delay that occurs before affected
muscles can relax after a contraction. This can often be demonstrated clinically by delayed
relaxation of the hand after sustained grip or by percussion of the belly of a muscle.
980. Streptococcal pharyngitis is the most common cause of pharyngitis in children, and the first
step in any case of pharyngitis is to do a rapid strep test. Oral penicillin for 10 days is the
treatment of choice.
981. Streptococcus pneumonia is the most common cause of acute sinusitis in childhood,
followed by Haemophilus influenzae and Moraxella catarrhalis.
982. Sinusitis is a clinical diagnosis in children and is treated with oral amoxicillin in
uncomplicated cases.
983. Acute lymphoblastic leukemia is the most common leukemia in children. Diagnosis is
mainly based on more than 25% lymphoblasts in the bone marrow.
984. Immune thrombocytopenic purpura typically presents in early childhood after a viral
infection with easy bruisability and petechiae. Labs show thrombocytopenia and normal Hb,
WBC, PT and PTT.
985. A positive Coombs' test points towards autoimmune hemolytic anemia, and a positive
osmotic fragility test points towards hereditary spherocytosis.
986. The intraosseous technique is an excellent site for IV access in children.
987. In children who develop thrombocytopenia after a viral infection, one should suspect
immune thrombocytopenia, which is a relatively benign condition.
988. In a newborn in the NICU, abdomen distension, bloody diarrhea, elevated WBCs, that occur
after feeding, usually represents necrotizing enterocolitis.
989. The organ system with the highest morbidity and mortality after HUS is the kidneys.
990. In a child who presents with a sudden onset of abdominal pain, bloody diarrhea, and a triad
of anemia, thrombocytopenia and renal failure, one should suspect the hemolytic uremic
991. In a febrile child who presents an isolated seizure, one has to think of a febrile seizures.
They are benign and need to be adressed with reassurance and antipyretics.
992. Trachoma, caused by Chlamydia trachomatis is the most common cause of blindness in the
world. The diagnosis is usually made by the presence of lymphoid follicles on the conjunctiva,
scarring and limbal follicles.
993. In a patient with sickle cell trait, some protection against malaria is obtained.
994. Asthma when it cannot be controlled by medications, should be an indication for
mechanical ventilation. Know when to intubate a patient.
995. Bordetella pertussis presents in children with paroxysms of cough, which can last up to two
weeks. The coughing spells are so severe that rectal prolapse and pneumothoraces can ensue.
996. In a patient with severe bouts of coughing and subcutaneous emphysema, a pneumothorax
must be ruled out by obtaining chest X-rays.
997. In a patient who presents with symptoms of an upper respiratory tract infection and later
develops a rash after exposure to ampicillin, one should think of infectious mononucleosis
caused by Epstein-Barr virus
998. When a child presents with chorea, sore throat, fever, pericarditis and subcutaneous
nodules, one should suspect Group A streptococcus. It is the leading cause of rheumatic fever.
999. In an infant with meningitis from Neisseria meningococcus, a sudden vasomotor collapse
and skin rash is due to adrenal hemorrhage, known as the Waterhouse-Friderichsen syndrome.
1000. In a neonate with signs of meningitis and a petechial rash, one should suspect
1001. Pyloric stenosis is a surgical condition. However, surgery should be undertaken only after
the infant has been resuscitated and electrolytes replaced.
1002. In a young child of 2-5 years age with a localized abdominal mass and hematuria, one has
to think of Wilms tumor. If the child age is less than 1 year think of neuroblastoma.
1003. The drug of choice for nocturnal enuresis is DDAVP. Bed-wetting is considered normal
until the age of 4-5 years. But if it persists either DDAVP or imipramine is used.
1004. Childhood obesity is a risk factor for development of type 2 diabetes later in life.
1005. Most cardiac murmurs in childhood are benign and require only observation
1006. DiGeorge syndrome is associated with cyanotic heart disease, craniofacial anomalies,
thymic hypoplasia, cognitive impairment and hypoparathyroidism. It is essential to monitor the
calcium levels in these infants.
1007. In a child who has proximal muscle weakness and exhibits a Gower’s sign, with depressed
reflexes and pseudohypertrophy, a muscular dystrophy must be suspected
1008. Turner syndrome is associated with a higher incidence of coarctation and bicuspid aortic
valve. The clinical presentation is that of short stature, short webbed neck and a low posterior
hairline. The chest is broad with widely spaced nipples.
1009. Duodenal atresia can present with bilious vomiting and 2 large air bubbles on an x-ray.
Remember its association with Down syndrome
1010. A typical presentation of TOF individuals is squatting, which increases the systemic
vascular resistance and forces blood into the lungs, thus improving cyanosis.
1011. Gall Stone Ileus: Plain abdominal x-rays revealed distended loops of small bowel
consistent with partial small bowel obstruction, and gas in the biliary tree and gallbladder. US
confirmed gas in the biliary tree, but could not identify the gallbladder and could not determine
the cause of intestinal obstruction.
1012. The treatment of recurrent aortic coarctation is balloon angioplasty.
1013. Down syndrome patients are prone to endocardial cushion defects, which can rapidly
cause pulmonary hypertension.
1014. In a child presenting with failure to thrive and steatorrhea, with a history of neonatal
jaundice, cystic fibrosis must be ruled out. The diagnosis of cystic fibrosis is made after
evaluating the sweat chloride.
1015. In a young child who presents with recurrent upper respiratory tract infections and bilateral
nasal polyps, cystic fibrosis must be ruled out.
1016. The most common cause of amblyopia is strabismus. Other causes include errors of
refraction, and opacity of media along the visual axis. The standard of treatment is occlusion of
the normal eye.
1017. Thyroid dysgenesis is the most common cause of congenital hypothyroidism in United
1018. Mongolian spots could most commonly be found in dark-skinned populations, present
from birth and usually fades and then disappears in several years.
1019. Neonatal chlamydial conjunctivitis is treated with systemic erythromycin because of the
risk of pneumonia.
1020. Anemia of prematurity is the cause of anemia in premature and low birth weigh infants.
The pathology involves a combination of diminished RBC production, shortened RBC life span,
and blood loss. Iron supplementation does not prevent falling hemoglobin and is not the cause of
anemia of prematurity.
1021. Vaginal discharge in newborn is due to the effects of maternal estrogens and reassurance
of the mother is all that is required.
1022. Osteogenesis imperfecta is caused by mutations in type 1 collagen and its typical features
are blue sclera and recurrent fractures.
1023. Painless gross hematuria is the most common presentation of sickle cell trait.
1024. Hydroxyurea is indicated in patients with frequent, acute, painful episodes, a
s it tends to increase Hb F levels.
1025. Dactylitis is the earliest manifestation of vaso-occlusive disease in sickle cell anemia.
1026. Pubertal gynecomastia is seen in about one-half of adolescent boys, at an average age of
14 years; it is often asymmetric or transiently unilateral, frequently tender, and just needs
1027. All children with recurrent episodes of nocturnal vulvar itching should be examined for
pinworms and may be treated empirically.
1028. Neonatal tetanus is generally seen in infants born to unimmunized mothers, frequently
following umbilical stump infection, and is characterized by poor suckling and fatigue, followed
by rigidity, spasms and opisthotonus in first two weeks of life.
1029. DBS is a macrocytic pure red aplasia associated with several congenital anomalies
including short stature, webbed neck, cleft lip, shielded chest and triphalangeal thumbs.
1030. Lesch-Nyhan syndrome is secondary to deficiency in HRPT. It presents with self-
mutilation and neurologic features including mental retardation, dystonia, choreoathetosis and
spasticity. Gout is usually seen in patients of above 50 years of age. If you see a boy with gout,
suspect this.
1031. Iron poisoning presents with nausea, vomiting, diarrhea, abdominal pain, gastrointestinal
bleeding and metabolic acidosis. As iron is radio-opaque, the tablets can be seen in the stomach
on abdominal x-ray. Diagnosis is confirmed by measuring serum iron levels. Deferoxamine, an
iron chelator, is used IV in moderate to severe intoxications.
1032. Neuroblastoma is the third most common cancer in the pediatric population (after
leukemia and CNS tumors). It arises from neural crest cells which secondarily populate
sympathetic ganglia and adrenal medulla. The most common site is the abdomen.
1033. Features of Prader-Willi syndrome (obesity hypogonadism syndrome) include hypotonia,
hypogonadism and obesity. Also, try to remember the mental retardation and dysmorphic
craniofacial features.
1034. In patients with sickle cell disease, acute severe anemia with absent reticulocytes in
peripheral blood is due to aplastic crisis.
1035. Beckwith-Wiedemann syndrome is characterized by macrosomia, macroglossia,
visceromegaly (liver and kidneys) and omphalocele, in addition to the neonatal hypoglycemia
and hyperinsulinemia.
1036. The three most common organisms that cause pneumonia in patients with cystic fibrosis
1. Hemophilus. 2. Pseudomonas. 3. Staphylococcus
1037. Rotavirus is the most common cause of acute diarrhea in children, especially in those
between 6 months and 2 years.
1038. Meconium aspiration syndrome occurs most commonly in low birth weight and post-
mature infants. It is characterized by respiratory distress at birth, rales and rhonchi on
auscultation, hyperinflation, coarse streaking and patchy opacities on chest x-ray.
1039. Mouth burns with drooling of saliva and difficulty in swallowing are classic indicators of
caustic acid or alkali ingestion. The patient is often conscious, but in severe pain.
1040. Replacement of diarrheal loss of fluid with lots of low solute fluid like water can lead to
water intoxication, hyponatremia and even seizures.
1041. Esophageal atresia presents with choking, regurgitation and coughing associated with the
first feeding of the newborn infant.
1042. Premature adrenarche and thelarche often have no clinical significance. Pubarche requires
a thorough evaluation, as it may be due to a CNS disorder in 50% of cases.
1043. Hypocomplementemia (low C3, CH50) in post streptococcal glomerulonephritis resolves
in 8 - 12 weeks.
1044. In the presence of a cyanosis, aggravated by feeding and relieved by crying, think of
choanal atresia.
1045. McCune-Albright syndrome is characterized by precocious puberty, pigmentation (cafe au
lait spots) and polyostotic fibrous dysplasia.
1046. Sudden infant death syndrome is the leading cause of mortality in infants between 1 month
and 1 year of age, and the third most common cause of mortality in infants < 1 year.
1047. For prevention of SIDS, infants should be placed on their backs while sleeping. Home
monitors do not decrease the risk of SIDS
1048. For pertussis prevention, all close contacts should be given erythromycin for 14 days,
regardless of age, immunizations, or symptoms.
1049. Individuals who are exposed to tick-infested areas should wear light-colored clothing with
long-sleeved shirts and long pants tucked into socks or boot tops.
1050. Cystic fibrosis presents with failure to thrive, which occurs due to fat and protein
malabsorption from a pancreatic insufficiency.
1051. COA patients have hypertension in the upper part of the body and relative hypoperfusion
of the lower part of the body. A mild, continuous murmur heard all over the chest is due to the
development of collaterals between the hypertensive and hypoperfused vessels. Rib notching,
caused by the dilatation of the collateral chest wall vessels, is specific for coarctation.
1052. In patients with fever and cough after upper GI endoscopy suspect anaerobic lung
infection. Clindamycin and ampicillin plus metronidazole are the commonly used agents for this
1053. Know how to manage various manifestations of exacerbation of COPD. Recognize
collapse of the lung on chest-x ray. Bronchoscopic removal of mucus pugging is crucial.
1054. Always consider candida albicans as a cause of infection in a patient with uncontrolled
diabetes mellitus.
1055. Tuberculosis occurs early in the course of HIV when the CD 4 counts are greater than
200/microL. Upper lobe consolidation and/or cavitation is the typical X-ray finding.
1056. Suspect acute bronchopulmonary aspergillosis in asthmatics with worsening asthma
symptoms, coughing brownish mucous plugs, recurrent infiltrates and peripheral eosinophilia.
1057. Atypical pneumonia presents with headache, malaise, low-grade fever, and dry cough.
Patient complaints exceed the physical findings since exam findings are often minimal. The most
common X-ray abnormality is peribronchial pneumonia pattern and have predilection for the
lower lobes. Erythema multiforme is one of the extra pulmonary manifestations of mycoplasma
1058. Any chronic smoker with hypertrophic osteoarthropathy should have a chest x-ray to rule
out malignancy. Hypertrophic osteoarthropathy is associated with chronic proliferative periostitis
of the long bones, clubbing, and synovitis.
1059. Know the three major complications of too high a PEEP: Alveolar damage, Tension
pneumothorax and Ventricular failure.
1060. Suspect choriocarcinoma in any postpartum women who presents with shortness of breath
and hemoptysis. The next step is chest x-ray, pelvic exam, and beta-hCG.
1061. Suspect pulmonary embolism in any patient who presents with sudden onset of SOB,
pleuritic chest pain, normal lung exam, hypoxic, and have tachypnea, tachycardia and
hypotension. New onset atrial fibrillation is seen in few patients with PE.
1062. Always consider the risk of fat embolism in patients with multiple complicated fractures.
Fat embolism is a clinical diagnosis usually characterized by a triad of respiratory insufficiency,
neurological impairment and a petechial rash. Early immobilization and operative fixation of
fractures reduces the chances of fat embolism.
1063. BAL (bronchoalveolar lavage) is > 90% effective in diagnosing pneumocystis carini
pneumonia in HIV positive patients, especially when CD4 count is less than 200.
1064. Identify occupational interstitial lung diseases: i.e. Hypersensitivity Pneumonitis, Organic
dusts (Byssinosis) and inorganic dusts (asbestosis, silicosis, berylliosis and coal worker’s
1065. Identify allergic granulomatosis of Churg-Strauss and remember that leukotreine
antagnoists are known to cause CSS.
1066. Know the pathophysiology of ARDS and how to differentiate between ARDS and
cardiogenic pulmonary edema. Criteria for ARDS diagnosis is:

1. A pulmonary capillary wedge pressure less than 18 mmHg favors ARDS over cardiogenic
pulmonary edema.
2. PaO2 to FiO2 ratio of 200 mmHg or less, regardless of the level of PEEP.
3. Diffuse, bilateral infiltrates on chest-X ray.
1067. Acute bronchopulmonary aspergillosis (ABPA) is characterized by transient recurrent
pulmonary infiltrates, peripheral eosinophilia, asthma and immediate wheal and flare reaction to
Aspergillus fumigatus and presence of antibodies in the serum against Aspergillus fumigatus.
1068. Remember bronchogenic carcinoma is the most common lung cancer associated with
asbestos exposure while malignant mesothelioma is almost exclusively associated with asbestos
exposure but is not the most common malignancy after asbestos exposure.
1069. A radiographic finding of pleural plaques is the hallmark of asbestos exposure
1070. There is strong association between silicosis and tuberculosis; therefore, steps should be
taken to prevent tuberculosis in all patients who have developed silicosis. Patients who have
already developed silicosis or they have been exposed to silica for more than 25 years, should be
tested yearly by PPD.
1071. The common diagnostic features of ABPA include:
1.Asthma like symptoms
2.Elevated IgE
4.Central bronchiectasis
5.Positive Aspergillus Skin test
1072. When it is unclear whether the patient has nocturnal asthma or gastroesophageal reflux
disease, a trial of proton pump inhibitors is both diagnostic and therapeutic.
1073. Patients who are on high doses of beta-2 agonists may develop hypokalemia and patient
should be monitored with daily electrolytes. The other side affects of beta-2 agonists are
tachycardia, tremor, and peripheral edema.
1074. Know the association of Leukotriene inhibitors with Churg Strauss vasculitis.
1075. Use of prophylactic inhaled corticosteroids is beneficial in the long term out come of
chronic persistent asthma.
1076. Due to high incidence of lung cancer among smokers, it should be suspected in any
smoker presenting with recurrent pneumonia.
1077. Suspect alpha-1 anti-trypsin deficiency in non-smoker with early onset emphysema.
1078. Obstructive sleep apnea is a common condition among obese population. With never
ending pandemic of obesity in US, this is getting wider clinical attention. So, know the causes
and management of this condition.
1079. Know the symptoms, clinical and X-ray findings of idiopathic pulmonary fibrosis. IPF is a
diagnosis of exclusion. It almost universally progresses and the prognosis is worse.
1080. A sudden drop in oxygen saturation, restlessness, and agitation in a patient on mechanical
ventilation in IPPV mode is suggestive of barotrauma. Chest-x ray should be the next step.
1081. High resolution CT scan of the lung is the diagnostic modality of choice for
1082. Remember Blastomyces blasts the lungs, skin and bone.
1083. The triad of meningoencephalitis, pneumonia, and spleenomegaly suggests Chlamydia
psittaci pneumonia.
1084. Rigid bronchoscopy is indicated in patients with massive hemoptysis as it allows rapid
visualization of the bleeding site and to control bleeding through cauterization or other means.
1085. After quitting smoking, home oxygen therapy is the only modality known to prolong
survival in COPD.
1086. Annual influenza vaccine is recommended for all persons aged 65 and older and persons in
selected high-risk groups. Pneumococcal vaccine is recommended for all immunocompetent
individuals who are 65 years and older or otherwise at increased risk for pneumococcal disease.
1087. A-a gradient is increased in interstitial lung disease due to poor oxygenation. In restrictive
lung diseases, total lung capacity (TLC), functional residual capacity and residual volume are all
reduced. Flow volumes are also reduced but the ratio of FEV1/FVC is either normal or
1088. Bilateral hilar adenopathy and non-caseating granulomas on biopsy suggests sarcoidosis.
1089. Increased ventilatory rate in patients on mechanical ventilation leads to auto PEEP and it
can be corrected by reducing the ventilatory rate.
1090. In Goodpasture’s blood studies usually show antibodies against the glomerular basement
membrane; it primarily involves the lungs and kidneys.
1091. Remember pneumonia, hyponatremia and diarrhea are almost classic for Legionella.
1092. Know how to manage various clinical situations in exacerbation of chronic obstructive
pulmonary disease.
1093. Learn the practical significance of various tests in predicting the usefulness of lung
resection in a patient with end stage lung disease.
1094. Know the role of beta agonists and mast cell stabilizers in the management of exercise-
induced asthma.
1095. ARDS can present with dyspnea, tachypnea and bilateral fluffy infiltrates on a chest x-ray.
It is a condition where hypoxemia persists and it becomes difficult to oxygenate the patient.
1096. When PEEP is increased, its major drawback is a decrease in cardiac output.
1097. Patients who are maintained on PEEP should be monitored with a Swan-Ganz catheter
1098. In ARDS, the one treatment that can improve oxygenation is the addition of PEEP.
1099. In any patient who presents with a lung lesion on a chest x ray, it is best to get old chest x
rays and compare the lesion. The lesion may have been present for along time and may be
1100. In a young thin male who smokes and suddenly becomes dyspneic with chest pain, think
of pneumothorax.
1101. The most serious complication of bronchiectasis is hemoptysis.
1102. In a patient who has had recent surgery and presents with shortness of breath and
tachycardia, the diagnosis of pulmonary embolus must always be suspected.
1103. The most common cause of superior vena cava syndrome today is bronchogenic
carcinoma. Benign causes of SVCS are rare and relatively easily diagnosed.
1104. In pulmonary embolism, there can be numerous presentations on a chest x-ray, but the
most frequent is a normal x-ray.
1105. IPF is a diagnosis of exclusion. Idiopathic pulmonary fibrosis is best treated with steroids.
Most patients will have a positive response in the first six months but they fail to have sustained
1106. The triad of upper respiratory tract disease, lower respiratory tract disease, and
glomerulonephritis defines Wegener’s granulomatosis. The demonstration of anti neutrophil
cytoplasmic antibodies confirms the diagnosis of Wegener’s granulomatosis. The cytoplasmic
pattern (C-ANCA) is highly specific
1107. Serologic assays for measurement of anti glomerular basement membrane antibodies
further help in confirming the diagnosis and monitoring treatment in patients with Goodpasture’s
1108. Proximal (above knee veins) deep vein thrombosis of lower extremities is the most
frequent source of pulmonary embolism.
1109. Therapeutic INR for most clinical indications of warfarin is 2.0 to 3.0.
1110. Patients with DVT in whom anticoagulation is contraindicated require placement of
inferior vena cava filter for the prevention of pulmonary embolism.
1111. The most common locations of post aspiration lung abscess in recumbent position are
apical segment of right lower lobe and posterior segment of right upper lobe.
1112. If you suspect a pulmonary embolism clinically, and chest-x ray, ABG and EKG results
rule out other differential diagnoses then you should begin treatment with heparin without
waiting for a V/Q scan to confirm your diagnosis.
1113. Two modalities that can decrease mortality in patients with COPD are home oxygen
therapy and smoking cessation.
1114. A lung mass with cartilage is most likely a hamartoma and can be observed.
1115. In a drug abuser, presence of well-circumscribed lung opacity is most likely due to
embolism of infected vegetation causing a pulmonary infarct.
1116. Primary spontaneous pneumothorax which occurs in young males is almost always due to
rupture of subpleural blebs.
1117. In a smoker with arm pain, cough and weight loss, a mass in the lung apex is a Pancoast
tumor until otherwise proven.
1118. Anterior mediastinal mass along with elevated AFP and HCG indicates nonseminomatous
1119. Subcutaneous emphysema in an asthmatic is a benign disorder. A chest-x ray must be
ordered to ensure that there is no pneumothorax.
1120. Adverse effects of low-dose inhaled corticosteroids are limited to topical problems like
dysphonia and thrush. However, systemic toxicity may occur in patients who are on high-dose
inhaled steroids for prolonged periods of time.
1121. Patients with suspected pulmonary embolism should have a chest-x ray and ABG,
followed by EKG and V/Q scan.
1122. An enlarged left atrium in mitral stenosis can cause a persistent cough and elevation of the
left main stem bronchus.
1123. Always consider lung abscess as an etiology of fever and foul- smelling productive cough
in patients predisposed to aspiration.
1124. Electrical alternans is an important EKG finding for diagnosis for pericardial tamponade.
Other findings include sinus tachycardia and low voltage QRS complexes.
1125. Know how to manage a case of CHF exacerbation due to atrial fibrillation with a rapid
response. Digoxin is the drug of first choice in this situation.
1126. The best test to confirm CSF leakage is the β-2-transferrin.
1127. Often ICU and burn unit support is required in patient with Toxic Epidermal Necrolysis
secondary to TMP-SMX.
1128. In an intravenous drug abuser the most frequent cause of skin abscesses is Staphlocccus;
however in users of black-tar heroin, Clostridium is the predominant organism. Crepitus is an
ominous sign suggesting gas forming organisms and deep infections.
1129. In atopic dermatitis keeping the skin moist with the over-the counter skin moisturizers
immediately after bathing/showering is one of the mainstays of therapy.
1130. Liver abscess complicating biliary tract disease is described as “pyogenic” abscess and
require drainage.
1131. The most dreaded consequence of pancreatitis is pancreatic necrosis. The biggest risk
associated with necrosis is superinfection. Necrotic pancreatic tissue is not always superinfected,
and before heroic measures such as surgical debridement are used, the tissue should be sampled.
1132. The most accurate test in patients with a left sided murmur on auscultation is left heart
catheterization and angiography because these test accurately delinates the position and nature of
the vulvular lesion, as well as determining the ejection fraction and left heart pressures.
1133. Panic disorders can be treated with benzodiazepines such as clonazepam
1134. In erysipelas a superficial cellulitis of the skin topical antifungals are applied for upto 2
weeks before clinical cure, and meticulous foot hygiene should be exercised to prevent
recurrences of the fungal infections.
1135. Adrenoleukodystrophy is an X linked disorder characterized by neurologic deficits and
adrenal insufficiency. It is caused by accumulation of very long chain fatty acid esters and
gangliosides in neurons and gangliosides in the neurons and adrenocortical cells.
1136. A step wise management is required for the management of fibromyalgia. According to
this approach, initial therapy includes TCA (amitriptyline) or cyclobenzaprone. If this
management is unsuccessful then addition of SSRIs is recommended.
1137. The most common association of optic neuritis is with a demyelinating disease such as
multiple sclerosis therefore a MRI of the brain should be performed looking for multiple white
1138. For patients with pneumonia whoa re admitted to the general medical ward the drug of
choice is IV β-lactam ( cefotaxime, ceftriaxone, ampi-sulbactum) this will cover atypical
pneumonia- mycoplasma, Chlamydia, and legionella. The newer qunilones such as gatifloxacin
are the other options for empiric therapy of pneumonia.
1139. In acute angle closure glaucoma the trabecular meshwork becomes blocked at the
iridocorneal junction. The iris then creates a block at the border of the lens, obstructing transit
and removal of vitreous fluid and rapidly increasing intraocular pressure. Definitive treatment is
1140. In a parotid tumor only a formal parotidectomy can provide complete removal with
permanent cure and sparing of facial nerve.
1141. A recommended age appropriate screening is that atleast every 5 years a random
cholesterol level should be checked. A fasting lipid profile is checked only if the screening test
shows a cholesterol of > 240mg/dl
1142. Sinus tachycardia is the most common ECG change seen in PE.
1143. The tidal volume for a person is calculated as 10mL/kg of weight.
1144. Multiple myeloma results in hypercalcemia which is associated with apathy, decreased
interest, psychomotor retardation and depression.
1145. Ulcerative colitis confined to the distal colon also known as proctosigmoiditis. Since the
disease is limited to the distal colon topical mesalamine is effective.
1146. Multiple endocrine neoplasia I is associated with gastrinomas, gastrin levels are often
elevated and it should be the first test to evaluate. Gastrin producing cells are functionally part of
endocrine cells.
1147. Type 1 autoimmune hepatitis is characterized by female predominance, extra hepatic
autoimmune disease, hypergammaglobulinemia and positive ANA and ASMA. This disease
usually responds to low dose steroids, or a combination of steroid and azathioprine.
1148. The appropriate treatment for Mycoplasma Pneumonia is oral doxycycline.
1149. The most common congenital vulvular disease is mitral valve proplase.
1150. Dopamine blocking and depleting agents are effective in decreasing the involuntary
movements of Huntington’s disease. Haloperidol is a dopamine receptor blocker and is
commonly used for control of chorea in Huntington disease. There is no specific treatment for
Huntington disease.
1151. The diagnosis of a urethral stricture can be made with a combination of direct visualization
and radiography. A retrograde urethrogram is performed by injecting dye through a catheter
placed just inside the tip of the penis, such that the urethra is outlined with radio-opaque contrast.
1152. Patients with a pulmonary embolus need prolong (6 months) of anticoagulant therapy.
1153. Primary biliary cirrhosis is associated with RA, Sjogren’s syndrome and scleroderma.
1154. Statins are associated with a 1-2 % incidence of marked persistent increase in transminases
which resolves with statin discontinuation. It is recommeded that liver transaminases be tested at
intitation of therapy at 6 and 12 weeks and periodically thereafter.
1155. For comedones the topical preparation are effective: benzoyl peroxide gels, retinoic acid,
adapelene, and topical antibiotics.
1156. For mild papulopustular disease, use topical gel preparation of benzoyl peroxide combined
with a topical antibiotic or an oral antibiotic with a topical retionoid.
1157. For severe papulopustular disease, use of an oral antibiotic with a topical retinoid;and for
nodulocystic that had not responded, consider isotretinoin.
1158. When a patient presents with a history of acute coronary syndrome, the next step will be
aspirin regardless of whether it is NSTEMI, STEMI or unstable angina. Early administration of
aspirin has shown to have a statistically significant decrease in mortality in those patients
presenting with a history of acute coronary syndrome.
1159. Pseudocyst may be asymptomatic or they may be infected or exert a mass effect on
surrounding structures such as the portal vessels, the GI tract, or the biliary tree. If any of these
complication occur drainage of pseudocyst is warranted.
1160. Shortness of breath is the most common presentation for those patients HOCM because of
decreased compliance, decreased end diastolic volume and back pressure to the lungs.
1161. The most common cause of type 1 diabetes is autoantibidy production against pancreatic
antibodies such as glutamic acid antobodies. These antibodies are present in over 70% of the
patient and can be used to help confirm the mechanism of disease in unclear cases.
1162. An infected pleural effusion or empyema can only be determined from a thoracocentesis.
1163. An acute exacerbation of chronic bronchitis in a patient with COPD that result from S.
Pneumonia and M. Catarrhalis should be treated with amoxicillin/clavunlate.
1164. Only when the patient is at term (36-38 weeks) should the cerclage be removed.
1165. Ganglion cyst is a cystic swelling on the dorsal aspect of the wrist and are usually attached
to tendon sheath and joint capsule.
1166. Serotonergic can develop with concomitant use of MAO inhibitor and serotonergic agents,
or if there has been a too short a period of wash out in crossing over from one agent to other.
Atleast 10 days after MAO discontinuation and 5 weeks after discontinuation of fluoxetine
should pass to avoid possible complication.
1167. In water intoxication, movement of water across the cellular membrane is passive and
follows a tonicity gradient.
1168. MRI with gadolinium is considered the most effective test for detecting microadenoma.
The test can reveal microadenoma in 20% of normal women.
1169. Spontaneous bacterial peritonitis should be suspected in all patients with ascites, mild,
diffuse abdominal pain, altered mental status, and low grade fever.
1170. Cerebral venography is the most effective method to identify the cerebral veins and dural
1171. The current recommendation of ACOG is that cesarean section is recommended for all
women with genital herpes lesions or symptoms. Some studies have shown that administration of
acyclovir to pregnant with a history of herpes outbreak during pregnancy can decrease the
likelihood of the women developing the outbreak and hence the need for cesarean section.
1172. In suspected CML, bcr;abl gene may be detected in the peripheral blood with the PCR; this
is now done over cytogenetic studies.
1173. In incomplete abortion, the cervix is dilated; there is incomplete evacuation of the
conceptus with fragments retained in the uterine cavity.
1174. Abrupt onset of hypoxia with respiratory failure, cardiogenic shock, DIC, in a patient who
has undergone amniocentesis or delivered, is most likely due to amniotic fluid embolism.
Respiratory support is always the first step in the management.
1175. In chlamydial infection, empiric treatment of gonorrhea is not recommended, but in
gonorrheal infection empiric therapy therapy of Chlamydia is recommended. A single dose of
azithromycin is the treatment of choice for genital Chlamydial infection. 7 days of doxycycline
can also be used for Chlamydia but because of the compliance issue single dose azithromycin is
1176. All patients who take metronidazole should abstain from drinking alcohol, as it is
associated with disulfiram like reaction.
1177. A menstrual diary of atleast 3 cycles is a useful aid for confirming the diagnosis in a
suspected case of premenstrual syndrome.
1178. OC pills are the first line agents in the treatment of endometriosis in young women
desiring future pregnancies.
1179. Semen analysis is a simple test that helps to identify male factor as the cause of infertility.
Semen analysis should be performed early in the evaluation of the infertile couple, usually as a
screening test.
1180. A child’s blood group frequently differs from the mother’s blood group, but this fact does
not create a potential for alloimmunization-related fetal damage. Antibodies to ABO antigens
belong to the IgM class and do not cross the placenta.
1181. Fetal alcohol syndrome presents with IUGR, microcephaly and facial dysmorphology,
which involves midfacial hypoplasia, micrognathia, flattened philtrum, microphthalmia, short
palpebral fissure, and thin vermillion border of the upper lip.
1182. BPP score of 39 C, nausea and vomiting and signs of ileus) adolescent, nulliparous, wome
with low socio-economic status and women who fail to respond to oral antibiotic therapy. It is
most commonly caused by N.gonorrhea, C.trachomatis and genital mycoplasma. In hospitalized
regimes include cefoxitin/ doxycycline, cefotetan/doxycycline and clindamycin/gentamycin.
1207. In case of post term pregnancy (42-43 weeks), the NST and BPP should be performed
twice weekly and if there is oligohydramnios or if spontaneous decelerations are noted, delivery
has to be accomplished.
1208. ZDV is administered orally during pregnancy after first trimester, intravenously during
labor and delivery, orally to the neonate for the first 6 weeks of life.
1209. Major complication of ovulation induction are OHSS and multiple gestation. Symptoms of
Ovarian Hyper Stimulation Syndrome include abdominal pain, abdominal distention, nausea,
vomiting, diarrhea, weight gain, hypotension and pleural effusion. OHSS may be complicated
with ovarian torsion, ovarian rupture, thrombophlebitis and renal insufficiency. Treatment is
1210. Lupus anticoagulant seen in SLE patients leads to recurrent abortion and thromboembolic
1211. Metformin is indicated in PCOD with impaired glucose tolerance. It helps in preventing
type 2 diabetes mellitus and correcting obesity, hirsutism, menstrual irregularity, and infertility.
1212. A search should be undertaken to determine the cause after the first episode of intrauterine
fetal demise.
1213. If Pap smear reveals a dysplasia, perform colposcopy. If it reveals an inflammatory atypia
(ASCUS) repeat after 4-6 months.
1214. Hypertrophic dystrophy of vulva is most commonly seen in postmenopausal women and is
treated with local application of 1% corticosteroid ointment three times a day for 6 weeks.
Hyperplastic dystrophy cannot be distinguished clinically from cancer of the vulva and biopsy is
therefore required every time the diagnosis is suspected.
1215. In severe preeclampsia, the patient has to be evaluated and stabilized before management
decisions are made. Bed rest and salt reduced diets are mandatory; patient with BP >160/110 mm
Hg necessitates antihypertensive therapy. If the response to treatment is prompt and the patient is
stabilized, the decision will then depend on term; if the patient is at term or fetal lungs are
mature, delivery must be done. In the opposite case, delivery can be delayed until 34 weeks’
gestation or until fetal lungs become mature.
1216. Amenorrhea during lactation is due to high levels of prolactin, which have an inhibitory
effect on the production of the hypothalamic hormone GnRH, preventing ovulation.
1217. The classic presentation of acute abruption placenta includes vaginal bleeding, abdominal
pain, uterine contractions and uterine tenderness. The absence of hemorrhage does not rule out
this condition because retroplacental bleeding may be concealed.
1218. Think of trichotillomania in patients with uncontrollable urges to pull out their hair,
resulting in alopecic patches.
1219. Tubo-ovarian abscesses are usually managed with triple antibiotic therapy. Drainage is
indicated if there is no antibiotic therapy after 24-48 hours.
1220. Vaginismus is managed with kegel exercise and gradual dilatation.
1221. In the case of amenorrhea-hyperprolactinemia first rule out hypothyroidism by measuring
serum TSH.
1222. Ectopic pregnancy should be suspected in any patient of child bearing age, presenting with
a triad of amenorrhea, abdominal pain and vaginal bleeding.
1223. Patients with endometriosis present with dysmenorrhea, dyspareunia, dyschezia and the
physical examination shows tender adnexal mass and firm nodularity located in the broad
ligament, the uterosacral ligament, or in the cul-de-sac.
1224. Prolactin production is stimulated by serotonin and TRH and inhibited by dopamine.
Hypothyroidism may result in amennorhea and galactorrhea.
1225. Infertility in premature ovarian failure is treated with egg donation.
1226. The peritoneal factor is the most common cause of female infertility.
1227. The risk factors include: thin body habitus, smoking, alcohol intake, steroid use,
menopause, malnutrition, family history of osteoporosis, and asian and Caucasian race.
1228. The most commonly used regimen for emergency contraception is a combination of
ethinyl estradiol and norgesterol: 2 tablets taken within 72 hoursof intercourse, and 2 other 12
hours later.
1229. Treatment of luteal phase defect is first attempted with progesterone supplement;
clomiphene citrate or hMG can be tried if progesterone gives no results.
1230. The treatment of choice for bacterial vaginosis in a pregnant ladi is clindamycin cream or
1231. The major source of estrogen in menopausal women is from the peripheral conversion of
adrenal androgens by fat tissues.
1232. Abdominal pain in a young female in the middle of her cycle with a benign history and
clinical examination is most likely Mittelschmerz.
1233. Vulvar papillomatosis, or condylomata acuminate, are genital lesions caused by HPV 6
and 11. Condylomas present as exophytic lesions with a raised papillamatous or spiked surface
and may grow into large and cauliflower-like formations.
1234. The chancre of primary syphilis is painless, indurated ulceration with a punched out base
and rolled out edge.
1235. Behcet’s disease is a rare multisystem disorder with an autoimmune etiology and manifests
with recurrent ulceration in the mouth and genital area associated with uveitis.
1236. In presence of antepartum hemorrhage pelvic examination must not be done before ruling
out placenta previa.
1237. Uterine rupture presents with an intense abdominal pain associated with vaginal bleeding
which can range from spotting to massive hemorrhage.
1238. Fetal hydantoin syndrome can present with a small body size with microcephaly,
hypoplasia of the distal phalanx of the fingers and toe, nasal hypoplasia, low nasal bridge, cleft
palate and rib anomalies.
1239. Most of the breech presentation assumes cephalic presentation by 36 weeks.
1240. The most appropriate test to confirm the diagnosis of IUFD is real time sonography.
1241. The most common cause of abnormal serum Alfa-feto protein is gestational –age error.
1242. Screening cultures for GBS should be performed at 36-37 weeks gestation, and positive
cases should be treated with Penicillin G during labor, even in absence of frank chorioamnionitis.