SMLE study revision Flashcards

Question

management of spontaneous bacterial peritonitis

Answer 1

Indications (presence of any of the following in a patient with cirrhosis and ascites): - Abdominal pain and/or tenderness - Fever \> 37.8°C (100°F) - Ascitic fluid neutrophil count ≥ 250/mm3 Most common isolates: Escherichia coli, Streptococcus spp., Staphylococcus spp., and Klebsiella Managemnet: community acquired infection with no beta lactam antibiotic exposure: IV 3rd generation cephalosporin (cefotaxime) hospital acquired infection: pipracillin tazobacam monotherapy

Answer 2

Patients present with the following signs and symptoms: Jaundice Fatigue Loss of appetite Hepatomegaly Splenomegaly Abdominal pain Liver function test results Liver function tests are usually deranged and indicate a hepatic pattern of disease such as Raised ALT and bilirubin with normal/mildly raised ALP. Patients may have an IgG predominant hypergammaglobulinemia. Type 1 - The commonest type. These patients have raised levels of anti-smooth muscle antibodies (80%), and antinuclear antibodies may also be positive (10%). Type II - Less common but often more severe; anti liver/kidney microsomal antibodies type 1 tend to be positive. Type III - Also less common, and often positive for anti-soluble liver antigen.

Answer 3

Initial complex febrile seizure Family history of febrile seizures Initial febrile seizure with temperature \< 40°C Age of onset \< 18 months [5] Structural brain lesions, cerebral palsy

Answer 4

1- McRobert manuver Or all four position 2- traction with -Wood's screw manuver -Robin manuver 2 3-Cleidotomy or symphysiotomy (division of the foetal clavicle or maternal symphysial ligament) 4-Zavanelli manoeuvre: replacement of the head into the canal and then subsequent delivery by caesarean section

Answer 5

Excess production can be due to increased foetal urination: Maternal diabetes mellitus Foetal renal disorders Foetal anaemia Twin-to-twin transfusion syndrome Insufficient removal can be due to reduced foetal swallowing: Oesophageal or duodenal atresia Diaphragmatic hernia Anencephaly Chromosomal disorders

Answer 6

Both of the Müllerian ducts fail to develop, leading to the absent or hypoplastic uterus, absent cervix, and vaginal agenesis (but functional ovaries) Develop normal secondary sexual characteristics Presentes with primary amenorrhea Normal female karyotype Investigation: testostrone.

Answer 7

no spontanous uterine bleeding has occured by the age of 16 years or if patient hasnt menstruated after 2 years of thelarche no evidence of breast development by age 14

Answer 8

BREAT PRESENT, UTERUS PRESENT: 1- imperforated hymen \>\> monthly dysmenorrhea but absent bleed \>\> hematocolpus on ultrasound \>\> hymenectomy 2- vaginal septum \>\> MRI \>\> surgical correction 3-anorexia nervosa \>\> hypogonadotropic hypogonadism BREAT PRESNET, UTERUS ABSENT: 1- Mullerian agenesis: (mayer rokitansky kvester hauser syndrome) karyotypically female 46XX absent fallopian tube, uterus, cervix, upper vagina. patient developes secondary sexual characteristics, normal pubic and axillary hair. 2-Androgen insensitivity: karyotypically male 46 XY lack of androgen receptor function \>\> wolffian duct structure atrophy \>\> patients grow up as females female secondary sexual characteristics are present (testes secrete estrogen) normal male level of testostrone no pubic or axillary hair Tx: testes removal at age of 20 BREAST ABSENT, UTERUS PRESENT: 1- gonadal dysgenesis: Turner syndrome 45X \>\> streak gonads 2- hypothalamic pituitary failure: severe weight loss, excessive exercise, low body fat

Answer 9

frequency: 24-38 cycle to cycle variation: +/- 2/20 days duration of flow: 4.5-8 days volume: 5-80mL

Answer 10

ACUTE 1- Hospitalize if Hb \<7g/dL, hemodynamically unstable stabiliaze pateints who are hemodynamically unstable. 2- High dose progestrone only therapy is first line for heavy acute bleeding 3- IV conjugated equine estrogen: 4- Combined oral contraceptives 5- Oral progestrone 6- Tranesxamic acid If there is no respose within 12-24 hours consider surgical managemnet 7- Dilation and currettage: 8- Balloon tamponade 9- Selevtive embolization 10- hysterectomy CHRONIC: (\>6 months) 1- NSAID: to normalize prostaglandin 2- Anti fibrinolytic therapy (Tranexamic acid) 3- Coordinate endometrial sloughing \*best for anovulation\* (oral medroxy progestrone acetate pr norethindrone) 4-Endometrial supression: (Levonorgesrel intrauterine system)

Answer 11

Gush of blood Lengthening of the umbilical cord Ascension of the uterus in the abdomen

Answer 12

Uteroplacental insufficiency leading to intrauterine growth restriction. This may be due to maternal disease such hypertension or pre-eclampsia, maternal smoking and placental abruption. Abnormalities with the foetal urinary system(amniotic fluid is derived mainly from foetal urine). Examples include renal agenesis, polycystic kidneys or urethral obstruction. Premature rupture of membranes Post-term gestation Chromosomal anomalies Maternal use of certain drugs (prostaglandin inhibitors, ACE-inhibitors)

Answer 13

- Irregular breathing - Bone loss (gained back after stopping medication) - Doesnt cause weight gain.

Answer 14

- Hypertension 140-159/90-99mmHg - Pregnancy - Acute liver disease - History of vascular disease: DVT, CVA, SLE, - Hormonally dependent cancer - Smoker age \>35 - Migraine with aura - Diabetes mellitus iwth vascular disease - Thrombophilia

Answer 15

Depo provera injections/ progestrone only pills

Answer 16

prevent ovulation oral ulipristal acetate and levonorgestrel

Answer 17

-Second trimester (at 24–28 weeks): Recommended in all pregnancies -Early screening (prior to 24 weeks) is recommended in women with risk factors Gestational diabetes prior to pregnancy Recurrent pregnancy loss At least one birth of a child diagnosed with fetal macrosomia Initial screening: 50-g, one-hour oral glucose challenge test Blood glucose level should be \< 135 mg/dl If positive, patients are given the 100-g oral glucose challenge test as confirmation Confirmation test: 100-g, three-hour oral glucose tolerance test (oGTT) ≥ 140 mg/dl--

Answer 18

Pathology: 1- Chronic anovulation: \>\> infertility, irrigular bleeding, endometrial hyperplasia and endometrial cancer 2- increase testrone \>\> increase LH, hirsutism 3- ovarian enlargement on ultrasound CLINICAL FEATURE: - Menstrual irrigularities: anovulation and infertility, amenorrhea - Obesity \>\> sleep apnea - Non alcaholic fatty liver disease - Acanthosis negricans - Hirsutism INVESTIGATIONS: 1- Hormonal profile: - LH to FSH ratio high -Progestrone low -Androgen high -Testostrone high -Sex hormone binding capacity is high - Estrol high -Estradiol high 2- Ultrasound: peripheral small fibers, necklace apperance, 3-10ml, dense stroma TREATMENT: 1- Irregular bleeding: OCP 2- Hirsutism: OCP or spironolactone 3- Infertility: clomiphene citrate for ovulation induction or human menopausal gonadotropin or Letrozole. metformin can increase ovultaion

Answer 19

1mg for average risk women supplements with 400micrograms per day/ 0.4mg women at increase risk of NTDs (either due to prior pregnancy with NTD or seizure disorders) \>\> 4mg of folic acid daily

Answer 20

1- Pyridoxine (vitamin B6) and/or doxylamine 2- For refractory symptoms, add one of the following: Diphenhydramine Dimenhydrinate Prochlorperazine Promethazine 3- For refractory symptoms despite combination therapy above, add one of the following: Metoclopramide Ondansetron Promethazine 4- Last resort: Add chlorpromazine or methylprednisolone. Thiamine repletion (in patients with severe recurrent vomiting)

Answer 21

presentation: could be asymptomatic, loss of pregnancy symptoms, falling B-HCG investigation: - Gestational sac measuring \>25mm and no visible embryo - No visible embryo during a follow-up endovaginal ultrasound ≥ 11 days after confirming the presence of a gestational sac with a yolk sac - No visible embryo during a follow-up endovaginal ultrasound ≥ 2 weeks after confirming the presence of a gestational sac without an embryo or a yolk sac

Answer 22

1- Expectant management (option for women \< 14 weeks gestation): Surgical evacuation is usually recommended if evacuation does not occur after 4 weeks. 2- Medical evacuation Misoprostol is used to induce cervical ripening and expulsion of the products of conception. When available, pretreatment with mifepristone 24 hours prior is recommended. 3- Surgical evacuation (dilation and curettage) Preferred method in septic abortion or if there is heavy bleeding or significant maternal disease, unstable patinets Complications include uterine perforation, hemorrhage, endometritis, and/or intrauterine adhesions [2] Rh(D)-negative women should receive Rh(D)-immune globulin in all cases of vaginal bleeding during pregnancy.

Answer 23

Placenta accreta occurs where adherence of the placenta directly to superficial myometrium but does not penetrate the thickness of the muscle. Placenta increta occurs where the villi invade into but not through the myometrium Placenta percreta occurs when the villi invade through the full thickness of the myometrium to the serosa. There is increased risk of uterine rupture and in severe cases the placenta may attach to other abdominal organs such as the bladder or rectum.

Answer 24

- Hemodynamically unstable - MTX sensitivity - Renal, liver or hematologic dysfunction - Active pulmonary disease - Active peptic ulcer - Breastfeeding - B-HCG 6000-15,000 - Gestational sac \>3.5 - Embryonic cardiac motion seen indications to treat surgically: - Hemodynamically unstable - Contraindications to MTX - Ruptured ectopic pregnancy or signs or intraperitoneal bleeding - Failed medical management surgical options: 1- laparoscopic salpingectomy: removal of the affected fallopian tube. 2- laparoscopic salpinsotomy: removal of the ectopic pregnancy. 3- laparotomy if hemodynamically unstable, ruptured ectopic pregnancy, large amount of intraperitoneal bleed.

Answer 25

following one ectopic pregnancy is 10% and following 2 ectopic pregnancy is 25%

Answer 26

penicillin 1- Rheumatic fever with carditis + residual heart disease: 10 years or until the age of 40 (which ever is longer) 2- Rheumatic fever with carditis but no residual heart disease: 10 years or until the age of 21 (whichever is longer) 3- Rheumatic fever without carditis: 5 years or until the age of 21 (whichever is longer)

Answer 27

monotherapy with an antipsudomonal beta lactam agent: cefepime, meropenem, imipenem, piperacillin tazobactam, ceftazidime

Answer 28

11-13+6 - AFP low - PAPPA low - Eostriol low - thickened nuchal translucency - B-HCG high

Answer 29

Clinical diagnosis typically before 24 weeks' (may be up to 28 weeks') gestation; OR History of ≥ 2 previous midtrimester pregnancy losses or ≥ 3 preterm births not explained by any other cause, and a transvaginal ultrasound cervical length \< 25 mm before 24 weeks' gestation (short cervical length) Management: In women with risk factors (i.e. previous preterm birth), serial cervical ultrasound monitoring between 16–24 weeks' gestation -Cervical cerclage placed at 13-14 weeks Definition: placement of a supportive suture in the cervicovaginal junction to prevent early pregnancy loss or preterm birth Indications: only in singleton pregnancies Progesterone supplementation (vaginal or intramuscular): indicated for a short cervical length at \< 24 weeks' gestation

Answer 30

low dose asprin initiated between 12-28 weeks gestation and until delivery

Answer 31

monitory reflexes for respratory depression treated with calcium gluconate

Answer 32

performed as part of the first trimester combined screening at 10-13 weeks A thickened nuchal translucency increases the likelihood of aneuploidy and cardiac disease

Answer 33

metronidazole or tinidazole

Answer 34

generally affects \< 2 years old Most common cause is RSV or parainfluenza virus presents with rhinorrhea, low-grade fever, cough, poor feeding followed by respiratory distress on auscultation wheeze and crackles 1- Supportive treatment -Adequate hydration -Relief of nasal congestion/obstruction -Monitoring 2- Indications for hospitalization Toxic appearance, poor feeding, dehydration, lethargy Marked respiratory distress Age \< 12 weeks and/or history of prematurity (\< 34 weeks) Pre-existing heart, lung, or neurological conditions Immunodeficiency 3- Treatment in severe -Bronchodilators, epinephrine and corticosteroids

Answer 35

HYPERTENSIVE URGENCY: \>180/120 without signs of end organ damage treatment: - outpatient management -consider a rapid-acting oral antihypertensive agent: clonidine, captopril, labetalol, prazosin HYPERTENSIVE EMERGENCY: -ICU admission -reduce blood pressure max 25% within the first hour to prevent coronary insufficiency and to ensure adequate cerebral perfusion pressure. -reduce blood pressure to 160/100-110mmhg over the next 2-6 hours -reduce BP to baseline over 24-48 hours -medications given IV 1- calcium channel blocker: Nicardipine, Clevidipine 2- Nitric oxide dependent vasodiltaor: sodium nitroprusside and nitroglycerine 3- Direct arterial vasocilators: hydralazine 4- antiadrenergic drugs: esmmolol, labetalol RECOMMENDATION BASED ON ASSOCIATED CONDITION: 1- aortic disseection: Esmolol, labetalol 2- pulmonary edema: clevidipine, sodium nitroprusside, nitroglycerine 3- acute coronary syndrome: Nitroglycerine, esmolo, labetalol, nicardipine 4- acute renal failure: clevidipine, nicardipine, fenoldopam

Answer 36

acute diffuse liver injury due to hypoperfusion 2% of patients admitted to the ICU develop ischemic hepatitis. ETIOLOGY: - impaired perfusion due to heart failure, severe hypotension, shock, thromboembolism, cardiac tamponade. - hypoxemia: respiratory failure. - septic shock, burns, surgery. INVESTIGATION: 1-Medical history and physical examination: cardiopulmonary disease, hypotension 2- Laboratory studies -Severely elevated AST levels (\> 1000 U/L) Serum levels peak 1–3 days Values return to normal within 7–10 days, once hepatic perfusion is restored. -Elevated bilirubin levels -Elevated LDH levels -ALT:LDH ratio of \< 1.5 -Elevated serum creatinine and BUN levels -Normal alkaline phosphatase levels -Coagulation studies: prothrombin time may be prolonged

Answer 37

give prophylactic paracetamol and give antihistamine if develop rash if the patient develop severe symptoms come back to ER.

Answer 38

live attenuated vaccines should not be given to women for 1 month before planned pregnancy. however if pregnancy occurs within 4 weeks from live vaccine then its safe to proceed the pregnancy and no reported cases of fetal damage from live vaccine the risk of damage to fetus is hypothetical

Answer 39

influenza vaccine

Answer 40

live attenuated vaccine: MMR Varicella Zoster Yellow fever Rotavirus Influenza (intranasal) Smallpox Adenovirus Typhoid (oral, Ty21a)

Answer 41

oral polio and BCG HIV patient can receive live vaccine if 1- asymptomatic 2- CD4 percentage is more than 15% in children less than 5 years 3- if CD4 count is more than 200 cell/micro in children above 5 years

Answer 42

- encephalopathy within 7 days of previous vaccine - unstable CNS condition - anaphylactic reaction to previous dose - High fever or severe acute illness (delay till the child is doing well) Precautions to DTaP vaccine - Febrile seizure after DTap - Hisrory of crying or high fever or febrile seizure from previous vaccine - History of gullian barre syndrome within 6 weeks of previous DTap

Answer 43

live attenuated vaccine in children less than 7 year: give 2 doses with 3 month apart in children above 7 years: give 2 doses with 4 weeks apart. -Primary immunization The CDC recommends two doses of the vaccine: first dose at 12–15 months of age ; second dose at 4–6 years of age (may be given earlier, but must be at least three months after the first dose) A combined measles, mumps, rubella, varicella (MMRV) vaccine is available. -Catch-up vaccination Two doses of varicella vaccine recommended for all children without evidence of immunity between the ages of 7–18 After 18 years of age: Individuals in close contact to individuals at high risk of infection (e.g., caretakers of immunocompromised patients) Individuals at high-risk of exposure to infected individuals (e.g., childcare employees) Before patients undergo immunosuppressive therapy or organ transplantation Seronegative women of child-bearing age Individuals with severe neurodermatitis

Answer 44

yellow fever vaccine

Answer 45

affect the immune response against live vaccine live vaccine should be given at 6 months or ideally at 12 months

Answer 46

live vaccine BCG yellow fever plague

Answer 47

neomycin and gelatin are contraindications to MMR and varicella

Answer 48

oral polio is contraindicated as it is transmitted feco orally

Answer 49

subacute sclerosing panencephalitis initial symptoms between 8-11 years of age Clinical presentation: characterized by four clinical stages Stage I: dementia, personality changes Stage II: epilepsy, myoclonus, autonomic dysfunction Stage III: decerebration, spasticity, extrapyramidal symptoms Stage IV: vegetative state, autonomic failure

Answer 50

4 weeks after stopping steroids oral steroid cause immunosuppression only if given more than 2 weeks with a dose 2mg/kg per day 12 weeks after stopping chemotherapy no live or killed vaccine after rituximab for 6 months

Answer 51

zoonotic disease from animal (from raw meat or unpasturized milk) affect CNS, heart (aortic valve endocarditis) **General** Flu-like symptoms (undulating fever) Night sweats High, potentially undulant fever Painful lymphadenopathy Localized infection Arthralgias, low back pain → osteoarticular infection (e.g., osteomyelitis, spondylitis) Epididymal and testicular tenderness, flank pain → genitourinary infection (e.g., epididymo-orchitis, pyelonephritis) Murmurs, friction rubs, tachycardia → cardiac infection (e.g., endocarditis, myocarditis) **investigation:** serum agglutination test **treatment** \<8 yeras: TMP/SMX and rifampicin \>8 years: doxycyclin and rifampicin duration of treatment: - 6 weeks if no CNS, CVS or back involvement - \>3-6 months non pregnant adults: doxycyclin + steptomycin or gentamycin pregnant female: TMP/SMX + rifampin adult or child \>8 years: brucellosis + spondylitis \>\> doxycyclin + rifampin

Answer 52

subtype of BCP-associated osteoarthritis characterized by noninflammatory osteoclast-mediated destructive arthritis of the shoulder joint clinical feature: typically affect shoulder causing joint pain, swelling, restricted range of motion, crepitus with joint movement diagnostics: - synovial fluid analysis: few WBC, many RBC, CPP crystals, alizarin red S stain - Calcium hydroxyapatite

Answer 53

delayed inflammatory complication of group A beta-hemolytic streptococcal (streptococcus pyogenes) pharyngitis that occur within 2-4 weeks of acute infection. post-acute tonsilitis or pharyngitis COMPLICATION: - acute pancarditis - chronic cardiac valvular changes CLINICAL FEATURE: JONES criteria: -constitutional symptoms: fever, malaise, fatigue -migratory polyarthritis -Heart: pancarditis, valvular lesion (mitral valve most common) -CNS: Sydenham chorea: involuntary, nonrepetitive movement of the limbs, neck, head, face. occur 1-8 months after infection. -Skin: subcutaneous nodule, erythema marginatum DIAGNOSTIC: - ANtistreptolysin O titer - Antistreptococcal DNAse B titer MANAGEMENT: -penicillin V (first line) for symptomatic management: 1- NSAID, asprin, naproxen 2- glucocorticoids PREVENTION: Primary infection: treatment of GAS tonsilitis or pharyngitis with penicillin V Secondary prevention: patients with a history of ARF are at high risk for recurrence IM penicillin G benzathine every 4 weeks whichever of the following results in the longest treatment duration: Possible ARF: 12 months Rheumatic fever without carditis: 5 years or until the patient reaches 21 years of age Rheumatic fever with carditis (with no residual heart disease): 10 years or until the patient reaches 21 years of age Rheumatic fever with carditis and permanent valvular heart defects: 10 years or until the patient reaches 40 years of age

Answer 54

normally implanted placenta seperates from the uterine wall before delivery TYPES: overt/external OR Concealed/internal RISK FACTOR: - previous abruptio - hypertension - maternal blunt trauma - cocaine abuse CLINICAL PRESENTATION: - painful late trimester vaginal bleed - uterine pain and tenderness - in moderate abruptio: fetal monitoring shows tachycardia, decreased variability, mild late deceleration. in severe cases fetal monitoring will show bradycardia. INVESTIGATON: ultrasound. TREATMENT: -emergency C-section if \>36 weeks and heavy bleed but controlled =\> vaginal delivery -conservative if pregnancy is remote from term and both fetus and mother are stable. COMPLICATION: - DIC - Acute tubular necrosis

Answer 55

dyspepsia with h pylori negative? PPI for 8 weeks H.pylori positive 1- Triple therapy: PPI + clarithromycin + amoxicillin (or metronidazole) for 10-14 days 2- Quadruple therapy: PPI + bismuth + tetracyclin + metronidazole CONFIRM ERADICATION: 4-6 weeks after completion of treatment regimen -Urea breath test -Stool antigen test -Biopsy

Answer 56

TRANSMISSION: -hand to mouth Echinococcus granulosus (cystic echinococcus): singular hydatid cyst; Echinococcus multilocularis (alveolar echinococcosis): infiltrative growth. CLINICAL FEATURE: -hydatid cyst: RUQ pain, N/V, hepatomegaly, lung involvement in 25% of cases INVESTIGATION: 1-LAB: mild eosinophilia, abnormal liver function test 2- Serology: positive ELISA 3- Ultrasound: initial 4- CT scan: diagnostic TREATMENT: CYSTIC: -medical therapy if \<5cm --\> albendazole -Ultraosund or CT guided percutanous drianage: in combination to medical therapy if \>5cm -Surgery: if \>10cm or complicated cyst. ALVEOLAR: 1- curative resection followed by at least 2 years of albendazole.

Answer 57

Entamoeba histolytica TRANSMISSION: feco oral CLINICAL FEATURE: 1- Intestinal amebiasis: -Incubation period: 1-4 weeks - loose stool with mucus and bright res blood -painful defcetation, tenesmus, abdominal pain, cramps, weight loss, anorexia -fever only in 10-30% -high risk of recurrence through self inoculation ALWAYS CONSIDE IN PATIENTS THAT PRESENT WITH DIARRHEA AFTER TRAVELING TO TROPICAL OR SUBTROPCAL DESTINATION. 2- Extraintestinal amebiasis: 95% amebic liver abscess: usually solitary abscess in the right lobe: RUQ pain, fever INVESTIGATION: 1- stool analysis: (BEST INITIAL) identification of cyst or trophozoit in fresh stool, trophozoit often contain ingested erythrocyte 2- colonoscopy with biopsy: flask shaped ulcer 3- serology (PCR or ELISA) the best diagnostic Extra intestinal amebia 1- serology antibody 2- aspiration of abscess 3- ultrasound: hypoechoic solitary lesion 4-CT or MRI: well defined round lesion with contrast enhancing wall TREATMENT: -asymptomatic: no treatment -Symptomatic intestinal and extraintestinal: metronidazole or tinidazole followed by luminal agent (paromomycin) to eradicate cyst (if liver abscess followed by Diloxanide furate) oral metronidazole for 7-10 days oral imidazole for 5 days IV is not superior to oral - Aspiration vua ultrasound or Ct guided if complicated liver abscesses: Indications: Localized in the left lobe Pyogenic abscess Multiple abscesses Failure to respond to pharmacotherapy -Surgical drainage: should generally be avoided COMPLICATION: ameboma: a tumor like mass caused by granulomatous reaction in the intestine in amebiasis which result in a large local lesion of the bowel

Answer 58

1- previously healthy patient without comorbidities or risk factor for resistant pathogen: Monotherapy with one of the following: Amoxicillin Doxycycline A macrolide (only in areas with a pneumococcal macrolide resistance \< 25%): Azithromycin, Clarithromycin 2- patients with comorbidites or risk factor for resistant pathogen: - Combination therapy An antipneumococcal β-lactam: Amoxicillin-clavulanate Cefuroxime Cefpodoxime PLUS one of the following: A macrolide Azithromycin Clarithromycin Doxycycline - Monotherapy: with a respiratory fluoroquinolone Gemifloxacin Moxifloxacin Levofloxacin DURATION OF TREATMENT: 5 days are usually sufficient

Answer 59

1- very early stage HCC: (\<2cm) First line Minimal concomitant liver disease: surgical resection Significant concomitant liver disease: liver transplantation if Milan criteria are met Alternative: ablative therapy e.g. radiofrequency ablation 2- intermediate stage (\>3 tumors or \>3cm) Locoregional therapy with: Transcatheter arterial chemoembolization Transarterial radioembolization 3- Advanced HCC: (portal vein invasion/ nodal or extrahepatic metastesis) Systemic chemotherapy First line: targeted treatment e.g., with atezolizumab/bevacizumab Alternatives Nontargeted chemotherapy Hepatic arterial infusion chemotherapy 4- End stage HCC: typically supportive care only

Answer 60

1- fetal heart rate - normal range 110-160 beats/min Tachycardia causes: terbutaline, atropine, scopolamine (beta adrenergic agonist), fever, thyrotoxicosis Bradycardia: beta adrenergic blockers, local anesthesia, fetal congenital heart block 2- baseline variability: - absent - minimal: \<5beats/min - moderate: 6-25 beats/min - marked variability: \>25 3- accelerations: - if \>32 weeks gestation: acceleration is \>15 beats/min above baseline for \>15 seconds but \<2 min - If \<32 weeks gestation: acceleration has a peak of 10beats/min above baseline for \>10 seconds but \<2 min 4- deceleration -Early deceleration: the peak of the deceleration occurs at the same time as the peak of contraction Associated with uterine contraction -Late deceleration: The deceleration is delayed in timing, the deceleration occur after the peak of contraction Associated with placental insufficiency -variable decelerations: Associated with umbilical cord compression -sinusoidal pattern: smooth sine wave like undulating pattern Indicated fetal anemia and vasa previa

Answer 61

Category 1: Normal - baseline 110-160 - baseline FHR variability moderate - late or variable deceleration: absent - early deceleration present or absent - acceleration: present or absent Category 2: intermediate Treatment: fetal resuscitation if no improvement \> c section Category 3: abnormal -recurrent late deceleration -recurrent variable deceleration -bradycardia -sinusoidal pattern Treatment: prepare for delivery + fetal resuscitation \>\> no improvement immediate C-section

Answer 62

1- decrease uterine contraction: turn off IV oxytocin 2- argument IV fluid volume 3- high flow oxygen administration 8-10L of oxygen by face mask 4- amino infusion: 5- change position to lateral position to decrease pressure on inferior vena cava 6- vaginal examination to rule out prolapse 7- scalp stimulation

Answer 63

NORMAL FIRST STAGE 1-Latent phase: onset of labor till 6cm cervical dilation 2- active phase: from 6cm to 10cm dilation ABNORMAL FIRST STAGE 1- prolonged latent phase In nulliparis women \>20 hours In multiparis women \>14 hours Management: Supportive care Unless rupture of membranes \>\> argumentation with oxytocin 2- prolonged active phase -No change in cervical dilation after 6hours of inadequate contraction -No change in cervical dilation after 4 hours of adequate contraction. Management: -argument with oxytocin -aminotomy 3-ARREST of active phase \>6cm dilation -\>4 hours of adequate contraction -\>6hours of i adequate contraction despite oxytocin Management: c-section

Answer 64

DEFINITION: Arrest of fetal descent \>3 hours in nulliparis women \>2 hours in multiparis women (One hour extra if epidural is given) Management: - instrumental delivery (if head is engaged at +2 station and beyond) - C- section (if 3 attempts of instrumental delivery failed)

Answer 65

- uterine tachysystole \>\> can lead to abruptio placenta or uterine rupture - category 2 or 3 FHR

Answer 66

1- Mg sulfate: decrease in short term variability, 2- Epidural analgesia: late or prolonged deceleration (maternal hypotension \>\> uteroplacental insufficiency 3- oxytocin: late or prolonged deceleration + uterine hyper stimulation

Answer 67

Should be offered \>37 weeks ABSOLUTE CONTRAINDICATION: - Previous classical C section - previous uterine surgery (myomectomy) - placenta previa - non reassuring fetal heart rate - multiple pregnancy - mechanical obstruction to vaginal birth (pelvic fracture, large fibroid, fetal hydrocephalus) - uterine rupture - macrosomia - unexplained APH RELATIVE CONTRAINDICATIONS - early delivery - oligohydramnios or rupture membrane - known nuchal cord - structural uterine abnormality - fetal growth restriction - prior abeuptio or it’s risk

Answer 68

If patient is 41 weeks gestation \> fetal surveillance If patient is 42 weeks gestation \> induction of labor If complications develop \> induction of labor If gestational age is uncertain \> induce labor by 41 weeks gestation.

Answer 69

Performed at 15-20 weeks gestation FOR DOWN SYNDROME - MS-AFP and estriol \>\> decreased - B-HCG and inhibin A \>\> increased FOR TRISOMY 18 All four markers are decreased

Answer 70

DTP/DTaP Hepatitis B IPV Hib PCV-7

Answer 71

Measles and yellow fever vaccine

Answer 72

FIRST LINE: 1- indomethacin if patient 24-32 weeks gestation 2- Nifedipine if 32-34 weeks gestation SECOND LINE 1- Nifedipine if 24-32 weeks gestation 2- terbutaline if 32 to 34 weeks gestation

Answer 73

MOTHER SIDE EFFECT:

Answer 74

Unstable patients Prompt delivery in: Patients with signs of intraamniotic infection, abruptio placentae, cord prolapse Signs of fetal distress (nonreassuring fetal heart rate) Additionally, collect cervical cultures and commence empiric antibiotic therapy ampicillin and gentamicin. Stable patients Gestational age: ≥ 37 0/7 weeks (term) Delivery by induction of labor is generally recommended. Expectant management for up to 12–24 hours is reasonable in otherwise uncomplicated pregnancies and in the absence of infection. Gestational age: 34 0/7–36 6/7 weeks (late-preterm) Expectant management and induction of labor are both reasonable options. Expectant management Bed rest, pelvic rest Induction of fetal lung maturity: single-course of antenatal corticosteroids if not previously given if there is no evidence of chorioamnionitis and delivery is anticipated in \> 24 hours and \< 7 days Gestational age: 24 0/7–33 6/7 weeks Expectant management Bed rest, pelvic rest Prophylactic antibiotics to reduce the risk of infection and delay delivery Ampicillin IV PLUS erythromycin IV followed by amoxicillin PO PLUS erythromycin PO OR Ampicillin IV PLUS azithromycin IV followed by amoxicillin PO PLUS azithromycin PO Single-course of antenatal corticosteroids (betamethasone or dexamethasone) Tocolysis can be used to delay delivery for up to 48 hours so that antenatal corticosteroids can be administered. [14] Magnesium sulfate if preterm delivery \< 32 weeks gestation is anticipated [15] Gestational age \< 23–24 weeks Fetal outcome is generally poor in PPROM before or at the limit of viability. The choice of management depends on patient-specific factors and preference. Expectant management Not recommended before viability Same approach as for pregnant women at 24 0/7–33 6/7 weeks

Answer 75

C\_SECTION \>\> B lynch suture \>\> artery embolisation (if hemodynamically stable) laparotomy and artery ligatioon (if hemodynamically unstable) \>\> hysterectomy VAGINAL DELIVERY \>\> Bakri balloon \>\> artery embolisation (if hemodynamically stable) laparotomy and artery ligatioon (if hemodynamically unstable) \>\> hysterectomy 1- oxytocin 10-40 units in 500-1000mL of normal saline 2- 0.2mg of ergonavine or methylergonavine IM (contraindicated in preeclampsia or hypertension) 3-prostaglandin F2a IM 4- Carboprost (Hemabate) IM (contraindicated in asthma) 5- misoprostol per rectum or subinguinal 6- uterine compression suture (B-Lynch suture) 7- bimanual compression and massage of uterine corpus 8-packing (large volume balloon cather) 9-percutanous catheter into the uterine arteries for injection of thrombogenic material to control blood flow and hemorrhage 10- hysterectomy

Answer 76

- \>5cm - Expanding - Painful

Answer 77

- Mass size graeter than 10cm - Irrigular - High flow on color doppler - Pappilary or solid (hypoechoid) mass - Presence of ascitis

Answer 78

all the vaccines

Answer 79

should be given at 9, 12, 18 and then again at 4-6 years Live vaccine MMR

Answer 80

If the wound is MAJOR with major scratches or involving mucus membrane or bleeding 1- give immunoglobulin 2- vaccinate -if not previously vaccinated \>\> give on days 0,3,7, and 28 -if previously vaccinated \>\> give on days 0 and 3 if the wound is MINOR with only minor scratch without bleeding: -no need for immunoglobulin -Give vaccination if not previously immunized on days 0,3 and 28 if previously immunized on day 0 and 3

Answer 81

Rota virus vaccine

Answer 82

- immunodeficiency - history of recet blood transfusion, blood products or immunoglobulin - steroids for more than 2 week more than 2mg/kg per day - should be delayed 3-11 months after IVIG - should be delayed after 6 months of PRBC - should be delayed after 7 month of givening FFP or platlet - immediatly after packed RBC products - Live attenuated vaccines should be delayed after 3 months or before 2 weeks of chemotherapy. - Pregnancy - if received another live vaccine 4 weeks ago - anaphylaxis to the vaccine - Allergy to neomycin or geeatin are contraindications to MMR and varicella

Answer 83

smallpox vaccine

Answer 84

INDICATIONS: - all infants \>6 months given annually - all children exposed to or living with healthcare workers, chronic illness or immunodeificnexy

Answer 85

it usually follows a gastroentestinal infection by 1-4 weeks - Campylobacter jeujeni - CMV (most common virus) - Influenza vaccine

Answer 86

1- Influenza 2- Pneumococcal vaccine

Answer 87

rubella is teratogenic and should be givem 1 month before getting pregnant or immediately after deliver.

Answer 88

- Severe or uncontrolled hemorrhage - Large, expanding or pulsatile hematoma - Thrills or bruits - Shock unresponsive to IV fluid resuscitation - Abset or diminished radial pulse - Neurologic deficit (hemiplegia) consistent with cerebral ischemia - Air bubbling from a wound - Massive hemoptysis or hematemesis - Respiratoy distres

Answer 89

in general staph aureus - for patients with underlying congenital herat disease: strept virdans \>\>\> vancomycin - for patients with normal heart: staph aureus \>\>\> vancomycin - for patients with prosthesis: staph epidermis \>\>\>\> treated with vancomycin, rifampicin and gentamycin

Answer 90

clinical feature: - Fever and conjunctivitis, coryza, cough and pathognomonic koplik spots on the buccal mucosa - Sudden development of a high fever, malaise and exantham (erythematous maculopapular rash) start on the face and spreads down - usually in children older than 5 - no hands and foot changes - no strawberry tongue treatment - supportive - vitamin A

Answer 91

most common ause below 2 years: - Streptcoccus pneumonia - Hemophilis influenza - Moraxella catarahlis most common in children above 2 years: - psudomona arguinosa - Staph aureus

Answer 92

proximal part invaginates into the distal part leading to mechanical obstruction. AGE: 6-18 months ETIOLOGY: 75% idiopathic. Meckle's diverticulum, enlarged payers patch, MOST COMMON SITE: ileocecal invagination. CLINICAL FEATURES: -abdominal pain, abdominal distension, vomiting, constipation -palpable sausage shaped mass in RUQ -high pitched sounds -current jelly stool INVESTIGATION: -Abdominal x ray: bowel obstruction sign -Ultrasound is best initial" target sign, donut sign, psudo kidney sign -Contrast or pneumatic ENEMA using ultrasound or fluoroscopy is best confirmatory TREATMENT: IV fluids, keep NPO, NG tube -NON surgical: air enema (hydrostatic reduction with normal saline or water soluble contrast enema) under ultrasound or fluscopy guidance Contraindicated in secondary intussuception, \<3m, peritonitis, necrosis can be done for 3 trials recurrence after enema is 10% -SURGICAL: indicated when pathological lead point is suspected failed conservated management suspected gangrenous or perforated bowel or peritonitis critically ill recurrence after surgery is 1%

Answer 93

aquired pyloric circler muscle hypertrophy resulting in gastric outlet obstruction AGE: 2 weeks to 2 months more common in males ETIOLOGY: smoking during pregnancy, first male boy, young maternal age, bottle feeding, macrolide antibiotics (erythromycin) CLINICAL FEATURE: repeated episodes of projectile non billious vomiting after meals, palpable olive mass, peristalitic waves, hungry after vomiting, electrolyte disturbance INVESTIGATION: -Ultrasound (initial) elongated \>16mm and thickened \>4mm pylorus -Barium study: narrow pyloric orifice, string sign, beak sign, double railroad tract sign TREATMNET: IV fluid, NPO, NG tube, correct electrolyte, Ramstad pyloromyotomy

Answer 94

staph aureus 30min to 8 hours vibrio cholera 2 hours to 48 hours clostridium perfringens 6-48 hours Salmonella, Ecoli, Cambylobacter 2-5 days Cyclospora and listeria 1-4 weeks

Answer 95

characterized by eruption of burning and intensly puritic papules and vesicle associated with celiac disease treatment: Gluten free diet, Dapsone

Answer 96

shigella Clostridum difficile sever dehydration prolonged illness (more than one week) immunosuppressed antibiotic treatment in shiga toxin Ecoli can lead to HUS however in shigella doesn't increase risk of HUS

Answer 97

- small gallbladder less than 1.9cm - thin gallbladder wall - irregular contour this triad is 97% sensitive and 100% specific for biliary atresia which is discontinuity of the extrahepatic biliary system treated with kasai hepatoportoenterostomy by age of 2 months

Answer 98

shigella can cause febrile seizures either due to electrolyte disturbance or affect the CNS directly leading to encephalopathy (Ekiri syndrome)

Answer 99

allergic inflammatory condition of the esophagus that involves eosinophils eosinophel migrates to the esophagus in large numbers, then precipitate an allergic reaction when a trigger food is eaten Clinical feature: excessive chewing associated with atopy best diagnostic: endoscopy and biopsy

Answer 100

- Age \<2 months - Clinical urosepsis (toxic apperance, hypotension, poor capillary refill) - Immune compromise - Vomiting or inability to tolerate oral medication - Lack of adequate outpatient follow up - Failure to respond to outpatient therapy

Answer 101

antiplatelet: either aspirin or clopidogrel

Answer 102

**for long-term prevention of ischemic stroke** recommend treatment with an antiplatelet agent using either [aspirin](https://www.uptodate.com/contents/aspirin-drug-information?search=stroke%20prophylaxis&topicRef=1086&source=see_link), [clopidogrel](https://www.uptodate.com/contents/clopidogrel-drug-information?search=stroke%20prophylaxis&topicRef=1086&source=see_link), or [aspirin-extended-release dipyridamole](https://www.uptodate.com/contents/aspirin-and-extended-release-dipyridamole-drug-information?search=stroke%20prophylaxis&topicRef=1086&source=see_link). asprin is first line

Answer 103

scopolamine first line diphenhydramine

Answer 104

Gastrointestinal problems, such as nausea, stomach upset, and loose stools ●Stomatitis or soreness of the mouth ●Abnormal liver chemistries, which are typically mild elevations in hepatic transaminases **(hepatotoxicity)** ●A macular punctate cutaneous eruption, which usually occurs on the extremities, often affecting the elbows and knees, but sparing the trunk ●Central nervous system symptoms, including headache, fatigue, malaise, or impaired ability to concentrate ●Alopecia ●Fever, which is drug-related, although fever can also occur due to infection ●Hematologic abnormalities, particularly macrocytosis, in addition to infrequent but severe myelosuppression (see ['Myelosuppression'](https://www.uptodate.com/contents/major-side-effects-of-low-dose-methotrexate?search=side%20effects%20of%20methotrexate&source=search_result&selectedTitle=2~148&usage_type=default&display_rank=1#H4) below)

Answer 105

**Etiology:** waterbone from drinking recreational water, child care setting, travelers, swimmers hhhth feco oral route **clinical feature** * foul smelling, volumonious, frothy and fatty stool (not bloody) * excessive gas, abdominal pain and cramps * fatigue * nausea and vomiting * anorexia diagnostic: stool analysis _(3 samples in different days)_ _best diagnostic: stool antigen or PCR_ treatment: 7-10 days of metronidazole or tinidazole

Answer 106

autosomal recessive impaired copper excretion **clinical features:** * hepatosplenomegaly, portal hypertension, abdominal pain, jaundie, ascitis, hepatic encephalopathy * kayser fleischer ring * parkinsonsim, dysarthria, dystonia, drooling, tremor * renal fanconi syndrome diagnostic 1- best initial: 24 hour urine collection for copper, low serum ceruloplasim 2- best test: lover biopsy or genetic (chromosome 13 treatment: D penicillamine or trienitine hydrochloride

Answer 107

-Inhaled beta agonist: Albuterol 2.5 mg diluted to 3 mL via nebulizer or 2 to 4 inhalations from MDI every hour for 2 or 3 doses; up to 8 inhalations may be used for intubated patients, if needed Short-acting muscarinic antagonist (anticholinergic agent): Ipratropium 500 micrograms (can be combined with albuterol) in 3 mL via nebulizer or 2 to 4 inhalations from MDI every hour for 2 to 3 doses Intravenous glucocorticoid (eg, methylprednisolone 60 mg to 125 mg IV, repeat every 6 to 12 hours) Antibiotic therapy\*: Appropriate for majority of severe COPD exacerbations; select antibiotic based on likelihood of particular pathogens (eg, *Pseudomonas* risk factors^¶, prior sputum cultures, local patterns of resistance) * No *Pseudomonas* risk factor(s)^¶: Ceftriaxone 1 to 2 grams IV, **or** cefotaxime 1 to 2 grams IV, **or** levofloxacin 500 mg IV or orally, **or** moxifloxacin 400 mg IV or orally * *Pseudomonas* risk factor(s)^¶: Piperacillin-tazobactam 4.5 grams IV, **or** cefepime 2 grams IV, **or** ceftazidime 2 grams IV Antiviral therapy (influenza suspected)\*: Oseltamivir 75 mg orally every 12 hours **or** peramivir 600 mg IV once (for patients unable to take oral medication)

Answer 108

* Symptomatic patients * Asymptomatic patients who meet at least one of the following criteria: * Age \< 50 years * Serum calcium level more than 1 mg/dL higher than the normal upper limit * Impaired renal function (eGFR \< 60 mL/min) * Increased calcium excretion (\> 400 mg/day) in combination with an increased risk for [nephrolithiasis](https://next.amboss.com/us/article/qg0Cw2#Z45c7ff4091f4118f9a1659cdec6c8bdd) * Evidence of [nephrolithiasis](https://next.amboss.com/us/article/qg0Cw2#Z45c7ff4091f4118f9a1659cdec6c8bdd) or nephrocalcinosis via imaging * Reduced bone mineral density ([T-score](https://next.amboss.com/us/article/cT0ap2#Z04d5607a7d534805841ab55f14ade5cd) \< -2.5 at [lumbar spine](https://next.amboss.com/us/article/E6085S#Zee3ee04f3405fd08ff4605042502f718), total [hip](https://next.amboss.com/us/article/A60RnS#Z24ac16f8fc5a2115a2e7a12bf9d88bf3), femoral neck, or [distal](https://next.amboss.com/us/article/xo0EVS#Zce232f978ea5a8fb9edbb980a41502b8) third of the radius, or preexisting asymptomatic [vertebral fracture](https://next.amboss.com/us/article/M30MQf#Zc9d0a33c4d29275740355c11311e789b))

Answer 109

* peripheral neuropathy, ataxia, paresthesia (neurologic side effects can be reduced by concomitant administration of pyridoxine “vitamin B6”) * hepatotoxicity

Answer 110

an organophosphate compound and irreversible acetylcholinesterase inhibitor **clinical feature:** * Acute [**cholinergic crisis**](https://next.amboss.com/us/article/HN0Kcg#Zb34c86e845591759a15a167ec69ab2d5) and paralysis * [Parathion](https://next.amboss.com/us/article/Af0RK2#Z887d68caba20ab3c9077dcfb464ac23e) has a garlic-like or petrol-like odor * [Sarin](https://next.amboss.com/us/article/Af0RK2#Z0fa6a33c5553721ba7d1ce5e33e463a5) is odorless and tasteless * [Parathion](https://next.amboss.com/us/article/Af0RK2#Z887d68caba20ab3c9077dcfb464ac23e) may cause blue-colored saliva and mucosa * Cardiovascular symptoms: [**bradycardia**](https://next.amboss.com/us/article/rM0fJg#Zd260d8e17660a21cb9baf0a449c178d7), [**hypotension**](https://next.amboss.com/us/article/rM0fJg#Zb5022b8fa3fa419ab039a0f8d70866a2) * Gastrointestinal symptoms: **diarrhea, vomiting**, abdominal [pain](https://next.amboss.com/us/article/xN0EWg#Zd673a3f7ee36023aab5a267899e984cc) * Uncontrolled [urination](https://next.amboss.com/us/article/Rp0l6S#Z1cb08fa60b75cadec38829ba7e1c22b7) * **↑ Sweating**, **↑ salivation** * Respiratory symptoms: [**bronchospasm**](https://next.amboss.com/us/article/or00Rh#Z445ba34e92bd5ca4952236c49610dadc), bronchorrhea * [CNS](https://next.amboss.com/us/article/lp0vpS#Z0111aade770ed6f7d136b455de1d6c1f)-related symptoms: [lethargy](https://next.amboss.com/us/article/br0Hfh#Za0496dba558578db7e8b96f7af556b34), [seizures](https://next.amboss.com/us/article/RR0l5f#Z34c7e6b1cab99047c956783229d49b59), [tremor](https://next.amboss.com/us/article/x30Ekf#Z31783b886c5b864e996ac90b710d2de9), possibly [coma](https://next.amboss.com/us/article/br0Hfh#Z04a92c21d7cc40aac02b1f4b3f2155cf) * Musculoskeletal symptoms: [**fasciculations**](https://next.amboss.com/us/article/o500Og#Ze95f9b2d232251637659c74f5b471b2e), **weakness**, spasms, **paralysis** → peripheral neuromuscular [**respiratory failure**](https://next.amboss.com/us/article/tH0XHh#Zd206d3003b59f90f089259c750dc00db) * Ocular symptoms: [**miosis**](https://next.amboss.com/us/article/qO0CtT#Z0e51d0270de0f8ebe0a316768eda24de)**,** **lacrimation** * Chronic low-dose exposure: chronic organophosphate-induced neuropsychiatric disorder characterized by fatigue, depression, impaired [memory](https://next.amboss.com/us/article/br0Hfh#Zba777276f381d2740a84a620fcfef0fe), [extrapyramidal symptoms](https://next.amboss.com/us/article/AN0Rdg#Za856c1ac95cc67d7a227f098f6705862), [peripheral neuropathy](https://next.amboss.com/us/article/qR0CLf#Z05ae6949b17de29f8671eb78b5df08be), and [autonomic dysfunction](https://next.amboss.com/us/article/560ilS#Ze9a4374f21f8617757cd3bdea15efa3e) management 1-decontaminate (wash skin, remove clothes) 2- measure erthrocyte chilinesterase activity 3- atropine

Answer 111

management of hirshprung disease is colostomy initially then followed by definitive surgical treatment by modified duchamel procedure, swenson procedure or pull through surgery (Suave procedure)

Answer 112

Marasus is deficiency in all major nutrients Kwashirkor is deficiency in protients primerily

Answer 113

* sharp opjects * long objects (more than 5cm) * round batteries * super magnetic object * patient is symptomatic: fever or pain * object not passed and still in stomach for 4 weeks

Answer 114

assumed to arise fro endocrine cells of the gut (mostly the duodenum) or pancreas best initial test: esophagogastroduodenoscopy to rule out H.pylori and malignant ulcers confirmatory: increase serum gastrin if non conclusive secretin stimulation test

Answer 115

softening trachea cartilage **clinical presentation:** * upper airway: stridor and barking cough * lower airway: monophonic wheeze **Classification** 1. type 1: congenital, sometimes associated with tracheoesophageal fistula or esophageal atresia 2. type 2: extrinsic compression sometimes due to vascular rings 3. type 3: acquired due to chronic infection or prolonged intubation or inflammatory condition like relapsing poluchondritis **management**: if mild and isolated usually resolve by 2 years if severe then requires surgical intervention

Answer 116

a flexible fibrooptic scope is required when * severe episode of distress * cyanotic spell * growth failure * feeding difficulty * suspicious of other cause in larynx

Answer 117

Treatment of PID consists of broad antimicrobial coverage against the likely pathogens, including *Neisseria gonorrhoeae*, *Chlamydia trachomatis*, and the gram-negative and gram-positive organisms that comprise the cervical and vaginal flora, including anaerobic organisms **Indications for hospitalization** – * Severe clinical illness (eg, high fever, nausea/vomiting preventing oral intake, severe abdominal pain) * Suspected pelvic abscess * Pregnancy * A possible alternative diagnosis that could warrant surgery (eg, appendicitis)

Answer 118

ADAMTS113 deficiency clinical feature: * [**Fever**](https://next.amboss.com/us/article/j50_Pg#Za5de83449ff6a749e6c1348b93b1f3b1) * **Neurological signs and symptoms** * Altered mental status, [delirium](https://next.amboss.com/us/article/6P0jfT#Zfd56fee25cf9f50f32c800e64a6e652a) * [Seizure](https://next.amboss.com/us/article/RR0l5f#Z34c7e6b1cab99047c956783229d49b59), focal defects, [stroke](https://next.amboss.com/us/article/UR0bmf#Zdd37bc451d2e210ed3e03be192079b6c) * [Headache](https://next.amboss.com/us/article/YL0nwg#Z67ba0252fff6842349617790ed19ae54), [dizziness](https://next.amboss.com/us/article/fH0kph#Z2902ea08bfe4d834c405462f8fae0720) * [**Low platelet count**](https://next.amboss.com/us/article/wT0hG2#Zdab14a350ac311c7a2589ab7d48358ad) (i.e. [thrombocytopenia](https://next.amboss.com/us/article/wT0hG2#Zdab14a350ac311c7a2589ab7d48358ad)) * [Petechiae](https://next.amboss.com/us/article/_405NT#Z407bfee1be646713a1d7c946d9f4d4f0), [purpura](https://next.amboss.com/us/article/_405NT#Zc8dd5ca664223e28e1b5912fb7e2b52b) * Mucosal bleeding * Prolonged bleeding after minor cuts * [**Microangiopathic hemolytic anemia**](https://next.amboss.com/us/article/rT0fH2#Zda0b304b42e7d61e473888461c687343) * Fatigue, [dyspnea](https://next.amboss.com/us/article/Xq09CS#Zec7af3634c75f9e5227d266d823e5ea7), and pallor * [Jaundice](https://next.amboss.com/us/article/jS0_z2#Z5f49d92f52d702a9bee9b2538ad7b454) * **Impaired renal function** * [Hematuria](https://next.amboss.com/us/article/Wq0PxS#Zf526abf597cc56e5ddc1862ca53aca12), [proteinuria](https://next.amboss.com/us/article/0Q0euf#Zf8ea53dacdf631df81e9f46e3ead20d1) * [Oliguria](https://next.amboss.com/us/article/kg0mv2#Z923732bc2a869fb5343909709f174a34), [anuria](https://next.amboss.com/us/article/kg0mv2#Z438c513d07e854c87f894ecca5d7f521) (uncommon) Prompt initiation of [**plasma exchange**](https://next.amboss.com/us/article/MM0M6g#Z6c6972cba04aaeaa70a493bfb6e9b66d) **therapy (PEX)** * High-dose [**glucocorticoids**](https://next.amboss.com/us/article/km0mfg#Z521ecba6f9748e7fed6b743a73ccfabd) * [Prednisone](https://next.amboss.com/us/article/km0mfg#Z7acc6b8a4fb3eecc9bdffe7ff1f88c25) * OR [methylprednisolone](https://next.amboss.com/us/article/km0mfg#Z8285bfff684cdbf2f8b9eba0d51576fd) * Patients with a high [pretest probability](https://next.amboss.com/us/article/ps0LDh#Z13c998f5ce11971464c36b69de467dc4) of TTP (based on clinical [judgment](https://next.amboss.com/us/article/br0Hfh#Zc8288f261f1e1d7335063fe9648fb778)) * Consider early caplacizumab. * Consider [rituximab](https://next.amboss.com/us/article/qM0Cpg#Ze00b1d8151bfbc4dd3b134e0567b0d43).

Answer 119

* **Follicular cyst of the ovary** (most common ovarian mass in young women) * Develops when a [Graafian follicle](https://next.amboss.com/us/article/O60IOS#Z7ee0261c3386a548429ddee17441ccd7) does not rupture and release the egg ([ovulation](https://next.amboss.com/us/article/Ek08pT#Z4444420b54b73b5aae96fe23b2824fc4)) but continues to grow * Eventually develops into a large cyst (∼ 7 cm) lined with [granulosa cells](https://next.amboss.com/us/article/Ek08pT#Zcbb01c1733af6c72627c25a54956d2b9) * Associated with [hyperestrogenism](https://next.amboss.com/us/article/uk0ppT#Z680111ae142a8c0b0518022151e6c74f) and [endometrial hyperplasia](https://next.amboss.com/us/article/UJ0btS#Z0ca58253632bb757248bb5b4a3244d40) * **Corpus luteum cyst** * Enlargement and buildup of fluid in the [corpus luteum](https://next.amboss.com/us/article/O60IOS#Z146800817289667775e64ffd65fe8e01) after failed regression following the release of an [ovum](https://next.amboss.com/us/article/O60IOS#Z6f9cf85e209c336035854438760d1213) * Produces [progesterone](https://next.amboss.com/us/article/uk0ppT#Zf885481311d66b6abb1510c2c20cd63d), which may delay [menses](https://next.amboss.com/us/article/Ek08pT#Zde588f17aefcfdcb408905a4dab65618) * Associated with [progesterone](https://next.amboss.com/us/article/uk0ppT#Zf885481311d66b6abb1510c2c20cd63d)-only [contraceptive](https://next.amboss.com/us/article/Em08hg#Z93101293ea78e61fe2d52070458667ce) pills and [ovulation](https://next.amboss.com/us/article/Ek08pT#Z4444420b54b73b5aae96fe23b2824fc4)-inducing medication * Common during [pregnancy](https://next.amboss.com/us/article/dO0orT#Zeba6f488931dd463917047bb9c5f18f4) * **Theca lutein cysts** * Often multiple cysts that typically develop bilaterally * Result from exaggerated stimulation of the [theca interna](https://next.amboss.com/us/article/O60IOS#Z7753e15a726cfc917086a0f19a8b2bea) cells of the [ovarian follicles](https://next.amboss.com/us/article/O60IOS#Z781caefdefd3d2f427822a0fdf7f8a8c) due to excessive amounts of circulating [gonadotropins](https://next.amboss.com/us/article/AT0Rt2#Zdffa21cf39d2cfd17a57001ad8317fce) such as [β-hCG](https://next.amboss.com/us/article/dO0orT#Zf824ea3cd7cea49116eda11b5d23f9b0) * Strongly associated with [gestational trophoblastic disease](https://next.amboss.com/us/article/2O0T7T#Z465c529e5c8b79cefc425000e58a7df4) and [multiple gestations](https://next.amboss.com/us/article/Yl0nvT#Z35d7fa46a5d058ab18ca95260a0ddd2e) * Usually resolve once [β-hCG](https://next.amboss.com/us/article/dO0orT#Zf824ea3cd7cea49116eda11b5d23f9b0) levels have normalized

Answer 120

Give **activated charcoal (AC)** 50 g to all adult patients presenting within 4 hours of ingestion, unless contraindicated; AC may be useful for coingestants beyond 4 hoursTreat with **N-acetylcysteine (NAC)** if:Serum APAP concentration drawn at 4 hours or more after a single acute ingestion is above the "treatment" line of the treatment nomogram for APAP poisoning * \<4 hours \>\> activated charcoal wait till 4 hours then plot the APAP * 4-24 \>\> plot the APAP \>\> if level are high enough NAC * \>24 hours \>\> give NAC if patient is symptomatic

Answer 121

Type 1: Hpoxemic: PO2 \<60mmHg on room air: pneumonia, pulmonary edema, pulmonary embolism Type 2: hypercapnic/ventilatory: PCO2\>50mmHg: COPD, asthma, neurological Type 3: peri-opeartive (a subset of type1) Type4: shock secondary to cardiovascular instability

Answer 122

in children below 5 years: Staph aureus in children above 5 years: pseudomonas aeruginosa

Answer 123

admit patient: * not tolerate oral antibiotic * severe hypoxia \<92% * severe tachypnea \>50 per minutes in infants and more than 70 per minutes in children older than 1 year * toxic appearance * patient with underlying medical condition * pneumonia complicated by effusion or empyema **Treatment:** Outpatient: Amoxicillin Inpatient: ceftriaxone + macrolide

Answer 124

admit patient: * not tolerate oral antibiotic * severe hypoxia \<92% * severe tachypnea \>50 per minutes in infants and more than 70 per minutes in children older than 1 year * toxic appearance * patient with underlying medical condition * pneumonia complicated by effusion or empyema **Treatment:** Outpatient: Amoxicillin Inpatient: ceftriaxone + macrolide

Answer 125

in diarrhea there will be metabolic acidosis because of loss of bicarbonate in stool

Answer 126

**Etiology**: 1- Central diabetes insipidus: absent synthesis or secretion of ADH from posterior pituitary * Primary idiopathic * secondary to brain tumor, neurosurgery, traumatic brain injury, pituitary ischemia, infection 2- Nephrogenic diabetes insipidus: defect in ADH receptors in the distal tubules and collecting duct **clinical features:** * Polyuria * Nocturia * Polydipsia * in severe cases of dehydration, altered mental status, lethargy, seizure, coma and hypotension **investigation**: * Sodium: mild hypernatremia * ADH levels: decreased * plasma osmolality: high-normal or slightly elevated * urine osmolality: low * Water deprivation test: plasma osmolality rises but urine osmolality remains low * Desmopressin test:if central DI \> urine osmolality rises BUT in nephrogenic osmolality remains low (due to resistance) Treatment: 1- Central diabetes insipidus: Desmopressin 2- Nephrogenic diabetes insipidus: Thiazide diuretic, NSAID, Amiloride

Answer 127

**investigate** nocturnal enuresis when 1- secondary enuresis: previous dryness was achieved for more than 6 months 2- growth failure 3- symptoms of UTI, weak stream urine, daytime incontinence, polyuria 4- daytime enuresis **Management**: treatment should be started for patients older than 8 year old initial treatment: behavior and modification therapy if not responding then Alarm or desmopressin should be started

Answer 128

Type 4 RTA: related to defect in aldosterone or renal obstruction * congenital adrenal hyperplasia * hyporaldosteronism * obstructive uropathy * spironolactone or amiloride

Answer 129

**Indications**: children below 6 months: * Recurrent UTI (2 pyelonephritis or 3 cystitis Or 2 cystitis and 1 pyelonephritis in 12 months) * Atypical UTI * UTI and renal ultrasound showed hydronephrosis from 6 months to 3 years: * Atypical UTI * Renal ultrasound showed hydronephrosis **_what is Atypical UTI:_** * no response to antibiotic after 48 hours * presence of hypertension * presence of renal failure * UTI caused by organism other than E coli * presence of abdominal mass * poor urine stream Ultrasound is performed after first febrile UTI DMSA scan is performed 6-12 months after UTI to detect scarring

Answer 130

* Grade 5 reflux * if patients reached 5 years old and still has reflux * hypertension * renal scar * renal failure * failure of medical treatment

Answer 131

oral antibiotic is the first line treatment in upper and lower UTI * oral cephalosporins * augmentin * TMP/SMX * nitrofurantoin indication to use IV antibiotic: * in neonates * severely ill * immunosuppressed patients * patients with underlying renal disease duration of treatment: for cystitis only 3-5 days * trimethoprim/sulfamethoxazole * nitrofurantoin * augmentin * second generation cephalosporins for pyelonephritis 7-10 days * oral second generation cephalosporins * amoxicillin and clavulanic acid * IV ceftriaxone

Answer 132

not responding to oral steroid for 4 weeks and additional 3 doses of IV methylprednisolone most common cause of steroid resistant nephrotic is focal segmental glomerulosclerosis in pediatric treatment of steroid resistant nephrotic syndrome: * cyclosporine * diuretic if needed * ACE

Answer 133

* age less than 1 year or more than 10 years * gross hematuria * hypertension * renal failure * low serum complement * steroid resistance

Answer 134

* hyperkalemia * hyperuricemia * hyperphosphatemia * hypocalcemia Management: 1- hydration 2- [**Hyperkalemia**](https://next.amboss.com/us/article/7g0492#Ze93669b61aa64eca250e144146f31db0): cardiac monitoring and standard therapy for [hyperkalemia](https://next.amboss.com/us/article/7g0492#Ze93669b61aa64eca250e144146f31db0) if K⁺≥ 6 mEq/L, e.g., glucose and [insulin](https://next.amboss.com/us/article/Gm0BSg#Z22bb3029af932ca3214f211adb89e9e3) (rapid action) **3-** [**Hyperphosphatemia**](https://next.amboss.com/us/article/Ln0wFg#Z0e95d8ffffc9b5af9526b6f899247144): hydration and possibly oral phosphate binders, e.g., [sevelamer](https://next.amboss.com/us/article/gg0Fu2#Zc73ed097cd1ab6950240ca24d2031371) **4-** [**Hypocalcemia**](https://next.amboss.com/us/article/Hg0K92#Z50c20097f106413aab2d2eb1b550c96d): Treat only if symptomatic and give the lowest calcium dose to relieve symptoms (see “[Hypocalcemia](https://next.amboss.com/us/article/Hg0K92#Z50c20097f106413aab2d2eb1b550c96d)”) **5-** [**Hyperuricemia**](https://next.amboss.com/us/article/YT0n62#Z680dc030aea5462f042ba212fc37d0d8) * [**Allopurinol**](https://next.amboss.com/us/article/YT0n62#Z37cef276c9984e4bfe2e112cee98bd33) * Indicated as prophylaxis in patients at low to intermediate risk * **Rasburicase**: recombinant uricase that catalyzes the breakdown of [uric acid](https://next.amboss.com/us/article/kg0mv2#Zb6a6fc26866322ecd909b8f1489e0451) to allantoin * Indications * Treatment of established [TLS](https://next.amboss.com/us/article/uJ0pDS#Zfe45dd1efbd69bdc8eb20067a0ceeea4) * Prophylaxis for intermediate to high-risk patients

Answer 135

**Etiology**: * Up to 90% of cases preceded by viral or bacterial infection 1–3 weeks prior ^[3] * Most commonly an [**upper respiratory tract infection**](https://next.amboss.com/us/article/Bm0z3g#Zddf21d7d8790502dc72c31a3696575cd) caused by [group A Streptococcus](https://next.amboss.com/us/article/Sn0ysg#Z9f6c2592249245985f57238ca4236807) **Clinical feature:** 1- Skin: (100% of the cases): symmetrically distributed palpable purpura (most commonly in the lower extremities) 2- Joints: (75% of the cases): arthritis and arthralgia (mmost commonly ankle and knee 3- GI: colicky abdominal pain, can cause intussusception, bloody stool, nausea and vomiting 4- Kidney: Nephritic syndrome symptoms Investigation: * clinical diagnosis * Biopsy is indicated in patients with unusual skin presentation or severe renal involvement. (skin leukocytoclastic vasculitis with IgA and C3 immune complex deposition. Kidney mesangial IgA deposition) **Management**: 1- General management: adequate oral hydration, bed rest, and symptomatic relief of joint and abdominal pain. 2- Treatment of joint and abdominal pain: NSAID 3- Severe refractory abdominal pain: (failed to respond NSAID, interfere with oral intake): systemic glucocorticoid

Answer 136

all children should be screened for anemia by doing CBC from 9-12 months in patients with underlying medical condition repeat screening should be done again at 15-18 months

Answer 137

**Clinical features:** * CNS: poor concentration, abnormal behavior, lethargy, seizure * GIT: abdominal pain * renal failure * **ABCDEFGH**: **A**nemia, **B**asophilic stippling, **C**onstipation, **D**emyelination, **E**ncephalopathy, **F**oot drop, **G**um deposition/**G**rowth retardation/**G**out, **H**yperuricemia/**H**ypertension **when to treat:** asymptomatic child with lead level more than 3.38mmol/l or 70mcg/dl symptomatic children but no encephalopathy with level \>2.16mmol/l or 45mcg/dl * **Treatment** ^[20] * Decrease exposure: professional lead paint abatement, dust reduction, minimization of contact with bare soil * Nutrition: calcium, [iron](https://next.amboss.com/us/article/Sp0yKS#Z35492e78cc83d9a3d833192b3c6e9674), [zinc](https://next.amboss.com/us/article/Sp0yKS#Z8bca5595924928177031c3e210cb61d4), [vitamin C](https://next.amboss.com/us/article/Ao0ReS#Za589ef9f8af9b30dd33130d2a398683e), and [vitamin D](https://next.amboss.com/us/article/Ao0ReS#Z081018821228b32f73f37b8fab7e95e7)-rich diet ^[21] * [Chelation therapy](https://next.amboss.com/us/article/Af0RK2#Zd1b22459121dcce775304dda0691688f) indications: ^[22] * Oral succimer with/without intravenous or intramuscular Calcium EDTA (calcium disodium ethylenediamine tetraacetic acid) ^[23] * Children with BLL ≥ 45 μg/dl ^[24] * Asymptomatic adults with BLL ≥ 80 μg/dl * Symptomatic adults with BLL ≥ 50 μg/dl * IM dimercaprol * Patients with lead encephalopathy

Answer 138

from birth high MCV, high HbF and high ADA autosomal recessive absent thumb short stature microcephaly blood transfusion dependent

Answer 139

* hemoglobin dropped by \>2g/l from baseline * patient is symptomatic (respiratory or hemodynamic instability) * hyperhemolytic crisis * aplastic crisis * mild acute chest syndrome * before major surgery

Answer 140

autosomal dominant * **Additional clinical features**: physical abnormalities manifest in ∼50% of affected individuals * Fatigue, poor feeding * [Short stature](https://next.amboss.com/us/article/c40aRT#Zc10f9f30073def93e59aa30e1dd2ebe8), [webbed neck](https://next.amboss.com/us/article/Wo0PaS#Zd0761d2c120278ac5031fb4a19b0dc10) * Upper extremity [malformations](https://next.amboss.com/us/article/vo0AdS#Za2917144496685a377f046c65f8f8102) (e.g., **triphalangeal thumbs**) * [Microcephaly](https://next.amboss.com/us/article/b40H3T#Z9b60fc15f45244252918c1ab18c82eb5), [micrognathia](https://next.amboss.com/us/article/e40xRT#Z55ab1e0836b46cc575ee502254e68ea9) * [Hypertelorism](https://next.amboss.com/us/article/240TiT#Z6aa22da372cf3171fb08564e90320938), flat nasal bridge, [cleft palate](https://next.amboss.com/us/article/FM0gqg#Zfd73a4ee1e2ea23b9769eeb04809c0d4) * [Congenital cataracts](https://next.amboss.com/us/article/pO0LtT#Z82439352dc33fe021c33865cedc4d0bc) or [glaucoma](https://next.amboss.com/us/article/IO0YFT#Z0b65b1763162e05726a612f24b7ad762) * Atrial and [ventricular septal defects](https://next.amboss.com/us/article/4403jT#Z37427ac24575cce09d2ea2f7b88638ad) * **Diagnostics** * [Electrophoresis](https://next.amboss.com/us/article/gp0FKS#Z4a3299d6ef2e1c42acab833eb614dc8c) * **Elevated** [**HbF**](https://next.amboss.com/us/article/WS0PA2#Z78447f6c644a984bc31fc82c7e1af394) **levels** * Low total [Hb](https://next.amboss.com/us/article/WS0PA2#Z94b6c5cf373e3de2a4f32b9f3fb10b4e) levels * Specific laboratory findings * **Elevated** **erythrocyte adenosine deaminase** **levels** (eADA) * Increased expression of i antigen in [RBCs](https://next.amboss.com/us/article/ln0vtg#Z79ddb9a0dd4dbd469d90aef3521a5f94) * **Treatment** ^[31] * [Corticosteroids](https://next.amboss.com/us/article/km0mfg#Z3733d22ef7bb87f743207060acda0451) (first-line treatment) * Chronic red cell [transfusions](https://next.amboss.com/us/article/2M0TLg#Z0d767a500a4efcb1314a93ab2616de44): individuals who do not respond to [corticosteroids](https://next.amboss.com/us/article/km0mfg#Z3733d22ef7bb87f743207060acda0451) * [Hematopoietic stem cell transplantation](https://next.amboss.com/us/article/gn0Fsg#Za618edd4a5927604448cdc70d4c16172) * **Complications** * Increased risk of [malignancy](https://next.amboss.com/us/article/WM0Png#Z8c3bce39ca977e0f872b6d9fb3be8cfb): [acute myelogenous leukemia](https://next.amboss.com/us/article/iT0Jq2#Zdf106029b619b896fe5d8c0363d4258b), myelodysplastic syndrome, solid tumors (e.g., [colon cancer](https://next.amboss.com/us/article/TS06_2#Z5f9a21e2819d2a5004da275e0fe8e909), [osteogenic sarcoma](https://next.amboss.com/us/article/HQ0Kxf#Z8ff05dcf1560740b28f49573a0389d8f)) * Treatment-associated complications: [iron overload](https://next.amboss.com/us/article/Ln0wFg#Zf139bb65d983ff923e421ae0b5654ca6) due to repeated [transfusions](https://next.amboss.com/us/article/2M0TLg#Z0d767a500a4efcb1314a93ab2616de44), [corticosteroid](https://next.amboss.com/us/article/km0mfg#Z3733d22ef7bb87f743207060acda0451)-induced [hyperglycemia](https://next.amboss.com/us/article/3g0SE2#Z41765cf0097c7ea6f788430b14b10a35) * Endocrine dysfunction: [adrenal insufficiency](https://next.amboss.com/us/article/Ug0bu2#Z9506c5c93356b984bdd17a7d48a36997), [hypogonadism](https://next.amboss.com/us/article/8o0OdS#Zaf806999b17acacf6559217fbdbb5c15), [vitamin D deficiency](https://next.amboss.com/us/article/XT0962#Za82d785558583383e2e6a126632b713e) ![]()

Answer 141

* severe acue chest syndrome * stroke * silent stroke * multiorgan failure

Answer 142

* low MCV * high MCHC * high RDW * high unconjugated bilirubin * low haptoglobin * high LDH * positive osmotic fragility test (initial) * Eosin-5-maleimide binding test (diagnostic) treated with splenectomy (sole definitive treatment)

Answer 143

* Dysmorphic features ^[11] * **Thin upper lip** * **Smooth** [**hypoplastic**](https://next.amboss.com/us/article/vo0AdS#Z8b886a5c6d6c17b40bcf17f556616561) [**philtrum**](https://next.amboss.com/us/article/jp0_6S#Z0b5c636deeb7ac49a78dbe73f19b9c19) * **Down-slanting, short** [**palpebral fissures**](https://next.amboss.com/us/article/cp0aoS#Z15d891c8f5c95aa42fc72145a8678760) * [Hypertelorism](https://next.amboss.com/us/article/240TiT#Z6aa22da372cf3171fb08564e90320938) * [**Microcephaly**](https://next.amboss.com/us/article/b40H3T#Z9b60fc15f45244252918c1ab18c82eb5) * Epicanthal folds * Receding chin * Features of specific systemic defects * [Heart](https://next.amboss.com/us/article/Up0bKS#Z4e3e2c1885949b623580f92078d56c7d) defects (mainly [ventricular septal defect](https://next.amboss.com/us/article/4403jT#Z37427ac24575cce09d2ea2f7b88638ad)) * [Heart](https://next.amboss.com/us/article/Up0bKS#Z4e3e2c1885949b623580f92078d56c7d)-[lung](https://next.amboss.com/us/article/ap0QLS#Z5a964768554f93e7967999032fda236f) [fistulas](https://next.amboss.com/us/article/vH0AHh#Z110d4126c6c4e2cb567242f4c0f4a60d) * Skeletal anomalies (limb [dislocations](https://next.amboss.com/us/article/P30Wif#Zabf4d676cc592e8b68bd468e98f4b563), [joint contractures](https://next.amboss.com/us/article/hQ0cDf#Zd2a2f37a9ccc074254e9331a5ba6126c), [pectus excavatum](https://next.amboss.com/us/article/hk0cnT#Zfd3946ce29c60eba7608733df338102d)/[pectus carinatum](https://next.amboss.com/us/article/hk0cnT#Zd7af67d5f21f234b5b0efcc9e8e5c368)) * Renal anomalies (aplastic/[dysplastic](https://next.amboss.com/us/article/WM0Png#Z409fc6a3e32d11acbee6f0b5c89913e1) [kidneys](https://next.amboss.com/us/article/m60VlS#Z517d2cc21845787cbf2c6ff27c21cd8e)) leading to [hypertension](https://next.amboss.com/us/article/Xh09cf#Zce0d4554dd0bc7f9fba742d2827ffc63) * Prenatal or postnatal growth retardation → [short stature](https://next.amboss.com/us/article/c40aRT#Zc10f9f30073def93e59aa30e1dd2ebe8) * Holoprosencephaly: a developmental field defect in which the forebrain fails to divide into two hemispheres, resulting in fusion of ventricles (leading to the formation of monoventricle) and other bilateral cerebral structures, e.g., [basal ganglia](https://next.amboss.com/us/article/WK0P2S#Z2eb2f30c001f2b5fa17eeba767aa7b39) ^[12] * Most commonly occurs during the 3^rd–4^th week of [pregnancy](https://next.amboss.com/us/article/dO0orT#Zeba6f488931dd463917047bb9c5f18f4) ^[13] * Potential genetic causes include: * Mutations in [SHH gene](https://next.amboss.com/us/article/uo0pdS#Zcc641b84fe286ae4728e058cea554090) coding for [sonic hedgehog](https://next.amboss.com/us/article/uo0pdS#Zcc641b84fe286ae4728e058cea554090) protein * [Trisomy 13](https://next.amboss.com/us/article/e40xRT#Zaaa58b42aa6473d9c637ff7b37ededed) * Associated clinical features * Craniofacial abnormalities (cyclopia, [cleft lip](https://next.amboss.com/us/article/FM0gqg#Zc9c6445b3f574d9f697f3a5fe6ff74a9)/[palate](https://next.amboss.com/us/article/jp0_6S#Z281012acfe74769bb5123dd3d8770405), hypotelorism, and/or proboscis) * Endocrine disorders related to [pituitary](https://next.amboss.com/us/article/AT0Rt2#Zf261fc5b32a905f3dde728d2f04a4b7a) dysfunction (e.g., [diabetes insipidus](https://next.amboss.com/us/article/_T05t2#Z1039c4d49b18b13c5d34432594b8806b)) * [Seizures and epilepsy](https://next.amboss.com/us/article/RR0l5f#Zbfb7d8e26a233a99718a61b60a9139a1)

Answer 144

The diagnosis of FMF should be suspected in individuals with recurrent febrile episodes accompanied by peritonitis, synovitis or pleuritis, recurrent erysipelas-like erythema, repeated laparotomies for an acute abdomen with no identifiable underlying pathology, a first-degree relative with FMF, and/or membership in an at-risk ethnic group. The diagnosis of FMF is made based on clinical symptoms and supported by ethnic origin and family history. Genetic testing is used to further confirm the diagnosis of FMF and to exclude other autoinflammatory syndromes mimicking FMF. In individuals who meet clinical criteria for FMF but in whom genetic testing is not diagnostic (only one or no pathogenic *MEFV* mutation), the diagnosis of FMF is supported by a six-month trial of [colchicine](https://www.uptodate.com/contents/colchicine-drug-information?search=familial%20mediterranean%20fever&topicRef=2635&source=see_link) therapy, which results in a relief of attacks and recurrence after cessation of treatment. side effect of clochicine: abdominal pain and diarrhea, muscle weakness especially when taking statin, acrolide, verapamil

Answer 145

usually happen in babies delivered at home because they did not receive vitamin L vitamin K deficient factors: 10,9,7,2 both PTT and PT will be prolonged

Answer 146

benign epilepsy with centrotemporal spikes **Clinical features** * Usually occurs during sleep * Facial twitching or numbness, hypersalivation, and [speech](https://next.amboss.com/us/article/br0Hfh#Zd423a68450327021f26303182c94ebe1) arrest (during and frequently even after the event) * Involvement of an arm/entire side of the body is possible, as is secondary generalization. **Diagnostics**: [EEG](https://next.amboss.com/us/article/Cn0qvg#Z0e525243b471b6544f999eab44e59454) shows centrotemporal spikes or [sharp wav](https://next.amboss.com/us/article/Cn0qvg#Z6f98292215bc530ebf317b4d5a5e1793)e

Answer 147

* 3–7 months * Sex: ♂ \> ♀ * [**Perinatal**](https://next.amboss.com/us/article/a40Q3T#Z24c4f7fe83ea326e4a4d922f38e9815f) **infections** * [**Hypoxic**](https://next.amboss.com/us/article/ZI0ZYh#Z11178ec3c2e582d07f19c0f784e018a3)**-**[**ischemic**](https://next.amboss.com/us/article/VP0GdT#Zbc05e544d46e794a60ac9ce9ec6883af) **injury** * [PKU](https://next.amboss.com/us/article/vR0AKf#Zd37af04f55fcda817c9f5d7129f4dc75) * [Tuberous sclerosis complex](https://next.amboss.com/us/article/Rk0lnT#Zb04d7a2607c625d98a54844723e589ff) * Idiopathic * Sudden **symmetric**, **synchronous spasms**, usually in clusters of 5–10 * **Jerking** [**flexion**](https://next.amboss.com/us/article/xo0EVS#Ze4037822f631cf13d894ef7837c90ad6) (jackknife movement) **or extension** of the neck, torso, and extremities * Followed by a tonic phase * **Hypsarrhythmia**: characteristic finding in [**interictal**](https://next.amboss.com/us/article/RR0l5f#Zeb518ef17f0f5bafd3edb6f971b8748d) [**EEG**](https://next.amboss.com/us/article/Cn0qvg#Z0e525243b471b6544f999eab44e59454); high-voltage delta waves with irregular multifocal spikes and slow waves * [Ictal](https://next.amboss.com/us/article/RR0l5f#Zcf4d08e511a21e6c2fb92c7b407c79d6) [EEG](https://next.amboss.com/us/article/Cn0qvg#Z0e525243b471b6544f999eab44e59454): very heterogeneous * **First-line treatment**: [**ACTH**](https://next.amboss.com/us/article/AT0Rt2#Z0693e64e06b8171ba41c7166f146a32d), [**prednisone**](https://next.amboss.com/us/article/km0mfg#Z7acc6b8a4fb3eecc9bdffe7ff1f88c25), or [**vigabatrin**](https://next.amboss.com/us/article/-N0Ddg#Ze95a583f8a97799d8cd2d9aa2685817b)

Answer 148

screening all pregnan women at least once performed at 12-16 weeks treatment options include beta lactam, nitrofurantoin (for 5-7 days) and fosfomycin if pyelonephritis is suspected nitrofurantoin and fosfomycin should not be used as it doesn't reach the kidney

Answer 149

Autodomal Dominant 1-Six or more café-au-lait spots or hyperpigmented macules =5 mm in diameter in prepubertal chil-dren and 15 mm postpubertal 2-Axillary or inguinal freckles (\>2 freckles) 3- Two or more typical neurofibromas or one plexiform neurofibroma 4- Optic nerve glioma 5-Two or more iris hamartomas (Lisch nodules), often identified only through slit- lamp examination by an ophthalmologist 6- Sphenoid dysplasia or typical long-bone abnormalities such as pseudarthrosis 7-Positive genete in allele for NF1 from WBC

Answer 150

Autosomal dominant TSC1 and TSC2 gene mutation Clinical features: * Ash leaf macules * cafe au lait spots * Peiungual fibroma * Angiomyolipoma of renal artery * cardiac rhabdomyoma * polycystic kidney disease * adenoma sebacioum * shagren batch

Answer 151

Autosomal recessive genetic disorder where nerve cells in the spinal cord die prematurely (degeneration of anterior horn cells) \>\> muscle atrophy **Spinal muscle atrophy type 1:** * hypotonia but alert * severe progressive disorder * diminished fetal movement during pregnancy * arthrogryposis (position deformity of the limb with contracture of at least two joints) * fasiculation of the tongue * symmetrical flaccid paralysis * absent deep tendon reflex * intercostal recession * weakness of bulbar muscle, weak cry, poor suck with pooling of secretion * never sit unaided * die of respiratory failure **Spinal muscular atrophy type2:** * infants are normal at birth * develop progressive weakness worse proximally * weak sucking, chewing, and swallowing (aspiration) * weakness in chest wall and diaphragm * can sit but never walk **investigation** 1- Genetic testing: best and initial 2- creatine kinase is elevated 3- EMG spontaneous large amplitude, low frequency 4- muscle biopsy atrophy of groups of motor units

Answer 152

* autoimmune myopathy * symmetrical proximal muscle weakness (most important clinical feature) * heliotrope rash (reddish purple rash on the upper eyelid often accompanied by swelling of the eyelid) * Gottron's papules (erythematous, papulosquamous eruption over the dorsal surfaces of the knuckles) (characteristic) * nailfold capillary changes, skin ulcerations, calcinosis (soft tissue calcification), nonerosive arthralgia and arthritis, lipodystrophy, and insulin resistance investigation: * serum creatinine kinase is best initial * muscle biopsy is diagnostic Treatment * Ultraviolate protection * physiotherapy * steroid * biological agent

Answer 153

* most common cause of acute hip pain in children 2-12 years * often follows or accompanied by viral infection * sudden onset hip pain or limp * no pain at rest * there is decrease range of motion particularly internal rotation * no fever * at risk of the development of perthes disease ( avascular necrosis of the capital femoral epiphysis of the femoral head) * ultrasound may show effusion

Answer 154

Elongated transverse aortc arch Bicuspid aortic valve coarcitation of aorta most common finding: fold skin at the nape of the neck

Answer 155

Triade of congenital rubella syndrome * Cardiac defect: most common (PDA, pulmonary, pulmonary artery stenosis) * Cataract: (other eye manifestations may occur later in life like glaucoma, salt and pepper retinopathy) * cochlear defect: bilateral sensorineural hearing loss * blueberry muffin rash

Answer 156

most common congenital heart anomaly: motral valve prolapse

Answer 157

* short * soft * healthy child * no radiation * change with posture * no thrill (grade 1 to 2) known as still's murmur

Answer 158

* high calorie diet (150 kcal/kg) * high dense calorie formula * immunization like influenza * RSV immunoglobulin prophylaxis

Answer 159

VSD usually close spontanously if small (less than 5mm) muscular VSD more likely to close than peirmembrenaous **Indications** for surgical closure: * heart failure not responding to medications * large pulmonary blood flow with a ratio to systemic blood flow 2:1 * early pulmonary hypertension Method of closure: surgical

Answer 160

* Oxygen * Sodium bicarbonate * Alpha agonist (phenylephrine) * Morphine * Adrenergic antagonist (beta blocker) * Hydration

Answer 161

modified jones criteria * two positive blood culture out of 3 for typical organism (street viridans, staph aureus, HACEK) * ECHO findings like vegetation, abscess or dehiscence of prosthetic valve * new valvular regurgitation * fever * predisposing factors like IV drug abuse or congenital heart disease * immune phenomena like: roth spot, osler node, glomerulonephritis * vascular phenomena like janeway lesion, mycotic aneurysm, conjunctival hemorrhage, septic emboli * blood culture result don't meet the major criteria **treatment**: IV vancomycin for 6 weeks surgery **indicated** in: * fungal endocarditis * severe valve regurgitation * dehiscence of prosthetic valve * myocardial abscess * mycotic aneurysm

Answer 162

Causes of neonatal sepsis: * Group B strept * Ecoli * Listeria mnocytogene Treatment of early: ampicillin + gentamycin Treatment of late: ampicillin + gentamycin + cefotaxime

Answer 163

* if persist more than 2 weeks * if it became yellow in color * if foul smelling * if mixed with blood

Answer 164

Congenital: 1. Jervell Lange syndrome: deafness, syncopal attacks and sudden death 2. Romano Ward syndrome: autosomal dominant, most common inherited long T syndrome, syncope and sudden death. Acquired: * During sleep * hypocalcemia * acute myocarditis * acute MI * hypothermia * HOCM * cerebral injury * advanced AV block

Answer 165

**Treatment**: Indications for hospitalization: * age \<2 months * clinical urosepsis * immunocompromised * vomiting and unable to tolerate oral * lack of outpatient follow up * failure to respond to outpatient therapy Emperic antibiotic therapy: * children without genitourinary abnormality: Cephalosporin (if enterococcal infection is suspected add amoxicillin or ampicillin) * pyelonephritis: second generation cephalosporin (cefuroxime) or third generation (cefixime, cefdinir) Duration of treatment: * Afebrile children are treated for 3-5 days * Febrile children are treated for 10 days Imaging: * First febrile UTI in children younger than 2 \>\> renal bladder ultrasound * recurrent febrile UTI \>\> ultrasound * voiding cystourethrogram to diagnose vesicoureteral reflux if 1. any age with \>2 febrile UTI 2. any anomaly on renal ultrasound 3. temp \>39c and a pathogen other than E coli 4. poor growth or hypertension 5. children less than 6 months + atypical UTI, recurrent UTI, hydronephrosis in US 6. in children above 6 months: atypical UTI, hydronephrosis in rental US

Answer 166

X linked recessive * pupura * eczema * recurrent opportunistic infection with encapsulated organism (eg otitis media) * thrombocytopenia Serum IgM is low serum IgG is normal Serum IgA and IgE are elevated

Answer 167

deficiency of superoxide production by neutrophils and macrophage Etiology: X linked recessive or autosomal recessive Clinical feature: * recurrent severe infection (chronic skin, lymph node, respiratory , Gi, urinary tract infection) with catalase positive organism (S.aureus, E.coli, candida, klebsiella, psudomonas, aspergillus) * Lymphadenopathy * Granulomas *

Answer 168

defect in neutrophil chemotaxis and microtubule polymerization dysfunction Autosomal recessive **Clinical feature:** * recurrent pyogenic infection (s. pyogenes, s.aureus, psudomonas) * partial _albinism_ * progressive degeneration of neurons and peripheral neuropathy

Answer 169

Prince Edward turned 18 * Prominent occiput * Rocker bottom feet * Intellectual * Nondisjunction (in meiosis) * clenched fist * low set ears * chromose 18

Answer 170

Patau syndrome * Microcephaly, holoprosencephaly * cleft lip and palate * low set ears * micropthalmia * polydactyly * congenital heart defect * ricker bottom feet * aplasia cutis congenita * omphalocele

Answer 171

* muscular hypotonia * hyperphagia and obesity * hypogonadism * almond shaped ears * intellectual disability * behavioral problems

Answer 172

* upward slanting palpebral fissure * epicanthal fold * brushfield spots * apperanc of protroduing tongue * broad and flat nasal bridge * transevere palmer crease * sndal gap * clindodactyly * short stature * atlantoaxial instability * Congenital heart defect: Atrioventricular septal defect (endocardial cushion defect) * GI: duodenal atresia, hirshprung disease, annular pancreas * autoimmune: DM type 1, celiac disease, hypothyroid * most common malignancy: leukemia * CNS: mental retardation, central hypotonia (most common feature), seizure * recurrent otitis media and deafness

Answer 173

* partial absence of abdominal wall muscle (prune like or wrinkled appearance) * bilateral cryptochrisim * urinary tract malformation (obstructed bladder neck: bladder distension)

Answer 174

* jaundice * seizure * metabolic acidosis * cataract * recurrent e coli infection * urinary positive for glucose, amino acid and phosphate

Answer 175

* shigella * yersinia * salmonella * campylobacter * chlamydia arthritis conjunctivitis urethritis

Answer 176

Rifampin Ceftriaxone (preferred during pregnancy) Ciprofloxacin (avoid during pregnancy and if patient \<18 of age)

Answer 177

a hydatid cyst is caused by echinococcosis is a parasitic disease caused by small tapeworm fecal contaminated food or water definitive foxes, dogs, cats treatment: * single cyst + \<5cm ==\> albendazole * single cyst + \> 5cm ==\> percutanous drainage (puncture, aspiration, injection, reaspiration) * daughter cells ==\> surgical deroofing + albendazole * ultiseperated (rossete like or honeycoming) ==\> surgical deroofing or albendazole

Answer 178

acute infection that manifests with fever, sore throat, herpes-like lesion on the posterior oropharynx and tonsils Etiology: Coxsackie A virus infection **Clinical feature:** * high grade fever * sore throat * herpes like oral lesion: multiple 1mm vesicles located on the posterior oropharynx and tonsils * pharyngeal and tonsillar redness **Treatment:** * supportive care

Answer 179

1. elevate head of the bed 30 degree 2. sedation and analgesia 3. maintain normothermia 4. target euvolemia and avoid serum hypoosmolarity (serum sodium \>135) 5. seizure control: prophylaxis for patients with high risk seizure 6. IV mannitol 7. Dexamethasone if ICP is caused by CNS infection or neoplasm 8. SURGICAL therapy * CSF drainage: External ventricular drain, lumbar drain, cerebral shunt * decompressive crainectomy:

Answer 180

typically affect age \<1 year Stages: 1- catarrhal stage: (1-2 weeks) mild cough, rhinorrhea, low-grade fever 2- paroxysmal stage (2-6 weeks): paroxysmal cough often at night, high pitched whooping cough, posttussive vomiting. 3- convalescent stage: coughing may persist for several weeks before resolving. **Diagnosis**: clinical diagnosis culture or PCR from deep nasopharyngeal aspiration or posterior nasopharyngeal swab (gold standard) **Treatment**: MAcrolide: azithromycin, clarithromycin post exposure prophylaxis: all household contact of pertussis (regardless of their vaccine status) should receive macrolide

Answer 181

1. beta blocker to control symptoms 2. thionamide (block new hormone synthesis): propythiouracil or methimazole 3. iodine solution (block release of thyroid hormone) 4. iodinated radiocontrast 5. glucocorticoids (reduce conversion of T4 to T3)

Answer 182

glucocorticoids

Answer 183

accumulation of pus in the pleural cavity Etiology: pneumonia Clinical feature: fever, cough, chest discomfort Diagnostic: * CT ches: split pleural sign * pleural fluid analysis: low pH, low glucose, increase LDH, purulent

Answer 184

* **Type 1 AIH** (80% of cases): characteristic [autoantibodies](https://next.amboss.com/us/article/x50Emg#Z07ff4a8efdae49ba17ed2b65e3db534d) include [antinuclear antibodies](https://next.amboss.com/us/article/ul0pAT#Z50118528301d2163a3a5d644e0e77a3d) ([ANAs](https://next.amboss.com/us/article/ul0pAT#Z50118528301d2163a3a5d644e0e77a3d)), anti-smooth muscle antibodies ([ASMAs](https://next.amboss.com/us/article/JM0spg#Zbf131289d4911aa4ab95b7cbb9720863)), anti-soluble liver antigen/liver pancreas antibodies ([anti-SLA/LP](https://next.amboss.com/us/article/JM0spg#Z5d25779513b2be637b3221c867a601b9)) * **Type 2 AIH**: characteristic [autoantibodies](https://next.amboss.com/us/article/x50Emg#Z07ff4a8efdae49ba17ed2b65e3db534d) include anti-liver-kidney microsomal-1 antibodies (anti-LKM-1), anti-liver cytosol antibodies-1 ([ALC-1](https://next.amboss.com/us/article/JM0spg#Z70dfab4e279cb7e0a9a5a08dba2ff58a))

Answer 185

Unexplained signs of blood loss or hypotension in a patient who cannot be stabilized and in whom intra-abdominal injury is strongly suspected ●Clear and persistent signs of peritoneal irritation ●Radiologic evidence of pneumoperitoneum consistent with a viscus rupture ●Evidence of a diaphragmatic rupture ●Persistent, significant gastrointestinal bleeding seen in nasogastric drainage or vomitus

Answer 186

gradual cognitive decline caused by small or large vessel disease. **Risk factors:** * Age * history of stroke * HTN * hyperglycemia * hypercholesterolemia and hypertriglyceridemia * obesity Investigation: * Brain MRI: multiple cortical infract, subcortical infract \*lacunar) * CT brain: microangiopathy lesion located in white matter, multiple lacunar lesion in subcortical brain

Answer 187

depends on disease activity which is determined by * CBC * anti DsDNA * ESR * CRP * C3 and C4 * GFR

Answer 188

* clyclophosphomide * methotrexate * mycophenalate * leflunamide

Answer 189

Etiology Group A streptococcal infection Most common in children aged 5-12 years Clinical feature: Fever Headache Tonsillitis Sandpaper like maculopapular rash with flushed cheeks perioral sparing Tongue is white and coated and may be sore or swollen Treatment Penicillin V Erythromycin

Answer 190

Hyperkalemia Hypocalcemia Hypoglycemia Citrate toxicity

Answer 191

Appendectomy is adequate treatment unless Lymph node involved visibly Tumor more than 2cm Mucinous element present in tumor Mesoappendix or base of cecum is invaded In these cases right hemicolectomy is recommended

Answer 192

Neuropsychiatric lupus: IV cyclophosphamide + corticosteroids Nephrotic and cardiac lupus: Mycophenalate + corticosteroids Systemic Hydroxycholochen + NSAID \> steroid \> methotrexate

Answer 193

**Acute management** * SC low molecular weight heparin or UF heparin * severe cases: high dose glucocorticods, plasmaphoresis, immunoglobulin secondary prophylasxis: 1- Low risk: low dose asprin 2- High risk: * wishes to get pregnant: LMWH + asprin * doesn't wish to conceive long term treatment with oral warfarin

Answer 194

* sharp objects * long objects \>5cm * round batteries * magnetic objects * not passed in stool for 4 weeks * symptomatic: pain or fever emergent removal ·When the patient shows signs of airway compromise ·When there is evidence of near-complete esophageal obstruction (eg, patient cannot swallow secretions) ·When the ingested object is sharp, long (\>5 cm), or a superabsorbent polymer and is in the esophagus or stomach ·When the ingested object is a high-powered magnet or magnets ·When a disk battery is in the esophagus (and, in some cases, in the stomach) ·When there are signs or symptoms suggesting inflammation or intestinal obstruction (fever, abdominal pain, or vomiting)

Answer 195

Brachilal plexus injury injury to the upper trunk of brachial plexus (c5-c6) Clinical feature * waiter tip posture = flexed wrist with an extended forearm and internally rotated and abducted * bicep brachii * weak infraspinatus and supraspinatus * weak deltoid and supraspinatus * weak wrist extensor * asymmetric more reflex in infants

Answer 196

* failure of endoscopy therapy after 2 trials * persistent hemodynamic instability despite aggressive resuscitation * cardiovascular disease with predictive poor response to hypotension * hemorrhagic shock * excluding esophageal varices * after transfusion of 6 units of blood

Answer 197

* open skull fracture * midline shift \>5mm

Answer 198

* hypokalemia * hypophosphatemia * hypomagnesemia * hyperglycemia

Answer 199

after 6 weeks

Answer 200

- size \>10cm Papillary Solid component Irrigularity Presence of ascitis High color Doppler flow

Answer 201

- \>10mm - \<3 polyps - increase in size \>2mm - age \>50 - symptomatic - associated with gallstones -Associated with primary sclerosis cholangitis with cirrhosis Otherwise continue ultrasound evaluation for 3-6 months.

Answer 202

- Smoking cessation - Vaccination (influenza and pneumococcal) - Home oxygen therapy

Answer 203

Pleural drain + pipracillin tazobatam

Answer 204

Chlamydia, ureaplasma urealyticum Shigella, yersinia, salmonella, campylobacter

Answer 205

Cefepime Meropenem Impeneum Pipracillin-tazobactam

Answer 206

Hypophosphatemia -Hypokalemia - Congestive heart failure -Peripheral edema -Rhabdomyolysis -Seizures- Hemolysis -Respiratory insufficiency Hypophosphatemia is the hallmark of the syndrome and predominant cause of the refeeding syndrome

Answer 207

Initial =\> D&C biopsy or hysteroscopy sampling Definitive =\> laparoscopic hysterectomy Indications for malignancy -old age \>55, or post menopausal -endometrial thickening \>20mm -abnormal uterine bleed

Answer 208

Both copper and progesterone -suspected pregnancy -Undiagnosed genital tract bleeding - Acute or chronic PID -Lifestyle risk for STI -Known distorted uterine cavity -Immediatly post septic abortion Copper IUD -known allergy to copper Not contraindicated but increases blood loss and duration of menses and dysmenorrhea

Answer 209

Wilms tumor Anirdia Genitourinary anomalies Retarded mentally

Answer 210

Endometrial polyp is usually a solitary homogenous and echo genie lesion

Answer 211

22 =\> no resuscitation 22-25 =:\> discuses risk and benefit with parents \>25 =\> resuscitation is always initiated

Answer 212

Anastomitic leak Esophageal stricture Recurrent fistula GERS

Answer 213

9-12 months

Answer 214

Voriconazole

Answer 215

Woman in 40-50 Fatigue and itching Normal bilirubin with an elevated alkaline phosphatase Xanthelasma/xanthoma Osteoporosis -Antimitochondrial antibody -Liver biopsy is definitive Treated with urodeoxycholid acid or obeticholic acid

Answer 216

Etiology: Streptococcus pneumonia H.influenza Moraxella catarrhalis Treatment Amoxicillin Amoxicillin-Calvulanate

Answer 217

Erythema toxicum neonatorum (ETN) presents with multiple erythematous macules and papules (1 to 3 mm in diameter) that rapidly progress to pustules on an erythematous base. The lesions are distributed over the trunk and proximal extremities, sparing the palms and soles. They may be present at birth but typically appear within 24 to 48 hours. The rash usually resolves in five to seven days, although it may wax and wane before complete resolution. Biopsy will show eosinophils

Answer 218

Biopsy will show neutrophils

Answer 219

Gallbladder necrosis Emphysematous cholecystitis Gallbladder perforation Patients without indications for emergency cholecystectomy, who are critically ill or in poor health, or unfit for general anesthesia should be treated with gallbladder drainage

Answer 220

Influenza given in first or second trimester DTaP given third trimester between 27-36 weeks

Answer 221

24-96 months (2 years to 8 years)

Answer 222

Size \>10mm \<3 polyps Symptomatic Age \>50 Associated with gallstones

Answer 223

1cm —\> appendectomy \<2cm —\> if on the tip of the appendix —\> appendectomy. If at the base of the appendix —\> right hemicolectomy. \>2cm —\> right hemicolectomy

Answer 224

Fetal growth restriction Perinatal mortality Low birth weight Preeclampsia Maternal mortality Eclampsia

Answer 225

Grade \<2 intensity Softer intensity when the patient is sitting compared to when he is supine Short systolic duration Minimal radiation Musical or vibratory quality

Answer 226

The initial B-hCG level is obtained within 48 hours after evacuation. (baseline) - Then weekly until undetectable. - Once B-hCG is undetectable(for three consecutive weeks), this is confirmed with monthly for another 6 months

Answer 227

Between 10-50% Go with 30%

Answer 228

Symptoms: LUQ pain Shoulder pain (kehr’s signs) LUQ mass (balance sign) Gastric bubble displacement Unstable patient \>\> FAST scan Stable patient \>\> CT scan Indication for non operative management: Hemodynamically stable \<2 units transfusion No increasing hematoma size when followed by ultrasound Stable Hb Indications for splenectomy Grade 5 traumatic injury

Answer 229

Atovaquone proguanil

Answer 230

If \<1cm —\> lobectomy If \>1cm —\> near total or total thyroidectomy

Answer 231

Usually wait until maturation of cyst 6 weeks If infected —\> percutanous drainage If not infected —\> endoscopic drainage

Answer 232

In infants below 6 months: face and scalp • Between 6 months to 2 years: extensor surfaces of elbows and knees • Between 2-5 years: extensor in elbows and knees, wrist and hands, around mouth and eyes • Above 5 years: flexor surfaces

Answer 233

Severe life threatening allergy Pregnant Weak immune system or on radiation, immunotherapy, steroids, or chemotherapy Has parent or siblings with history of immune system problem Bleeds or bruise easily Recent blood transfusion (wait 3 months0 Has TB Has gotten any other vaccine within 4 weeks ago Moderate to severe illness

Answer 234

Absolute side effect: constipation Most common side effect: weight gain

Answer 235

Long thoracic nerve: wining of scapula Thoracodorsal nerve: cant push up + weak adduction Medial and lateral pectoral nerve: weakness of the muscle Intercostobrachial nerve:anesthesia in the inner arm

Answer 236

Refractory fluid overload ●Severe hyperkalemia (plasma potassium concentration \>6.5 mEq/L) or rapidly rising potassium levels ●Signs of uremia, such as pericarditis, encephalopathy, or an otherwise unexplained decline in mental status ●Severe metabolic acidosis (pH \<7.1) ●Certain alcohol and drug intoxications

Answer 237

Azithromycin and third generation cephalosporine (cefixime or ceftriaxone) trimethoprime-sulfamethoxasole and ampicilin are also susciptible

Answer 238

Common localized skin infection caused by molluscum contagiosum On trunk, face, and genitalia Sexually transmitted Lesion appear smooth, dome shaped papilledma with central umbilication Self limited and heals spontaneously Could persist in immunocompromised individual treated with cryotherapy with liquified nitrogen If in the genital region it should be treated

Answer 239

Important predictors of severity 8 • Age \> 55 • Gastrointestinal bleeding • Fall in Hct within 48 hours • Hypocalcemia and/or hyperglycemia • Inflammatory markers: ↑↑ CRP, ↑ IL-6, ↑ IL-8 • Evidence of shock and/or organ failure o ↑ AST, ↑ ALT o ↑ BUN, creatinine o ↑ LDH pO2 \< 60 mm Hg, metabolic acidosis with a base deficit \> 4 mmol/L

Answer 240

nitrofurantoin contraindications Children \< 1 month of age Breastfeeding women Women at 38–42 weeks' gestation or during delivery Hepatic dysfunction [70] Renal dysfunction with a creatinine clearance \< 60 mL/min

Answer 241

laparoscopic repair indications: A- Recurrent B- Bilateral C- Needs less time for recovery. D- Femoral hernia (UTD) E- Female patient (UTD) laparoscopic repair contraindications: A-Inability to tolerate general anesthesia B-Prior pelvic surgery in the preperitoneal space C-Incarcerated inguinal hernia D-Strangulated inguinal hernia E-Large scrotal hernia F-Ascites G-Active infection

Answer 242

Influenza vaccine Pneumococcal vaccine Herpes zoster vaccine And Tdap one time if not immunized after age 65

Answer 243

children \> 1 month and adults: any macrolide; If macrolides are not tolerated, use trimethroprim-sulfamethoxazole. Infants \< 1 month: azithromycin

Answer 244

Cephalosporins as first Line oral agent Trimethoprime-sulphamethoxasole Nitrofurantoin Amoxicillin-clav

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