USMLE Step 1,2,3 & Residency Match Prepration. |
| | NOTES FOR STEP 3 | |
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rock82
Posts : 101 Points : 212 Join date : 2009-06-11 Age : 40 Location : Jalandhar
| Subject: 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 | |
| | | rock82
Posts : 101 Points : 212 Join date : 2009-06-11 Age : 40 Location : Jalandhar
| Subject: 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 | |
| | | rock82
Posts : 101 Points : 212 Join date : 2009-06-11 Age : 40 Location : Jalandhar
| Subject: 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 | |
| | | rock82
Posts : 101 Points : 212 Join date : 2009-06-11 Age : 40 Location : Jalandhar
| Subject: 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 | |
| | | rock82
Posts : 101 Points : 212 Join date : 2009-06-11 Age : 40 Location : Jalandhar
| Subject: 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 | |
| | | rock82
Posts : 101 Points : 212 Join date : 2009-06-11 Age : 40 Location : Jalandhar
| Subject: 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 | |
| | | rock82
Posts : 101 Points : 212 Join date : 2009-06-11 Age : 40 Location : Jalandhar
| Subject: 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 | |
| | | rock82
Posts : 101 Points : 212 Join date : 2009-06-11 Age : 40 Location : Jalandhar
| Subject: 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 | |
| | | rock82
Posts : 101 Points : 212 Join date : 2009-06-11 Age : 40 Location : Jalandhar
| Subject: 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 epitheliumâ€). 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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