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 NOTES FOR STEP 3

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rock82



Posts : 101
Points : 212
Join date : 2009-06-11
Age : 33
Location : Jalandhar

PostSubject: NOTES FOR STEP 3   Fri Jun 12, 2009 11:46 am

1. Gastroparesis (DM) Rx = metoclopramide,erythromycin; symptoms: post-prandial fullness,hypoglycemia, sweating, dizziness, constipation

2. Drugs that lead to hypercalcemia = thiazides,lithium

3. Calcium greater than 12 or symptoms = NSS IV 3-6 l in 24 h, furosemide if necessary

4. Hungry bones syndrome = hypocalcemia post opremoval of parathyroid adenoma

5. Sarcoidosis = increase in vit D levels

6. Familial hypocalciuric hypercalcemia = low 24 h urine calcium

7. Chronic thyroiditis (Hashimoto) = antimicrosomalantibodies

8. Drugs that lead to hypothyroidism = lithium, ASA

9. Large nodule (cold) in multinodular goiter (hot) =FNA; if follicular elements = excision

10. Psammoma bodies = papillary carcinoma of thyroid = MC type of thyroid cancer, RF radiation exposure, lymphatic spread

11. Thyroid cancer types = papillary, follicular (hematogenic spread), anaplastic, medullary (MEN); painful, low uptake, increased ESR

12. Graves disease Rx = bring the patient to euthyroid stae, then: radioactive iodine, steroids for ophtalmopathy

13. Plummer disease = long-standing multinodular goiters that become thyrotoxic later

14. Thyroiditis = low 24 h radioactive iodine uptake

15. Graves disease Dx = increased thyroid, "hot", proptosis, positive TSH Ig

16. Nitroblue tetrazolium test = chronic granulomatous disease; tets phagocyte fuction, oxidative burst

17. Cellular deficiency disease = fatal infections after receiving live viral vaccines (MMR, varicella)

18. Ab deficiency disease = encapsulated organisms, sino=pulmonary bacterian infections, sepsis

19. Phagocytic deficiency disease = recurrent abcesses, lymphadenitis, periodontal infections, Gram negatives, catalase positives, e.g. CGD, Chédiak-Higashi

20. Complement deficiency dis = C2-C4: autoimmune dis; terminal: Neisseria; C3: encapsulated, unusual strains

21. Severe combined immunodeficiency = first year of life, decrease in T and B cells

22. Ig A deficiency = MC primary immune deficiency, major anaphylatic reaction to blood products

23. X-linked hypogammaglobulinemia Rx = IV Ig; defect in tyrosine kinase

24. X-linked lymphoproliferative disease = catastrophic after EBV infection

25. Chronic granulomatous disease = decreased intracelular and fungal killing; S. aureus, Aspergillus; Rx: prophylatic antibiotics (TMP/SMX, doxycycline), interferon gamma; vaccinate: Haemophilus, Pneumoccocus, Neisseria, viral vaccines

26. T-cell deficiency Rx = bone marrow transplant

27. Transfusion in cellular deficient patient = irradiated, leukodepleted, virus free product

28. C3 deficiency = increased number of pyogenic infections

29. Properidin and C5 deficiency = increased Neisseria infections

30. C1 inhibitor deficiency = hereditary angioedema

31. Decay accelerating factor deficiency = paroxysmal nocturnal hemoglobinuria

32. Clomiphene citrate use = ovulation induction (for patients with good estrogen production, such as in OPCD)

33. Pregnancy = increase in alkaline phosphatase does not indicate disease necessarily, may be normal finding

34. Primary hypothyroidism = may lead to increase in pituitary, amenorrhea, galactorrhea

35. Meconium ileus suspicion = barium enema

36. Cystic fibrosis tests = sweat test, nasal potential testing

37. Hepatitis B mother = breastfeed is OK!

38. Graves in pregnancy Rx = propylthiouracil

39. Cocaine use in pregnancy = placental abruption

40. Clue cells = bacterial vaginosis; Rx = metronidazole - counsel not to drink alcohol because of disulfiram-like reaction

41. Pruritic urticarial papules and plaques of pregnancy = third trimester

42. RF for ectopic pregnancy = age, PID, salpingitis, more than 3 pregnancies

43. Testicular feminization = dysfunction or absence of testosterone receptors; patient is XY, normal breast development, scant pubic and axilar hair, blind vagina, undescendent testicles, may be felt on the groin.

44. fever greater than 38 C in less than 4 m.o. = admission, IV antibiotics, full evaluation, multiple cultures

45. Pyloric stenosis = non-bilious emesis, midepigastric olive: Dx = USG; RF = erythromycin use

46. MCC of jaundice in pregnancy = viral hepatitis

47. Symptomatic biliary stones = pregnancy Rx = laparoscopic cholecystectomy

48. Asymptomatic biliary stones Rx = none

49. N. gonorrhea = Gram negative diplococci; Rx = ceftriaxone + azithromycin (to cover Chlamydia, which generally is there too); notify publc health authorities

50. Trichomonas vaginalis = motile flagellated microorganisms in vaginal wet mount
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rock82



Posts : 101
Points : 212
Join date : 2009-06-11
Age : 33
Location : Jalandhar

PostSubject: NOTES FOR STEP 3   Fri Jun 12, 2009 11:47 am

51. Low grade squamous intraepithelial lesion (cervix) = CIN I; Rx = rescreen in 4-6 months

52. Abnormal vaginal bleeding in woman older than 35 yo next step = office endometrial pipelle biopsy

53. Small subchorionic henorrhage Rx = clinical and USG observation

54. Menorrhagis, anovulatory bleeding = order a TSH!

55. Group B strep prophylaxis = penicillin or ampicillin to mother during active labor, CBC and blood culture on the newborn

56. Low plasma bicarbonate causes = diarthea, renal tubular acidosis

57. Erythema infectiosum = not contagiuos during the rash (slapped face, lacy), only before it

58. Bleeding in pregnancy = order bood type, Rh, atypical antibodies

59. Bilious vomiting in infant = think malrotation with volvulus; if no peritoneal signs, flexible sigmoidoscopy is diagnostic and treatment at the
same time

60. Bilious vomiting in newborn = remember the 3 Ds: duodenal atresia, double bubble on abd XR, greater incidence in Down's syndrome

61. Side effects of MgSo4 use for the NB: meconium plug syndrome; in this case, contrast enema is both diagnostic and curative

62. Polythelia = accessory nipple

63. Polymastia = extraglandular breast tissue

64. Hugh grade intraepithelial lesion (cervix) management = colposcopy + endocervical curetage + biopsy

65. Following a molar pregnancy = contraceptives for 1 year, monitor beta HCG, if it goes up, it could be choriocarcinoma

66. Fetal alcohol syndrome = cardiac malformation (VSD), CNS abnormalities, face deformities

67. Tuboovarian abscess Rx = IV atbtcs; surgery only if necessary - it's one of the few cases of abscess that are cured without incision!

68. Prostate cancer Dx = USG guided needle biopsy with 6-12 specimens

69. Metastatic prostate cancer Rx = GnRh agonists (flutamide), orchiectomy + chemo

70. Staging for testicular cancer = serum LDH, AFP, beta HCG, CT chest/abd/pelvis; Rx = radical inguinal orchiectomy + spermatic cord ligation

71. MC sites of melanoma = trunk for men, legs for women

72. Basophilic palisiding cells, pearl apperance, upper 1/3 of the face = basal cell ca (the MC skin ca)

73. Moh's micrographic surgery = for squamous cell ca (lower 1/3 of the face), makes 1-2 mm margins

74. MCC of encephalitis in adults = HSV; meningeal signs + focal neurological signs, temporal lobe changes on CT; Rx = IV Acyclovir 14-21 days

75. Listeria monocytogenes meningitis Rx = ampicillin; NB, elderly

76. Chronic sinusitis = longer than 3 months; clinical Dx, but if something is going to be ordered = CT sinus; Rx = amoxicillin +/- clavulanate +/-
clindamycin for 21 days, nasal steroid sprays, endoscopic surgery if necessary

77. Otitis media, ac. sinusitis Rx = TMP/SMX or amoxicillin +/- clavulanate

78. Otitis externa Rx = topical ofloxacin with steroids; remember to clean the ear before applying the Rx; Pseudomonas, swimmers

79. Chr carriers of group A strep Rx = clindamycin

80. Smoker with pneumonia, diarrhea, increased LDH = think Legionella; Dx = urine Ag; Rx = doxycycline

81. Cystic fibrosis pneumonia Rx = IV ceftazidime + IV levofloxacine = IV aminoglycoside; MCC = Pseudomonas

82. Aspiration pneumonia Rx = IV ceftriaxone + IV azythromycin + IV clindamycin; chronic, not presentiated, RF positive

83. Aspiration pneumonitis = acute event, presentiated by somebody, no need for atbtcs

84. PCP pneumonia Dx = silver stain of sputum, bronchial lavage; Rx = IV TMP/SMX or inhaled pentamidine, add prednisone if: PaO2 less than 70 or A-a gradient more than 35

85. TB Rx = RIPE for 8 w., then INH + rifampin for 16 w. more

86. Add vit. B6 for INH

87. Keep an eye on uric acid for Pyrazinamide

88. Order ophtalmologic avaliation for Ethambutol

89. Latent TB Rx = nine months of INH (+ B6)

90. TB + HIV = use Rifabutin instead of Rifampin because of possible drug interaction

91. Ac. prostatitis Rx = TMP/SMX or fluoroquinolone for 14 d

92. Chr prostatitis Rx = fluoroquinolone 1 m. or TMP/SMX 3 m.

93. Primary/secondary syphilis Rx = Penicillin G 2.4 million U IM; if disease present for more than 1 year = three doses with 1 w. intervals; notify health department

94. Neurosyphilis Rx = Penicillin G IV for 14 days

95. DM Dx = random glucose test >200 + symptoms OR twice fasting glucose > 126 OR 75 GTT > 200 at 2 h. OR 50 g GTT > 146 at 2 h

96. Annual influenza vaccine = patients older than 50 yo, healthcare workers

97. OCPs = decrease risk for gonococcal PID

98. Osteoporosis Rx with drugs, not only calcium is indicated when = T-score < 1.5 OR < 2.5 + RF

99. Dual X-ray absorptiometry (DEXA) T-score = compared to young adults

100. DEXA z-score = compared to age and race matched population
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rock82



Posts : 101
Points : 212
Join date : 2009-06-11
Age : 33
Location : Jalandhar

PostSubject: NOTES FOR STEP 3   Fri Jun 12, 2009 11:48 am

101. Elderly + fall = do a home safety evaluation, avoid narcotics

102. Woman sexually active, younger than 25 yo or with RF = screen for Chlamydia

103. HTN Dx = 3 separate readings with increased BP

104. Post exposure TB prophylaxis = 2 drugs chosen according to bug susceptibility

105. Smallpox Rx = Cidofovir

106. Anthrax Rx and prophylaxis = ciprofloxacin (adults), penicillin (children)

107. Household with children = water heater < 120- 130 F

108. Pneumococcal vaccine = q5 y for >50 yo with chr disease

109. Td vaccine = q10 y or once at age 50 yo

110. woman with relative with breast ca = mammogram 10 y before the affected person age + self breast examination

111. Men with relative with prostate cancer = annual PSA + DRE after 40 yo

112. Bipolar I = Hx of mania; major depression + or -

113. Bipolar II = Hx of hypomania + major depression; NO mania

114. Autism suspicion = order a hearing test before saying it is!

115. Gingko biloba + warfarin = increased risk of bleeding

116. 1 yo vaccines = Hib, MMR, varicella, PCV

117. Adopted foreign child = serology hep B, C, HIV, syphilis, PPD, stool tests

118. HIV + CD4 , 200 = TMP/SMX prophylatic for PCP pneumonia

119. Pediculosis, scabies Rx = permethrin lotion; in scabies: treat all household members

120. Necrotizing infection + DM Rx = X-ray, OR for debridement, amputation if needed

121. Infection in CRF + indwelling catheter Rx = vancomycin + gentamycin

122. Tinea versicolor Rx = topical ketoconazole

123. Waterhouse-Friderichsen syndrome = adrenal infarction after/during meningococcal meningits, decreased cortisol level

124. Postherpetic neuralgia Rx = amitriptiline

125. Mononucleosis = leukopenia with atypical lymphocytes, heterophile Abs

126. Bacteremia in a baby Rx = ampicillin + cefotaxime; covering group B strep, Listeria, E. coli

127. Hep. B window period = surface Ag and Ab negative (they cancel each other), Dx may be made through core Ag IgM Ab +

128. Rat bite fever Rx = penicillin G or tetracycline

129. HUS = ac. renal failure + anemia + thrombocytopenia; E. coli 0157:H7, raw meat

130. Tinea pedis Rx = topical antifungal for 2-3 w, if not gone = oral griseofulvin 6-8 w

131. Invasive aspergillosis = multiple bilateral lung nodules with surrounding hemorrhages

132. Post chemo fever Rx = hospitalize, broad spectrum atbtcs, antifungal if no response

133. HPV infection Dx when lesions not apparent = apply vinegar to the region

134. Cat scratch disease Dx = lymph node biopsy; treat only if = bact superinfection (S. aureus), encephalitis

135. Ac. post-infectious cerebellar ataxia = post varicella infection or vaccine; differential = poisoning

136. Fever + neutropenia Rx = antipseudomonal third generation cephalosporin OR antipseudomonal penicillin + aminoglycoside

137. First generation cephalosporin = cefadroxil, cefalexin, cefalotin, cefazolin

138. Second generation = cefaclor, cefuroxime; antianaerobe: cefotetan, cefoxitin

139. Thrid generation = cefixime, cefotaxime; antipseudomonal: cefoperazone, ceftazidime

140. Herpes zoster Rx = acyclovir

141. Crush injuries Rx = copious alkalinized IV crystaloid (for renal protection)

142. Exertional heat stroke = may lead to DIC and rhabdomyolysis; Rx = ice water, cold wet sheets + fan

143. Ecstasy intoxication = may lead to rhabdomyolisis

144. Ac. ethanol withdrawal Rx = chlordiazepoxide

145. Edrophonium = acetylcholinesterase inhibitor

146. Organophosphate poisoning Rx = atropine, pralidomide

147. Ac. tubular necrosis due to contrast prophylaxis = hidration, acetylcysteine

148. Avoid/suspend metformin use before tests with, IV contrast (for renal protection)

149. Opioid intoxication = miosis, resp. depression, coma, hypotension, bradycardia; Rx = naloxone

150. Severe dehydration in elderly = may lead to ac. suppurative parotitis by S. aureus; Rx = IV hidration, sialogogues, atbtcs; surgical drainage if not better in 12 h
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rock82



Posts : 101
Points : 212
Join date : 2009-06-11
Age : 33
Location : Jalandhar

PostSubject: NOTES FOR STEP 3   Fri Jun 12, 2009 11:48 am

151. Intoxicated patient = impossible to clear cervical spine because you need to have patient communicating symptoms to do it

152. Priapism causes = TPN, sickle cell disease, crack/cocaine, trauma, spinal or general anesthesia,trazodone, leukemia

153. Alcohol withdrawal = happens in hours to 10 days

154. Urinary retention causes = BPH, prostate ca, prostatitis, urethral stricture, meds, blood clots

155. Cyanide toxicity (nitroprusside) Rx = sodium thiosulfate

156. Gallbladder rupture suspicion = exploratory laparotomy

157. Compartment syndrome signs = most sensitive is loss of DTRs, most ominous is loss of pulse; 6 Ps = pallor, pain, paralysis, paresthesia, pulselessness, poikilothermia

158. Hyperkalemia + EKG changes Rx = calcium gluconate

159. Motor vehicle accident with seat belt in place = may cause pancreatic fracture = order a CT scan with IV contrast

160. Carboxy hemoglobin level > 40% (>15% in pregnancy) Rx = hyperbaric O2 therapy

161. Methylene chloride (paint remover) intox. = carbon monoxide poisoning; use co-oxymeter

162. Methemoglobinemia Rx = Methylene blue

163. IV epinephrine = Rx of pulseless VT or VF (post eletric cardioversion try), not for hypovolemia

164. PCP intoxication = aggression, ac. psychosis, ataxia, violence, nystagmus, suicide, fever, hypersalivation, hyperacusis

165. QRS amplitude alternance = cardiac tamponade

166. ERCP complications = ac. pancreatitis, infected pancreatic pseudocyst formation, cholangitis, perforation

167. Disrupted/transected urethra suspicion next step = retrograde urethrogram; blood at meatus + high riding prostate

168. Leaking CSF (ears) = cribiform fracture = blind nasogastric or nasal intubations are contraindicated!

169. Femoral canal = NAVEL from lat. to medial

170. Radial head fracture (outstretched hand, Cole's fracture) Rx = sling 2-3 days, early exercises

171. Wound dehiscence = new onset serous discharge

172. CXR in pneumothorax = at maximal expiration

173. Compartment syndrome suspicion = measure compartment pressures, emergent fasciotomy if confirmed

174. In burn patients, succinylcholine use is contraindicated due to the risk of hyperkalemia

175. Thioridazine S. E. = prolonged QT

176. Diuretic for sulfa alergic patients = etacrinic acid

177. Anabolic steroids S. E. testicular atrophy, liver disease, gynecomastia, impotence

178. Concussion = head trauma + transient LOC + short amnesia, may have not serious late symptoms up to 6 m. later

179. Increased ICP first steps in management = intubation + hyperventilation

180. Lumbar puncture headache = positional, within 24 h.

181. Anterior spinal arterial occlusion = decreased motor function, decreased sensation, decreased pinprick, preserved proprioception

182. AST = less specific for liver than ALT; increased in alcoholic liver injury

183. Ketorolac = NSAID, IV, used in testicular torsion; S.E. = gastric ulceration, GI bleeding

184. Human bite Rx = ampicillin-sulbactam OR TMP/SMX + clindamycin; if HIV involved = don't worry, it doesn't get transmitted by bite (yet!)

185. Methanol toxicity = vision changes; order: ABG, electrolytes, osmolality; Rx = IV ethanol, dyalisis

186. Amytriptiline S.E. = constipation, ac. glaucoma, urinary retention, dry mouth, paralytic ileus; but the worst event in intoxication = cardiac arrhythmias
187. Electromyography = checks nerve and muscle integrity

188. Evoked potential studies = monitor transmission of motor impulses in the anterior columns of spinal cord

189. JC virus + HIV Rx = HAART

190. JC virus causes = progressive multifocal leukoencephalopathy

191. Epididimoorchitis Rx = Doxycycline 100 mg PO bid for 10 d + ceftriaxone 250 mg IM

192. HTN + BPH Rx = terazosin, doxazosin

193. Increase in AFP = embryonal, yolk sac elements (nonseminomas)

194. Increase in HCG = seminomas and nonseminomas

195. Hydrocele = Dx with USG, no Rx required

196. Metastatic prostate ca Rx = leuprolide, goserelin OR bilateral orchiectomy

197. Priapism etiology = idiopathic (60%), leukemia, sickle cell dis, pelvic tu and infections

198. PSA > 4 next step = prostate biopsy

199. Chancroid = Haemophilus ducreyi, painful, unilateral lymphadenopathy, lesion with purulent base; Rx = ceftriaxone, azithromycin

200. Granuloma inguinale = C. granulomatis, painless, beefy-red lesion; Rx = TMP/SMX I love you
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rock82



Posts : 101
Points : 212
Join date : 2009-06-11
Age : 33
Location : Jalandhar

PostSubject: NOTES FOR STEP 3   Fri Jun 12, 2009 11:48 am

201. Lymphogranuloma venereum = Chlamydia trachomatis, herpetiform vesicle with erosion, bilateral suppurative lymphadenopathy; Rx = doxycycline

202. Syphillis = Treponema pallidum, painless papula with clear, clean base, nontender, nonsuppurative lymphademopathy; Dx = RPR, VDRL, dark field mycroscopy; Rx = penicillin, doxycycline, erythromycin; notify health authorities

203. Hematospermia with normal PE and labs = observation and reassurance

204. Tertiary syphilis = not contagious

205. HAART indications = symptomatic HIV, CD4 < 200, pregnancy

206. CD4 < 200 = PCP prophylaxis = TMP/SMX, dapsone or atovaquone

207. CD4 < 50 = MAI prophylaxis = azithromycin weekly

208. Toxo Ig G + and CD4 < 100 = TMP/SMX OR dapsone + pyrimethamine + leucovorin

209. TB contact OR PPD > 5 mm + HIV = INH + vit B6 for 9 m.

210. HIV Dx = vaccines to be given = pneumococcal q 5 y., influenza q 1 y., hepatitis B

211. Mefloquine S.E. = bradycardia, neuropsychiatric symptoms, prolonged QT

212. NB of woman with SLE may have = congenital CHB

213. Chronic fatigue syndrome = fatigue + cognitive changes for 1 y. or more; infectious basis: virus, Chlamydia pneumoniae

214. Fibromyalgia = pain, tender points (11 of 18 ), sleep changes, psychological distress, allodynia, more than 3 m., realated to SLE, RA

215. Allodynia = even gentle touch is unpleasant

216. Avascular necrosis of femoral head causes = pancreatitis, alcoholism, fat embolus, sickle cell anemia, air emboli, steroids; Dx = MRI, SPECT

217. Idiopathic AVN = Legg-Calve-Perthes disease

218. AVN Rx = avoidance of activity, taper steroid

219. Pyogenic granuloma Rx = shave, electrodesiccate base, send it to pathology evaluation

220. Amelanotic melanoma = It can resemble pyogenic granuloma clinically

221. Temporomandibular joint disease = orofacial pain, noisy joint, restricted jaw function; Dx = MRI

222. Complication of hand/wrist trauma = AVN of scaphoid (navicular) bone

223. Osler-Weber-Wendu = hereditary hemorrhagic telangiectasia = epistaxis, GI bleeding, polycystic kydneys

224. Von-Hippel-Lindau dis.= cavernous hemangiomas, hemangioblastomas in CNS, retina, renal cell ca

225. Sturge Weber syndrome = facial port wine stain, seizure, ocular changes

226. Caplan syndrome = rheumatoid nodules in the lings

227. Felty syndrome = splenomegaly + neutropenia in severe R.A.

228. Tuberous sclerosis = ash leaf macules (hypopigmented), calcified intracranial nodules, epilepsy, low inteligence, adenoma sebaceum

229. Leser-Trelat sign = multiple pruritic seborrheic keratosis associated with internal malignancy

230. Polymyalgia rheumatica = very high ESR; Rx = low dose corticoids; keep an eye open for possible temporal arteritis

231. Vitiligo Rx = topical sterois, phototherapy

232. Porphyria cutanea tarda = blistering in a sun exposed area + milia; Dx = urine prophirin level + hepatitis panel

233. Dermatitis herpetiformis = chr. pruritic papulovesicular lesions on extensor surfaces, post. hairline; Rx = dapsone

234. Pemphigus vulgaris Rx = immediate high dose corticosteroids

235. Hypertensive urgency = the goal is to decrease the diastolic BP to about 100-105 mmHg within a period of 2-6 hours

236. Avoid nitroprusside infusion for more than 48 h (it may lead to cyanide toxicity)

237. Hypert. urg. in pregnancy Rx = hydralazine, labetalol

238. In pheochromocytoma, serotonin syndrome, cocaine use = IV phentolamine

239. In aortic dissection = nitroprusside + labetalol/metoprolol

240. Joint replacement in osteoarthritis indications = refractory pain, functional limit, inability for ADLs

241. Alendronate (Fosamax) S.E. = esophageal irritation, ulceration and it has to be taken with an empty stomach, so always counsel the patient to take it in the morning and sit or stand upright for 30 minutes

242. Achantosis nigricans = DM, hypothyroidism, Cushing's, Addison's, malignancy

243. Kaposi's sarcoma = vascular tu, purplish lesions, extravasation of erythrocytes

244. MCC of alergic contact dermatitis = nickel

245. Methotrexate, azathioprine, chloroquine, etanercept, infliximab = disease modifying antirheumatic drugs

246. Lumbar stenosis = pseudoclaudication, worse with hyperextending movements, better with leaning forward, normal ankle-brachial index; Dx = MRI of the lumbar spine

247. Knee ligament injury Dx = MRI

248. PNH = GPI anchor prot defic. = hemolytic anemia + pancytopenia + venous thrombosis (e.g. hepatic)

249. PNH Dx = flow cytometry, HAM test

250. PNH labs = increased LDH, reticulocyte, decreased or negative haptoglobin, hemosiderinuria, hemoglobinuria
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Posts : 101
Points : 212
Join date : 2009-06-11
Age : 33
Location : Jalandhar

PostSubject: NOTES FOR STEP 3   Fri Jun 12, 2009 11:49 am

251. PNH Rx = iron, folic acid, transfusion, corticoids, eculizumab

252. Erythema nodosum Rx = NSAIDs

253. Back pain MRI indications = spinal stenosis, osteomyelitis, epidural abscess, post trauma

254. Down syndrome = should NOt participate in contact sports

255. Fracture on landing on feet = calcaneum, spine, acetabulum, post. hip dislocation

256. Melanoma suspicion = excisional biopsy

257. Osgood-Schlatter dis. = apophysitis of tibial tuberosity; Rx = decrease physical activity

258. Rotator cuff tear = weakness, instability; Dx = MRI; Rx = arthroscopic repair

259. Slipped capital femoral epiphysis = Dx = X-ray; Rx = fixation of epiphysis with long screws

260. Iliotibial band syndr. = pain in lat. aspect of knee

261. Axillary adenopathy in woman = mammography

262. Supraclavicular lymph node = lymph node biopsy

263. Miliaria = heat rash

264. Erythema multiforme minor = bull's-eye on palms, herpes simplex; Rx = long-term use acyclovir

265. Pustular psoriasis = sterile, post steroids, fever, malaise, arthralgia, diarrhea; Rx = cyclosporine

266. Seborrheic keratitis = "stuck=on", waxy grease scale

267. Dermatomyositis = often is paraneoplasic

268. Hypercalciuria (renal stones) Rx = hctz orally

269. Dye S.E. = ac. tubular necrosis = muddy granular casts

270. ATN = BUN/Cr < 20:1; cisplatin is one of the causes

271. Ac. interstitial nephritis (drugs) = rash, fever, hematuria, white cell casts, eosinophiluria

272. Increase in eosinophils = tumors, parasitic infectious, autoimmune diseases

273. Renal calculi = Abd XR, if - = CT scan of abdomen (shows all types of stones) - actually this information is conflicting between some sources,
so one should do some research about it

274. Indinavir (HIV drug) S.E. = renal stone

275. Struvite stones = Mg ammonium phosphate, pH>7.2, presence of urea splitting bugs (Proteus, Pseudommonas, Klebsiella; Rx = removal

276. Uric acid stones = radiotranslucent

277. Asymptomatic bacteriuria in non-pregnant, healthy patient = no Rx is indicated

278. Doxorubicin (Adriamycin) S.E. = cardiac toxicity, myelosuppression

279. Vincristine S.E. = motor, sensory and autonomic neuropathy

280. Bleomycin S.E. = pulmonary fibrosis

281. Myelosuppressant drugs = methotrexate, vinblastine, doxorubicin

282. Polycystic kidney dis = colonic diverticular dis (with increased risk for perfuration), it may evolute to end stage renal dis, 10-15% of the patients have intracranial aneurysm

283. Chrug-Strauss dis = nephritic syndr + eosinophilia + asthma, p-anca +; Rx = steroids, cyclophosphamide, azathioprine

284. Goodpasture syndr = nephritic syndr + pulmonary hemorrhage; Abs to glomerular basementmembrane

285. Wegener granulomatosis = nephritis + nasal/sinus problems, c-anca +; Rx = same as Chrug- Strauss

286. Berger's syndr = IgA nephropathy, no latent period post infection, nephrotic syndr

287. DMSA renal scan = radionucleotide study for renal function

288. IV pyelogram = C.I. in renal insufficiency

289. Kegel exercises = benefits within 6 weeks

290. Dribbling + dyspareunia + dysuria in woman = urethral diverticulum; Dx = urethroscopy or voiding cystourethrography

291. Nephrotic syndr = increased susceptibility to bact. infections, hyperlipidemia, mildly hypercoagulable state, hypovolemia

292. Renal cell ca suspicion = radical nephrectomy; Bx only for metastatic cases (when Sx is not indicated)

292. Rapidly progressive GN Rx = high dose IV methylprednisolone

293. Alport syndr = hematuria +/- blindness +/- deafness; type IV collagen of GMB in abnormal

294. Membranous glomerulonephropathy = MCC of nephrotic syndr in adults; Rx = ACEi

295. Membranoprolipherative GN = nephrotic sundr; renal dis + decreased complement, realted to hepatitis C virus

296. Painless hematuria = CT urogram or IVP (check ureteres)
297. Pyelonephritis suspicion = blood + urine cultures, urinalysis

298. Immunotherapy = for asthmatics patients with a single allergen

299. Interstitial fibrosis = decerased FVC, FEV1, RV, TLC, diffusion; increased FEV1/FVC; no response to bronchodilator

300. Immunisuppressed pat + pulm. aspergilosis Rx = IV amphotericin B
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Points : 212
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Age : 33
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PostSubject: NOTES FOR STEP 3   Fri Jun 12, 2009 11:50 am

301. Primary pulm. HTN Rx = inhaled nitrous oxide, Calcium channel blockers

302. ARDS Rx = limit tidal volume to 6 cc/kg or less

303. Lung nodule on X-ray = thorax CT scan with contrast

304. Appropriate tube placement = colorimetric detection of end-tidal carbon dioxide

305. Sarcoidosis Dx = skin, transbronchial lung biopsy

306. To decrease aspiration risk during entubation = cricoid pressure

307. After pulm HTN Dx = vasodilator response testing

308. Albuterol usage > twice a week = add triamcinolone MDI

309. Ipratropium bromide = takes about 45 minutes to make effect

310. Non-massive hemoptysis = CXR, then bronchoscopy, then high resolution CT scan to Dx; not all tests necessary every time, though

311. Croup (laryngotracheobronchitis) = subglotic swelling, steeple sign on XR, parainfluenza, barking cough; Rx = mist tent, racemic epinephrine, IV corticosteroid, diphenhydramine

312. TB confirmatory Dx test = sputum acid-fast stain

313. Ciprofloxacin = does NOT cover streptococcus

314. Community acquired pneumonia Rx = azithromycin, levofloxacin

315. Sup. vena cava syndr due to ca Rx = radiation therapy

316. Penicillin alergy = cephalosporin use is OK if penicillin skin test is -

317. Heparin = given with warfarin untill 2 days after INR reaches desired level

318. Foreign body aspiration in children = rigid bronchoscopy, methylprednisolone, cefazolin

319. Gout Rx = for overproducers = allopurinol; for underexcreters = probenecid

320. Cauda equina syndr. suspicion = MRI; it's an emergency!

321. Gian cell arteritis Rx = Prednisone 40-60 md daily for 1-2 m., then taper down; if there is suspicion, treat immediately, even before biopsy, to
avoid blindness as a complication!

322. Fight bite bug: Eikenella

323. Thompson test = pressure on gastrocnemius does not cause foot flexion, + in Achilles tendon rupture

324. Fibromyalgia symptoms with less than 11 trigger points = myofascial pain syndr.

325. Gottron's paules = happen in dermatomyositis

326. Polymyosistis Dx = increased creatinine, aldolase, CPK; EMG; muscle Bx; Rx = high dose corticosteroids

327. Urobilinogen = increased in hemolysis, hepatocelular dis.; decreased in biliary obstruction

328. Lithium S.E. = nephrogenic diabetes insipidus, hypothyroidism

329. Symptomatic hyponatremia Rx = 3% hypertonic saline to increase PNa by 3-5 mEq in 6 h, but no more than 12 mEq per day, because of the
risk of central pontine myelinolisis

330. Central pontine myelinolisis = flacid paralysis, dysarthria, dysphagia

331. Osmotic diuresis = Uosm/Posm>0.7

332. Diabetes insipidus = Uosm/Posm<0.7

333. Hypernatremia Rx = correct < 12 mEq/d to prevent cerebral swelling

334. Symptomatic hypercalcemia or > 13.5 Rx = hydration + furosemide, then biphosphonate or calcitonin; hemodyalisis if necessary

335. Hypercalcemia has no specific signs and symptoms, only hypocalcemia has them (Chvostek, carpal pedal spasm)!

336. Intraductal papilloma = bloody nipple discharge

337. Duct ectasia = fever, greenish cheesy discharge, pain, tenderness

338. Breast ca = single, hard, immobile, irregular borders, >2cm

339. Triple Dx = PE + mammogram + FNA citology/Bx

340. Around 15% of breast cancers have a false negative mammogram

341. Breast lump in woman younger than 35 yo = if cystic = FNA = if nonbloody liquid = reassurance, if bloody = citology; if not = US and core Bx or excisional biopsy

342. MC sequelae of meningitis = hearing loss; rememeber to order audiometry in ccs once the meningitis is cured

343. Meningococcal meningitis prophylaxis = rifanpim or cipro for close contacts

344. Measles = high fever for 3 days, then Koplik, then 1 day after head-to-toe rash; pneumonia; O.M.; encephalitis (ac.), subac. sclerosing panencephalitis (even after years)

345. Roseola infantum (exanthema subitum) = high fever for 4 days, stop, then rash on trunk; human herpes virus 6

346. Erythema infectiosum (fifth disease) = slapped cheek rash; parvovirus B19; when the rash is there, it's not contagious anymore

347. Varicella Ig = for immunodebilitated, NB, within 4 days of exposure

348. Scarlet fever = sand paper rash, circumoral pallor, strawberry tongue; Rx = penicillin to prevent RF

349. Kawasaki syndr Rx = aspirin + IV Ig; f/u with echo

350. Rocky mountain spotted fever Rx = tetracycline + chloranfenicol OR doxycycline; it may cause DIC, delirium
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PostSubject: NOTES FOR STEP 3   Fri Jun 12, 2009 11:50 am

351. Epiglottitis Rx = entubate ot tracheostomy, third generation cephalosporin; "thumb sign" on XR, child 2-5 yo, H. influenzae, S. aureus

352. RSV/bronchiolitis Rx = O2, mist tent, bronchodilators, IV fluids, ribavirin if severe, child <18 mo

353. Diphteria = grayish pseudomembranous + myocarditis; Rx = atbtc + antitoxin

354. Pertussis = paroxysmal coughing + whooping inspiratory noise; Rx = atbtc

355. Post-streptococcal GN = NOT prevented by atbtc

356. Congenital toxoplasmosis = IC calcifications, chorioretinitis

357. Congenital varicella-zoster = limb hypoplasia, scarring of the skin

358. Congenital CMV = deafness, cerebral calcifications, microphtalmia

359. Conjunctivitis in the first day of life = chemical reaction

360. Gonorrhea conjunctivitis Rx = erythromycin ointment for 2-5 days

361. Chlamydial conjunctivitis Rx = topical + oral erythromycin for 5-14 days; the intention is to avoid that it becomes a Chlamydial pneumonia

362. NB cataracts = TORCH, inherited metabolic dis (e.g. galactosemia)

363. Orbital cellulitis = ophtalmoplegia, ptosis, severe pain, decreased acuity, it's an emergency!; Rx = blood culture, inpatient IV atbtc

364. Uveitis in juvenile RA = Dx = slit-lamp exam; Rx = steroid drops

365. Orchiopexy = correction of cryptorchidism after 1 yo; does NOT affect risk of testicular ca, wich is increased in these cases

366. PDA = congenital rubella, high altitudes

367. T4F = VSD + RV hypertrophy + pulm. stenosis + overriding Ao

368. "Tet" spells = squatting after exertion; increases venous return and peripheric resistance, keeping more blood in lungs and improving oxygenation; very common in T4F, although not patognomonic

369. Coarctation of Ao = Turner syndr; mid upper back systolic murmur, BP difference between arms and legs

370. VSD = MC congenital cardiac defect; muscular type is the one that has the greater cahnce of closing by itself before 2 yo, but rarely after 4 yo; fetal alcohol syndr, TORCH, Down syndr

371. Necrotizing enterocolitis = premature, fever, rectal bleeding, air in bowel wall; Rx = NPO, gastric tube, IV fluids, atbtcs

372. Cystic fibrosis = meconium ileus, rectal prolapse

373. Kernicterus = increased unconjugated bilirubin, depoists into the basal ganglia, poor feeding, seizures, flaccidity, opisthotonus, apnea

374. Breast milk jaundice = peak at 2-3 w; Rx = temporary bottle feeding

375. Increased unconjugated bilirubin = Criggler- Najar dis., Gilbert dis.

376. Increased conjugated bilirubin = Rotor, Dubin- Johnson dis.

377. Sulfa in neonates = displace bilirubin from albumin, leads to kernicterus

378. Exchange transfusion = unconjugated bilirubin >20 mg/dl + failed phototherapy

379. MC primary immunodeficiency = Ig A deficiency: respiratory and GI infections; avoid giving Ig (anti IgA antibodies)

380. Bruton agammaglobulinemia = 6 mo, lung + sinus infections; Streptococcus, Haemophilus

381. Wiskott-Aldrich defic. + boy, eczema + thrombocytopenia + resp. infections

382. Chediak-Higashi syndr. = giant granules in neutrophils + oculocutaneous albinism

383. Complement defic. (C5-9) = recurrent Neisserial infections

384. Chr. mucocutaneous candidiasis = often associated with hypothyroidism

385. Osteosarcoma = 10-20 yo, about the knee, "sunburst" on X-ray

386. Job-Buckley syndr = intense increase in IgE, recurrent Staph infections; fair skin, red hair, eczema

387. Unicameral bone cyst = expansile, lytic, prox. portion of humerus

388. Bitot spots(debris in conjunctiva) = vit A deficiency

389. Vit A toxicity = pseudotu cerebri, bone thickening, teratogenicity

390. Vit. E defic. = anemia, peripheral neuropathy, ataxia

391. Give vit. A for = patients with measles

392. Give vit. E for = Alzheimer's patients

393. Give vit C for = iron deficiency anemia (increases absorption of Fe; calcium decreases it)

394. Vit E toxicity = necrotizing enterocolitis in infants

395. Vit K toxicity = hemolysis (kernicterus)

396. Vit. B6 defic. and toxicity both manifest as = peripheral neuropathy

397. Vit. B12 (cobalamin) defic. = megaloblastic anemia + neurologic symptoms

398. Folic acid defic. = megaloblastic anemia

399. Bone pain in vit C defic = periosteal hemorrhages

400. Wernicke/Korsakoff syndr = vit B1 deficiency (thiamine); never give glucose before thiamine for an alcoholic in the ER
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PostSubject: NOTES FOR STEP 3   Fri Jun 12, 2009 11:51 am

GIT and hepatobiliary
Dysphagia: Dysphagia to solids and liquids often indicates a motility problem (i.e., achalasia and esophageal spasm). Dysphagia to only solids indicates mechanical obstruction (i.e., tumor or Schatzki’️s ring).
Achalasia - Dx 1-Barium studies, 2-Esopgaguscopy 3-Manometry. The CONFIRMATION test is Manometry. We also need to do Endoscopy to rule out malignancy.
Barium swallow: Bird’️s beak or steeple sign: Achalasia. Corkscrew-shaped: DES
NB: In patients with suspected upper esophageal lesion it is always safer to proceed with barrium swallow than with endoscopy.
Patients with achalasia often lift their arms over their heads or extend their necks to aid in swallowing.
TREATMENT
Nitrates and calcium channel antagonists: Relax LES tone, but have only modest efficacy.
Botulinum toxin injection: Injected into the LES. Performed endoscopically and associated with an 85% initial response, but > 50% of patients require repeated injection within six months. Ideal if the patient is a poor candidate for more invasive treatment.
Pneumatic dilation: Of those treated, > 75% have a durable response. The perforation rate is 3–5%. Does not compromise surgical therapy.
Surgery: Laparoscopic Heller myotomy with partial fundoplication (preventing severe reflux that can occur with myotomy). Of all cases, > 85% have a durable response.
Diffuse Esophageal Spasm – Usually seen in young females. Manifest with chest pain and dysphagia. Etiology in unknown but its related to emotional stress. Unlike Achalasia LES has a normal relaxation response. Esophagogram might show Corkscrew. Tx is with antispasmic drugs, dietry modulation and psychiatric counselling. for USMLE know 1-pathophys, 2-present or absence of perstalsis, 3-LES tone. MERCK:A generalized neurogenic disorder of esophageal motility in which phasic nonpropulsive contractions replace normal peristalsis and, in some cases, lower esophageal sphincter malfunctions occur. Esophageal manometry shows: contractions are usually simultaneous, prolonged or multiphasic, and possibly of very high amplitude.*****Esophagography may not show the corkscrew, so do Manometry, if revealed "repetitive,nonpeistoltis,high amplitude contraction either spontaneoud or after Ergonovin stimulation then its Dx.
Unlike achalasia, diffuse esophageal spasm and nutcracker esophagus often present with chest pain rather than with dysphagia.
A sticking sensation in the throat accompanied by heartburn is characteristic of scleroderma. The absence of a peristatltic wave in the lower two thirds of the esophagus and a significant decrease in lower esophegal sphincter tone are also very characteristic.
Squamous cell carcinoma usually affects the upper and middle parts of the esophagus. It is more common in African American and shows significant association with smoking, alcohol consumption and some dietry factors.
Adencocarcinoma is more common in Caucassians and usually arise from Barrets esophagus.
Zenker Diverticulum –
A 56-year-old man complains of food feeling “stuck” on its way down and vomiting food he ate days ago. Think: Zenker’️s diverticulum.
Zenker is defined as herniation of mucosa through the fibers of cricopharyngeal muscle.
Pt presents with orophareangeal dysphagia, halitosis, neck mass and are >50yo. UES dysfunction and esophageal dysmotility (motor dysfunction and motility problem) are believed to be the cause. Barium exam helps to delineate the diverticulum, the surgical tx includes excision and frequently cricophareangeal myotomy.. Barieum Esophagograpghy is the confirmatory test od choice, not Esophagoscopy.
Esophageal cancer: Risk factors include cigarette smoking, alcohol use, obesity, and Barrett’️s esophagus. Presents with dysphagia, odynophagia, weight loss, cough, and hoarseness.
Staging evaluation: Evaluate with endoscopy and biopsy, chest CT, endoscopic ultrasound, and bronchoscopy (to rule out tracheal invasion).
Pathology: The 1° histologies are squamous cell and adenocarcinoma (increasing in incidence; associated with obesity and GERD).
TREATMENT
Localized esophageal cancer: Treat with chemoradiation (5-FU plus cisplatin and external beam radiotherapy) or surgery. Postoperative chemoradiation should be considered for locally advanced cancers.
Metastatic disease: Few good options are available; drugs include cisplatin, paclitaxel, 5-FU, and gemcitabine.
PEG tubes are often required to get patients through chemoradiation (as in head and neck cancer).
Esophageal Rings, Webs, and Strictures
Lower esophageal (Schatzki) rings: Common (found in 6–14% of upper GI exams); located in the distal esophagus. Often associated with hiatal hernia, congenital defects, or GERD.
Webs: Less common; located in the proximal esophagus. Congenital.
Strictures: Result from injury (e.g., reflux, caustic, anastomosis).
SYMPTOMS/EXAM
Dysphagia with solids is more severe than that with liquids.
DIAGNOSIS
Barium esophagography: May be diagnostic. Normal peristalsis; luminal abnormality is seen.
Endoscopy: Required to exclude esophageal stricture or tumor.
TREATMENT
Esophageal dilation; PPIs to ↓ the recurrence of peptic stricture.

Esophagitis Infectious
Most common in immunosuppressed patients (e.g., those with AIDS or malignancies, post-transplant, and patients undergoing chemotherapy) and in the setting of chronic steroid use or recent antibiotic use. Common pathogens include Candida albicans, HSV, and CMV.
SYMPTOMS/EXAM
Presents with odynophagia, dysphagia, and chest pain. Oral lesions are not reliable diagnostic indicators.
C. albicans is the etiologic agent in < 75% of cases and CMV or HSV in < 50%.
Exam reveals shoddy cervical lymphadenopathy.
DIAGNOSIS
In immunocompromised patients, attempt a trial of empiric antifungal therapy (e.g., fluconazole). In immunocompetent hosts, proceed with endoscopy.
Upper endoscopy with biopsy is the treatment of choice if the empiric trial yields no response. Findings are as follows:
C. albicans: Linear, adherent plaques that may be yellow or white.
CMV: Few large, superficial ulcerations.
HSV: Numerous small, deep ulcerations.
Idiopathic AIDS ulcers: Low CD4 count; large ulcerations.
TREATMENT
Treat or adjust underlying immunosuppression.
C. albicans: Treatment depends on host immune status.
Immunocompetent patients: Topical therapy; nystatin swish and swallow five times a day . 7–14 days. Test for HIV.
Immunocompromised patients: Oral therapy, initially with fluconazole. If the patient is unresponsive, consider increasing fluconazole or giving itraconazole, other azoles, caspofungin, or amphotericin.
CMV: Ganciclovir 3–6 weeks.
HSV: Acyclovir or valacyclovir
Idiopathic ulcers: Trial of prednisone.
COMPLICATIONS
Stricture, malnutrition, hemorrhage.
Esophagitis Pill induced
Variables include contact time, drug type, and pill characteristics. Most cases arise without preexisting swallowing problems. Pills can remain in a normal esophagus > 5 minutes or for much longer in the presence of stricture or dysmotility. Risk is higher if pills are large, round, lightweight, or extendedrelease
formulations.
SYMPTOMS/EXAM
Presents with odynophagia, dysphagia, and chest pain.
DIAGNOSIS
Review medications. Common causative agents include the following:
NSAIDs: Aspirin, naproxen, ibuprofen, indomethacin.
Antibiotics: Tetracyclines (especially doxycycline), clindamycin (look for a young patient with acne presenting with odynophagia).
Antivirals: Foscarnet, AZT, ddC.
Supplements: Iron and potassium.
Cardiac: Quinidine, nifedipine, captopril, verapamil.
Bisphosphonates: Alendronate, pamidronate.
Antiepileptics: Phenytoin.
Asthma/COPD medications: Theophylline.
Upper endoscopy: Evaluate for stricture or mass lesion.
TREATMENT
Discontinue the suspected drug. Expect symptom relief within 1–6 weeks.
Patients should drink eight ounces of water with each pill and remain upright at least 30 minutes afterward.
Proton pump inhibitors (PPIs) may facilitate healing in the setting of concurrent GERD.

GERD - In neonates is regurgitation after eating and failure to thrive. The child assumes the position of tilted head and arched back. Dx is 24hr pH monitoring of esophagus. When its unclear whether the pt has nocturnal asthma or GERD, a trial of proton pump inhibitor (Omeprazole) before breakfast is both Dx and therpeutic.
Esophagoscopy is indicated when a pt fails to respond to antibiotics and or theye are signs of implications (weight loss in cancer).
Dx Process: once pt presents with cough, and the vigniette says esophagoscopy is normal, the next thing is 24 hour pH monitoring. Then Manometry will confirm dx.
GERD can happen due to hiatal hernia. Chronic GERD can lead to metaplastic change in lower esophagus called Barret esophagus and is a risk for Adenocarcinoma of esophagus.
When pt comes in with symptoms of GERD you need to differenciate b.w Barrets,PUD,Gastritis, or tumor. Endoscopy is the most informative procedure for all these. Now if the vingette says "he has no Dysphagia" then you can skip the normal Barium test that precedes endoscopy and go straight to endoscopy. Indications to endoscopy are: 1-Nausea/vomiting, 2-
weight loss, anemia or melena, 3-Long duration of symptoms (>1-2 yr), 4-Failre to responde to PPI. So here is the order, if there if Dysphagia first do BS, then EC then Manometry. If no dysphagia, first EC and then Manometry, you can skip BS.
Diagnosis
For typical symptoms, treat with an empiric trial of PPIs for 4–6 weeks.
Response to PPIs is diagnostic.
If the patient is unresponsive to therapy or has alarm symptoms (dysphagia, odynophagia, weight loss, anemia, long-standing symptoms, blood in stool, age > 50), proceed as follows:
Barium esophagography: Has a limited role, but can identify strictures.
Upper endoscopy with biopsy: The standard exam in the presence of alarm symptoms (dysphagia, odynophagia, weight loss, bleeding, anemia).
Normal in > 50% of patients with GERD (most have nonerosive reflux disease), or may reveal endoscopic esophagitis grades 1 (mild) to 4 (severe erosions, strictures, Barrett’️s esophagus).
Strictures can be dilated.
Ambulatory esophageal pH monitoring: The gold standard, but often unnecessary. Indicated for correlating symptoms with pH parameters when endoscopy is normal and (1) symptoms are unresponsive to medical therapy, (2) antireflux surgery is being considered, or (3) there are atypical symptoms (e.g., chest pain, cough, wheezing).
Treatment
Behavioral modification: Elevate the head of the bed six inches; stop tobacco and alcohol use. Advise patients to eat smaller meals, reduce fat intake, lose weight, avoid recumbency after eating, and avoid certain foods (e.g., mint, chocolate, coffee, tea, carbonated drinks, citrus and tomato
juice). Effective in 25% of cases.
Antacids (calcium carbonate, aluminum hydroxide): For mild GERD. Fast, but afford only short-term relief.
H2 receptor antagonists (cimetidine, ranitidine, famotidine, nizatidine): For mild GERD or as an adjunct for nocturnal GERD while the patient is on PPIs. Effective in 50–60% of cases.
PPIs (omeprazole, lansoprazole, rabeprazole, pantoprazole, esomeprazole):
The mainstay of therapy for mild to severe GERD. Generally safe and effective, but now associated with pneumonia, atrophic gastritis (hypergastrinemia), enteric infections (C. difficile), and hip fractures. Daily
dosage is effective in 80–90% of patients. Fewer than 5% of patients are refractory to twice-daily dosage.
Surgical fundoplication (Nissen or Belsey wrap):
Often performed laparoscopically. Indicated for patients who cannot tolerate medical therapy or who have persistent regurgitation. Contraindicated in patients with an esophageal motility disorder.
Outcome: More than 50% of patients require continued acid suppressive medication, and > 20% develop new symptoms (dysphagia, bloating, dyspepsia).
Endoscopic antireflux procedures: Remain investigational.
COMPLICATIONS
Peptic strictures: Affect 8–20% of GERD patients; present with dysphagia.
Malignancies must be excluded via endoscopy and biopsy; can then be
treated with endoscopic dilation followed by indefinite PPI therapy.
Upper GI bleeding: Hematemesis, melena, anemia 2° to ulcerative esophagitis.
Posterior laryngitis: Chronic hoarseness from vocal cord ulceration and granulomas.
Asthma: Typically has an adult onset; nonatopic and unresponsive to traditional asthma interventions.
Cough: Affects 10–40% of GERD patients, most without typical GERD symptoms.
Noncardiac chest pain: After a full cardiac evaluation, consider an empiric trial of PPIs or ambulatory esophageal pH monitoring.
Other: Barrett’️s esophagus, adenocarcinoma
Barrett’️s Esophagus
Intestinal metaplasia of the distal esophagus 2° to chronic GERD. Normal esophageal squamous epithelium is replaced by columnar epithelium and goblet cells (“specialized epithelium”). Found in some 5–10% of patients with chronic GERD, and incidence ↑ with GERD duration. Most common in
Caucasian men > 55 years of age; overall incidence is greater in males than in females. The risk of adenocarcinoma is 0.5% per year. Risk factors include male gender, Caucasian ethnicity, and smoking.
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