+ All Categories
Home > Documents > Notes From MCQs for MCCEE

Notes From MCQs for MCCEE

Date post: 04-Jan-2016
Category:
Upload: haifeng-yu
View: 465 times
Download: 1 times
Share this document with a friend
Popular Tags:
13
N o t e b o o k : E x a m T h r e a d s C r e a t e d : 3 / 1 0 / 2 0 1 3 2 : 2 6 P M U p d a t e d : 4 / 5 / 2 0 1 3 2 : 1 2 P M S t e p 2 C K N o t e s C A R D I O V A S C U L A R P r o l o n g e d Q T i n t e r v a l : C a u s e : H y p o c a l c e m i a , t o x i n s , h y p o t h e r m i a , m e d i c a t i o n s , S A H i f < 1 / 2 R R u s u . s a f e . M a y c a u s e t o r s a d e s d e p o i n t e s - > M g J u g u l a r V e n o u s d i s t e n t i o n : J V D > 7 c m a b o v e s t e r n a l a n g l e , R A P r e s s u r e K u s s m a u l s s i g n ( J V P w i t h i n s p i r a t i o n ) : R V i n f a r c t i o n , p o s t o p c a r d i a c t a m p o n a d e , t r i c u s p i d r e g u r g i t a t i o n , c o n s t r i c t i v e p e r i c a r d i t i s L V H + S T > 1 m m A N Y r e a s o n - > p r e c l u d e s r o u t i n e s t r e s s t e s t i n g , u s e n u c l e a r i m a g i n g C o r P u l m o n a l e - P u l m H T N - > R V h y p e r t r o p h y , d i l a t e - > p e a k P w a v e , r i g h t a x i s d e v , R i n V 1 - V 3 , S i n V 6 , S T - T c h a n g e s A F + r i s k f a c t o r ( s t r o k e , T I A , H T N , L V d y s f u n c t i o n , C A D , r h e u m a t i c M V d i s e a s e , p r o s t h e t i c v a l v e , d i a b e t e s , t h y r o t o x i c o s i s ) - > w a r f a r i n ( I N R 2 - 3 ) * * p r o s t h e t i c v a l v e : I N R 2 . 5 - 3 . 5 S V T : A d e n o s i n e ( s h o r t t 1 / 2 . i n i t i a l d o s e 6 m g - > 1 2 m g m i n u t e s l a t e r i f n e e d ) w o r k f o r 9 0 % i f n o t c u r e d - B B , C C B ( o n l y d i l t i a z e m / v e r a p a m i l ) , D i g o x i n V T d u e t o c a r d i a c i s c h e m i a - > A m i o d a r o n e * ( 1 ) m a y c a u s e H Y P E R t h y r o i d i s m ( 2 ) a n k l e e d e m a W P W : a v o i d B B , C C B , d i g o x i n M g m t a c u t e : s t a b l e - p r o c a i n a m i d e , a m i o d a r o n e , u n s t a b l e - i m m e d i a t e s y n c c a r d i o v e r s i o n M g m t l o n g t e r m : a b l a t i o n m a y t r y a d e n o s i n e B N P : b r a i n - n a t r i u r e t i c p e p t i d e s e n s i t i v e t o L V d y s f u n c t i o n ( > 5 0 0 ) C H F : a v o i d N S A I D s ( r e t e n t i o n + v a s c u l a r c o n t r a c t i o n ) c i l o s t a z o l ( m e d i c a t i o n f o r c l a u d i c a t i o n , p h o s p h o d i e s t e r a s e i n h i b i t o r , i n c r e a s e e x e r c i s e t o l e r a n c e ) c o n t r a i n d i c a t e d f o r i n c r e a s i n g H R K + a n d D i g i t a l i s c o m p e t e f o r m y o c a r d i a l b i n d i n g s i t e - > K + i n c r e a s e i n b l o o d = d i g o x i n a c t i v i t y - P e r i p a r t u m / p o s t p a r t u m c a r d i o m y o p a t h y : l a s t t r i m e s t e r o r < 6 m o a f t e r d e l i v e r y , m o s t c o m m o n 1 m o b e f o r e / a f t e r d e l i v e r y ½ o f p t s r e c o v e r c o m p l e t e l y m o r t a l i t y 2 0 - 3 0 % a v o i d f u t u r e p r e g n a n c y A C E I c o n t r a i n d i c a t e d i n p r e g n a n c y C a r d i o m y o p a t h y T x D i l a t e d H y p e r t r o p h i c R e s t r i c t i v e A C E I , B B * N O C C B ! B B C C B I C D m o s t e f f e c t i v e t o p r e v e n t s u d d e n d e a t h P a l l i a t i v e o n l y H e a r t m u r m u r w i t h p r e l o a d ( v a l s a l v a ) : ( 1 ) H y p e r t r o p h i c c a r d i o m y o p a t h y ( 2 ) M V p r o l a p s e P r i n z m e t a l s a n g i n a : D e f i n i t i v e D x : E r g o n o v i n e d u r i n g a n g i o g r a p h y - > t r i g g e r v a s o s p a s m T x C C B ( p r e v e n t r e c u r r e n t v a s c u l a r s p a s m ) o r N i t r a t e s S u m a t r i p t a n i s v a s o c o n s t r i c t i v e a n d c o n t a i n d i c a t e d N S T E M I : T r o p o n i n I , T r o p o n i n T o r C K - M B b e g i n t o @ 4 h C l o p i d o g r e l : l o a d i n g d o s e 3 0 0 - 6 0 0 m g t h e n 7 5 m g d a i l y A C E I n o t u s e d w i t h i n 2 4 h o f a c u t e M I t o a v o i d s h o c k S t r e p t o k i n a s e : a l l e r g e n i c s h o u l d n o t b e g i v e n r e p e a t e d l y
Transcript
Page 1: Notes From MCQs for MCCEE

Not ebook: Exam Threads

Creat ed: 3/10/2013 2:26 PM Updat ed: 4/5/2013 2:12 PM

Step2 CK Notes

CARDIOVASCULARProlonged QT interval:Cause: Hypocalcemia, toxins, hypothermia, medications, SAHif <1/2 RR usu. safe. May cause torsades de pointes -> MgJugular Venous distention: JVD>7cm above sternal angle, RA Pressure ↑Kussmaul’s sign (↑JVP with inspiration):RV infarction, post op cardiac tamponade, tricuspid regurgitation, constrictive pericarditisLVH + ST ↓>1mm ANY reason -> precludes routine stress testing, use nuclear imagingCor Pulmonale - Pulm HTN -> RV hypertrophy, dilate-> peak P wave, right axis dev, R in V1-V3, S in V6, ST-T changesAF+ risk factor (stroke, TIA, HTN, LV dysfunction, CAD, rheumatic MV disease, prosthetic valve, diabetes, thyrotoxicosis) -> warfarin (INR 2-3) **prosthetic valve: INR 2.5-3.5SVT: Adenosine (short t1/2. initial dose 6mg->12mg minutes later if need) work for 90%if not cured - BB, CCB (only diltiazem/verapamil), DigoxinVT due to cardiac ischemia -> Amiodarone *(1) may cause HYPERthyroidism(2) ankle edemaWPW: avoid BB, CCB, digoxinMgmt acute: stable - procainamide, amiodarone,unstable - immediate sync cardioversionMgmt long term: ablation may try adenosineBNP: brain-natriuretic peptide sensitive to LV dysfunction (>500)CHF: avoid NSAIDs (retention + vascular contraction)cilostazol (medication for claudication, phosphodiesterase inhibitor, increase exercise tolerance) contraindicated for increasing HRK+ and Digitalis compete for myocardial binding site -> K+ increase in blood = digoxin activity -Peripartum / postpartum cardiomyopathy:last trimester or <6mo after delivery, most common 1mo before/after delivery½ of pts recover completelymortality 20-30%avoid future pregnancyACEI contraindicated in pregnancyCardiomyopathy TxDilated Hypertrophic RestrictiveACEI, BB *NO CCB! BB CCB

ICD most effective to prevent sudden death Palliative only

Heart murmur ↑ with preload ↓ (valsalva) : (1) Hypertrophic cardiomyopathy (2) MV prolapsePrinzmetal’s angina:Definitive Dx: Ergonovine during angiography -> trigger vasospasmTx CCB (prevent recurrent vascular spasm) or NitratesSumatriptan is vasoconstrictive and containdicatedNSTEMI: Troponin I, Troponin T or CK-MB begin to ↑ @4hClopidogrel: loading dose 300-600mg then 75mg dailyACEI not used within 24h of acute MI to avoid shockStreptokinase: allergenic should not be given repeatedly

Page 2: Notes From MCQs for MCCEE

Post MI arrhythmias:*bradycardia (sinus) common after M, caused by ↑ vagal tone -> atropine*VT caused by cardiac ischemia -> amiodarone*slow V tach, R60-100 develops in 25% post MI -> benignLifestyle change - HDL is most sensitive in cholesterol boardThiazide cause K+↓ and uric acid ↑ in the blood2nd dyslipidemia: DM, hypothyroidism, obstructive liver Dis, Chronic RF, medications2nd HTN: Cushing’s syndrome, Conn’s syndrome (hyperaldosteronism), Aortic coarctation, Pheochromocytoma, stenosis of renal arteriesLabetalol for HTN emergencies not to be used on asthma pt, for β2 blockadeEchocardiography is sensitive and specific for pericardial fluidCCB + BB = bradycardia, contraction disturbancesACEI may worsen R failure in renovascular HTN, ↑azotemia, not in angioneurotic edema pt.NSAID weakens ↓ BP effect of ACEICoxsackie B virus is the most common cause of pericarditis in North AmericaProphylaxis of infectious endocarditis(IE):Hx of previous IEPt with prosthetic heart valvesPt with unrepaired congenital cyanotic heart diseasePt with prosthetic graft not yet endothelialized (<6mo)One time screening for AAA: 65-75 yo, male, with any history of smokingSevere MVR + pulmonary edema -> use vasodilator (ACEI) , ↓ LV afterload to ↑ anteflowPt had DVT during pregnancy and on heparin: continue for 6 weeks LWMT or warfarinEnoxaparin: 1mg/kg bid subcutaneousAneurysm >5.5 cm - surgical repairASD - fixed split S2Warfarin + TMP-SMX: ↑ warfarin effect → cause bleedingRheumatic fever: 5 major criteria: chorea, carditis, erythema marginatum, subcutaneous nodules and migratory polyarthritis. Fever is a minor criteriumBifid pulse - Hypertrophic cardiomyopathyPulsus alternans - severe CHFPulsus paradoxus - constrictive / restrictive heart disease or pericardial diseaseWide pulse pressure - aortic insufficiency

DERMATOLOGYType I hypersensitivity reactions: IgE mediated first and fast - diphenhydramineEczema - ↑ risk of asthmaReiter’s syndrome: a type of reactive arthritis happens in reaction to a bacterial infection in the body. Characterized by arthritis, urethritis and conjunctivitisSeborrheic dermatitis - Pityrosporum ovale; symptom worsen in Wintersuspect HIV in severe young pt. Tx can use both steroid or antifungal, coal-tar shampooPsoriasis common exacerbating factors: stress, medication, injury of skin1st line tx: high potency steroids i.e. fluticasone (w/o joint involvement)Topical calcipotriene (avoid face and mucous)Urticaria: acute- bugs, drugs, food; chronic: pressure, cold, vibration (idiopathic in most cases)Systemic antihistamines: loratadine, fexofenadine, cetirizineErythema Multiforme: red rings (small) DDx: Lyme dis -red rings larger than 5cm, multipleTx: symptomatic only, usu, resolve in 4-6 wksBehçet's disease - genital ulcer + oral ulcer + uveitis -> fatal due to vascular aneurysmsFalse +VDRL: erythema nodosum or SLE

Page 3: Notes From MCQs for MCCEE

Celiac sprue: IgA. - osteopenia, Iron Deficiency Anemia, Type I DM, ↓ proteinTx: Dapsone sulfones or sulfonamidesCan have rice/corn (gluten free)Impetigo can cause nephritis but not rheumatic feverTx. topical bacitracin or mupirocin, or oral dicloxacillin /cephalexinStrawberry tongue: in scarlet fever or Kawasaki’sFungal infections: best initial test - KOH, most accurate test - fungal culture (4-6wks)Emp Tx: no hair/nail - topical ~conazolehair/nail - topicals don’t penetrate - oral terbinafine or itraconazoleOnychomycosis - nail fungus infection - terbinafine 6 wks hands 12 wks feetHAIR-AN syndrome: subset of PCOS:

→ hyperandrogenism, insulin resistance, acanthosis nigricansLichen Planus: may appear suddenly, intensive pruritic, low-grade feverBasal Cell Carcinoma - low risk cancer, no metastasisMelanoma: malignancy related with the thickness of lesion, unpredictable metastatisMycosis Fungoides (cutaneous T-cell lymphoma) a rare type non-Hodgkin’sPhotopheresis: FDA approved for T-cell lymphomaBuffy Coat + platelets separated from blood, chemically treated with 8-methoxypsoralen, exposed to UV, returned to PtPhotochemically demaged T-cell -> induce cytotoxic effect on T-cell formationRash on palms and soles: consider(1) rocky mountain spotted fevertick is the vector, recent camping Hxfever + myalgias + macular rash with petechial lesions(2) 2nd Syphilis(-) fever, (-) myalgiaDrugs can cause urticaria → erythema multiforme → SJS → TENpenicillin, sulfa, allopurinol, rifampin (rifampicin)Acne: Benzoyl peroxide (topical cleanser)Retinoic acidAdd topical erythromycin / clindamycinSwitch to oral minocyclineSwitch to oral accutane, isotretinoin (teratogenic)Granuloma annulare - self limited, not contagious, inj. corticosteroids (oral not effective)

ENDOCRINOLOGYDM - gastroparesis common; scintigraphic gastric emptying studyworsen by amylin analogue (pramlintide) and glucagon-like peptide 1 (exenatide)Monofilament test for neuropathic foot ulcersBariatric surgery for BMI >35 usu. resolves DMMetformin - 1st line DM type 2 TxTZD contraindicated in CHF (cause fluid retention), relative contraindicated in pregnancyExenatide not for elderlyMetabolic Syndrome: LDL>4.13mmol/L and 2+ risk factors = Tx requiredLow TSH level >65yo ↑ risk of hip/vertebral fractureTSH<10mu/l no symptoms → subclinicalTSH receptor immunoglobulins → Grave’s TSH R-blocking Ab → Hashimoto’sPropylthiouracil usually cause mild leukocytopenia no need to discontinue.Rarely cause agranulocytosis (infection) → monitor CBC and differentialLiver injury possible, renal injury not associated

Page 4: Notes From MCQs for MCCEE

Choice for woman may become pregnantMethimazole - preferred in Men or non-childbearing age womenTPoAb (thyroid peroxidase autoantibody) exist in 90-95% autoimmune hypothyroidismLevothyroxine 500mcg bolus+50-100mcg/d lead to TSH ↓ → ↑ risk of hip fractureProlonged use of phentoin → osteoporosis ( ↑ hepatic metabolism of Vit D)Long steroid Tx users (>3mo, >5mg/d) → Vit D + Ca + bisphosphonate therapyCanadian Recommendation: Age >50 - daily Vit D 400 IUVit D deficiency → low serum Ca2+ → elevated iPTH (1) → alkaline phosphatase ↑(2) → normal ionized Ca2+Hyperparathyroidism - Lab Hypercalcemia, hypophosphatemia, hypercalciuriaIf Ca ↓ in urine → suggest other etiologyCushing reflux: trial of HTN, Bradycardia and Resp. depression, in ⅓ Pt with ↑↑ICPAdrenal Insufficiency: Cortrosyn stimulation testHyperaldosteronism HTN: esp diastolic

↑ aldosterone/plasma renin activity ratio (if >30 strongly suggest)Ambiguous genitalia - check newborn for congenital adrenal hyperplasia - immediate fluid resuscitation and salt repletionIncidental adrenal mass: if >1cm 1st step determine functioning or notserum metanephrines (pheochromocytoma)dexamethasone suppressed cortisol (Cushing’s)

EPIDERMIOLOGYIntranasal live, attenuated influenza vaccine is an option for healthy, Non-pregnant 2-49 yoScreening in CAN: M/F>65 yo or F 50-64 with risk factor of fracture → DEXA screeningPreschool speech screening: insufficient evidence to support or againstChance corrected agreement : Kappa =(P0-Pc)/(1-Pc)P0: observed agreement; Pc: chance agreementGASTROINTESTINALGilbert’s syndrome: BIL (indirect)↑ impaired glucuronyl transferase activityDubin-Johnson Disease: Benign liver disease - Direct BIL ↑In adult, lower esophageal sphincter is the most common site for impactionsGlucagon may relax smooth muscle → allow passTetracyclines esp. doxycycline associate with esophagitis in elderly ( ↓peristaltic clearance)Achalasia - no pain swallingBarrett’s esophagus - <1% risk of esophageal adenocarcinoma, endoscopy don’t ↓ risk of deathRoute-en-Y operation may lead to iron/VitB12 deficiencyDiarrhea DDx: (1) incontinence of stool (2) rectal urgency (3) incomplete evacuation (4) bowel movement immediately after a mealTraveller’s Diarrhea: E ColiMg, NSAIDs, Antibiotics, HTN drugs, Arrhythmia drugs may cause diarrheaCampylobacter Jejuni: the most common etiology of infectious diarrhea Tx ErythromycinClostridium Difficile: Pseudomembranous Tx PO metronidazole or vancomycinEntamoeba Histolytica: History of endemic visit - NO steroids! may cause fatal perforationCarcinoid syndrome: 5-HIAA >100mg/24h very specific diagnostic (normal <8mg/24h)IBS: rarely awaken pt from sleep; uncommon vomiting, sig. weight loss, constitutional symptomsSigmoid volvulus: sigmoid scope decompression is therapeuticStrep. Bovis is associated with colon cancerOgilvie Syndrome → pseudo obstruction: elderly M>F parasympathetic dysfunctionassociate with trauma/ surgery+bed rest

Page 5: Notes From MCQs for MCCEE

Tx: naso-gastric tube to decompress stomach, relieve vomiting, surgical decompression with flexible colonoscopeBloody stool in elderly → colon cancer until proven otherwise; CEA more useful to follow upColon cancer: depth of invasion is important for prognosis; Rad Tx usu. for rectal cancer ↓ recurPUD is responsible for 45% of upper GI bleedingCD and UC:noncaseating granulomas only on CDno barium on acute UC - risk of perforationavoid antidiarrheal agent in UC - toxic megacolonRisk factor for cholesterol gallstone: F>M, Age ↑, Obesity, Pregnancy, OCP or hormone tx, Rapid weight loss, Crohn’s disease, TG ↑Primary biliary cirrhosis: antimitochondrial antibody test - sensitive and specific if >1:40Pancreatic necrosis → high level of c-reactive proteinAlcoholic Ketoacidosis (AKA): (1) Chronic alcohol abuse + binge drinking (2) little or no recent food intake (3) had persistent vomiting (AG ↑: Na -(HCO3+Cl) >12) Mainstay Tx: hydration with 5%Glucose in normal SalineMegestrol for appetite stimulation may result in adrenal suppressionHepatic adenoma: rarely ruptures or cancerous, common seen in childbearing age using OCP

HEMATOLOGYHeparin overdose: PT/aPTT not sensitive; anti-factor Xa can be measured in renal failure ptsWarfarin does not cause depressionUFH in DVT bolus 7000-10000 then 10000-1500/hClumped platelet in Lab - change anticoagulant and re-testUse DDAVP: restrict fluid to avoid hyponatriemiaHeparin induced thrombocytopenia: NO heparin (even low molecule), NO warfarin (skin necrosis / venous gangrene); Use lepirudinTTP following virus infection - most resolve spontaneouslyAnemia: in elderly, most common reason is chronic disease’Howell-Jolly body in RBC smear - asplenia (sickle cell anemia)Sickle cell disease - indication of a 2nd dose pneumococcal polysaccharide vaccine in childrenMay cause avascular necrosisSCD+fifth disease(parvovirus B19) - aplastic anemiaThalassemias - Schistocytes not likely to be seen, normal RDWWith β-thalassemia major, increased hemoglobin α2With α-thalassemia minor, normal Hb electrophorosisPCV (polycythemia vera): erythropoietin ↓ 2nd polycythemia: erythropoietin Normal or ↑Needle aspiration biopsy is insufficient to diagnose suspected lymphomaTumor lysis syndrome: K, Phos, Uric Acid ↑ ; Ca ↓Multiple myeloma: age mean = 61; bone pain at REST raise concern of malignancyMesothelioma → exposure to asbestosHemochromatosis: Dx Serum transferrin saturationVit K → reverse warfarin (fast: fresh frozen plasma)Protamine sulfate → reverse heparin1st year in cardiac transplant: mortality/ morbidity due to infection

INFECTIOUS DISEASE4mo-4yo pneumonia - RSV - wheezing + rhinorrhea, winterPalivizumab given to specific child in RSV season: <2yo, chronic lung disease that required medical therapy within 6mo before RSV season.RSV Tx: supportive care

Page 6: Notes From MCQs for MCCEE

S. Pneumoniae is the most common pathogen for asplenic pt pneumoniaNursing home acquired pneumonia: Emp. antibiotics - levofloxacinOutpatient community acquired pneumonia: macrolide, doxycycline or fluoroquinolone. If pt was treated with antibiotics in 3 mo - use quinolonesTubercular Meningitis: chloride lowMeningococcal vaccine is not effective for B type (30-40% of infection)PCP: prophylaxis when CD4<200. Lab: methenamine silver stain -> cyst like structureChlamydia “test for cure” is NOT recommended now other than pregnancy (3-4 wafler tx) yearly test for chlamydia is recommended for <25yo, ↑ risk, new/multiple sex partner, pregnancyTx: Doxycycline 100mg PO BID * 7 days or azithromycin (for pregnant) 1g po *1 dayEBV: infectious mononucleosis - resume contact sports when physical exam is normalRocky mountain spotted fever - tick bites face usu. spared↑ creatinine → ↑ risk of death, tx: doxycyclineSplinter hemorrhage: emboli from subacute bacterial endocarditisDiarrhea pathogen: cryptosporidium and Giardia cysts are resistant to chlorineDiarrhea/food poisoningStaphylococcus: vomiting is major, 4h after eatingSalmonella: beef, poultry, eggsE.Coli: O157:H7 improper hamburger - watery - bloody stool starts 3-4 d, last 1wkGiardia: Traveller’s d -ground water - fecal-oral - mild bloody stool - start 2-3d - last 1wkParonychia: chronic- 95% candida albicansRabies prophylaxis - ALWAYS immunoglobulin + vaccine

MUSCULOSKELETALDe Quervain’s tenosynovitis more common in (1) pregnancy (2) after trauma (3) pt with RAwrist region (radial), Tx: steroid injectionSupracondylar fracture of humerus → risk of compartment syndromeColles’ fracture: cast - flex, pron ulnar positionGamekeeper’s thumb: avulsion of attachment of the ulnar collateral lig - surgical repair, splint is not adequateACL: most frequent injured lig in the kneeMeniscal tears: medial > lateralPrepatellar bursitis → knee swellingBursitis of medial collateral ligament → tenderness of median aspect of kneeAnserine bursitis: pain esp. at night, medial knee to the upper tibia, can be bilateralOsteoarthritis: Normal CBC/ESR, (-)RF, (-)ANA. Pain reduce with muscle strengtheningFibromyalgia --> may have sleep disturbance, no muscle weakness, no objective lab findingsTx: Antidepressants (SSRI/CA) comb. have efficiency i.e. amitryptylineSteroids/NSAIDs don’t helpGout: elderly differ from usual presentations. young: podagraGout PseudogoutM>F M=Fmiddle aged M postmenopausal F olderacute onset acute or insidiousneedle shape neg. birefringence pos. birefringence rhomboid shapemonosodium urate calcium pyrophosphate dihydrateNSAIDs, Steroids, Colchicine, allopurinol NSAIDs, Steroids

Polymyositis: old (50-70yo) EMG- potential with fibirllations, biopsy necrotic m.fibre +inf.infiltratesDuchenne’s muscular dystrophy (X-recessive) young (2-4yo)

Page 7: Notes From MCQs for MCCEE

Both CK ↑, proximal muscleSLE: ANA sensitive Anti-Sm Anti-dsDNA specificScleroderma Anti-Scl-70: poor prognosisSjogren’s syndrome is associated with high risk of non-Hodgkin’s lymphomaRheumatoid arthritis: no rash Capsaicin, topical substance P depleting drug can relieve painRA compare with OA(1) thumb squaring (2) Heberden’s nodes (distal) (3) Bouchard's nodes (proximal)Rotator Cuff Injury: Rest, pain control, acetaminophen or NSAIDsif not improved 3-6mo under supervised rehab program: consider surgeryPolymyalgia rheumatica: C-protein ↑, CK normal (CK ↑ strongly suggest other etiology)Duchenne Muscular Dystrophy (DMD) 1. young (3-5yo) 2. Gower’s maneuverTransient synovitis of Hip: a postinfection conditionBier Block anesthesia: indicated for fracture of forearm, wrist or hand, NOT for fracture above the elbowTibial nerve injury: paralysis of the plantar flexors of foot affects flexion of ankle(L4) and toes (L5)Anterior Drawer Test: integrity of ACLStress fracture: No cast, NSAID not recommended for delaying healing.Activity can continue as long as it does not cause painLittle League Elbow - located over the medial epicondyle (apophysitis)Iliotibial band syndrome: common, lateral knee / thigh painPatellofemoral syndrome - discomfort moving patellaFacet joint syndrome - low back radiate to thigh or knee

NEUROLOGYLimbic system - associate with emotionHTN is the most powerful risk factor for strokeBroca’s area - inferolateral frontal lobeL parietal lobe damage → Gerstmann’s syndrome R-L confusion difficulty writing or mathsR parietal lobe damage → contralateral neglect, difficulty in making things, draw, deny deficitsCrossed hemiplegia: brain stem hemorrhage or lesionsChronic subdural hematoma may cause a reversible form of dementiaHeadache warning signs: - onset >50yo, very sudden onset, ↑ frequency / severity, with signs of systemic disease, focal neurologic symptoms, papilledema, headache after traumaMigraine Headache: Ergotamines older than triptans, but much less expensive. VitB12 showed some effect, Biofeedback might be useful as alternative txCluster Headache: always unilateralTramadol has potential to cause seizure (rare)Phenytoin → related with osteoporosis, may worsen acneToxicity sign: ataxiaTonic-clonic seizure, prolactin ↑ ↑ ↑ test within 20 minTx: first line valproic acid 2nd line phenytoin and carbamazepineTopiramate not to be used with history of kidney stone or taking high dose of Ca/VitCMS - use MRI, CT doesn’t show, Std Tx interferon betaGBS - ↓ or absent deep tendon reflexLeading cause of permanent bilateral visual loss >55yo is macular degenerationRisk factor: HTNEssential tremor of hand: propranolol, topiramate or primidoneNewborn: tear start to be produced after 3 weeks of lifePropoxyphene is NOT recommended to manage chronic pain in elderly nursing home ptRestless leg syndrome: carbidopa / levodopa

Page 8: Notes From MCQs for MCCEE

Related with Iron Deficiency, check ferritin levelCerebellopontine angle tumor - of 8th cranial N. benign. CM ↓ corneal reflex & hearing loss

OBSTETRICSmelasma / chloasma: common, 70% pregnant women affected → hypermelanosis of face, symmetric distribution, UV worsens the conditionQuad screening: AFP ↑ → neural tube defectInitial visit (prenatal) - discuss Tay Sachs if Jewish ancestry. HIV needs consentChloramphenicol - grey baby syndromeparvovirus B19 in mother → HydropsVaricella zoster: first ½ pregnancy period cutaneous / bone defects, chorioretinitis, cerebral cortical atrophy,hydronephrosis3 spontaneous abortions (SABs) in 1st trimester - chromosomal consultEpidural anesthesia mother: hypotension commonNST not reassuring -- BPPEven if BPP 8-10, mind early decelerationsEngagement : biparietal diameter through pelvic inletChlorpropamide (sulfonylurea) - contraindicated in type 2 DM with pregnancy or gestational DM (may cause prolonged symptomatic hypoglycemia)MgSO4 - monitor Cr, reflexes (knee) and resp.1st sign of Mg ↑ - deep tendon reflex disappearPreeclampsia: 1 control BP 2 prevent seizure 3.induction or C-section (indicated>34wks)Atenolol related with fetal growth delayPlacenta previa - transvagina US acceptable but NO vaginal exam!IUGR - chronic HTN is the most common reasonNormal pregnancy: S/D ratio ↓ (doppler) with pregnancy avanceSymmetric IUGR → look for congenital abnormalitiesSinusoidal pattern of FHR → severely affected Rh- isoimmunized fetus, or mother medicationSaltatory pattern: episodes of brief / acute hypoxia usually seen during labourErb palsy C5-6 limpy extended arm internally rotatedKlumpke paralysis C7-T1 hand paralyzedShoulder dystocia - obstetric emergency - call for helpAmnioinfusion - effective for severe variable decelerations and meconium stained fluidPremature Rupture of Membranes (PROM) Risk factors:low socioeconomic condition, STDs, Previous preterm birth, vaginal bleeding, smokingProlonged latent phase - meperidine (demerol) IMTocolysis: indomethacin / indocin → may cause oligohydraminosnifedipine → low BP, monitorRitodrine/terbutaline → tachycardia, hypotension, pulmonary edemaMgSO4 → high dose cause respiratory and cardiac depressionTwins delivery (1) vertex/vertex (2) vertex/breechBacteroides fragilis → resistant to penicillin and gentamicin ⇒ use clindamycinSheehan’s syndrome affected hormones - “FLAT PiG”FSH, LH, ACTH, TSH, Prolactin, Growth HormoneDuring pregnancy, high level of estrogen inhibits lactationUmbilical artery *2 → deoxygenated blood to the placentaSulfa drugs in 3rd trimester may cause kernicterusObstetric conjugate: shortest - promontory of sacrum and symphysis pubis -10.5cm not clinicalDiagonal conjugate: lower margin of symphysis - sacral promontoryTrue conjugate: top of symphysis - sacral promotory

Page 9: Notes From MCQs for MCCEE

Episiotomy: 1 D tear: vaginal mucosa, perianal skin , 2D tear: subcutaneous tissue 3D rectal sphincter affected 4D tear extend to rectal mucosaCtst of ovarian during pregnancy mostly benign, 14-16w is best time to operateAntiphospholipid antibody syndrome in preg - ↑ risk of embolism, fetal loss, thrombocytopeniaMisoprostol for induction or cervical ripening, NOT ind. in prev. uterine surgery or active laborCrown-rump length - accurate in 1st trimesterBiparietal diameter - more accurate in 2nd trimesterIntrahepatic cholestasis of pregnancy (ICP) - severe pruritus in 3rd trimester, absence of primary skin lesion + ↑ bild acidGYNECOLOGYFemale thelarche → adrenarche (pubic hair) → growth spurt → menarcheHot flushes: Tx SSRI effectiveInjectable medroxyprogesterone acceptable as HRT → not linked with thrombotic casesInability to conceive after 1yr sex life - infertilityCopper IUD main action is spermicidalOvulatory disorder: most common cause for female infertilityConstitutional growth delay: can watchful wait and observeMedication cause hyperprolactinemia → amenorrhea: (usu. <100ng/ml)-Benzodiazepines, SSRIs, TCA, Phenothiazine, buspirone, sumatriptan, valproate, ergot derivatives, estrogen/contraceptives, atenolol, verapamil, reserpine, methyldopa1st Dysmenorrhea prostaglandin synthetase inhibitor trailOCPs suppress PG release and ↓ menstrual fluid volumeEndometriosis most common location other than pelvic organs: GI tractAtypical or adenomatous hyperplasia → hysterectomyHeavy bleeding: estrogen 25mg every 4h until bleed abates (high dose)Ambiguous Genitalia → 1st step is physical exam → screen congenital adrenal hyperplasiaPCOS - ↑ ↑ estrogen in blood (+progesterone challenge test), a risk of endometrial CaTrichomonas: Tx single dose metronidazole 2g or tinidazole. If fail, metronidazole 500mg bid *7 if fail, metronidazole 2g *3-5 daysToxic shock syndrome: tampons or diaphragms in body >24hrsAGUS - cervical intraepithelial neoplasia is the most common histologic DxVulvar cancer - long standing pruritusOvarian Ca - pregnancy, breast feeding and OCP all decrease riskBreast development in pregnancy - progesteroneHealth Exam: Screen chlamydia for all sex active women <25yo or older at riskPAP at least every 3 yr, sex active + have a cervixHep B: recommended for pregnant womenSpironolactone can improve post menstrual syndrome

PEDIATRICSBreast milk lacks Vit D, Cow’ milk lacks IronMost common reason for visual loss in child: amblyopiaBaby sleep on back ↓ risk of sudden deathChild safety seat: : rear facing until 9kg(20lb) forward facing 9-18kg booster seat 18-36kg belt for >36kg, >145cm or 8yoSBS - may have long bone fracture or soft tissue injuryEisenmenger’s syndrome: maternal mortality 50%, L to R → Pulm HTN → R to LPGE1 iv maintain PDA - in transposition or F4Lithium → Ebstein’s anomalyRetinoic acid → bilateral microtia anotia

Page 10: Notes From MCQs for MCCEE

Decreased Folate → spina bifidaACEI → renal dysgenesis“Ted spells” - diminish R to L shunting by ↑ systemic vascular resistanceAndrogen insensitivity - X linked recessiveMeconium aspiration → patchy atelectasisHyaline membrane disease → homogeneous opaque infiltrates with air bronchogramsDown’s syndrome 14% pt atlantoaxial subluxationNoonan syndrome: autosomal dominant, M/F symptom similar to Turner’sPKU: autosomal recessive 1st child PKU → 25% later chanceCF: - nasal polypsBleeding of diverticulum (Meckel's) → mostly due to ectopic gastric mucosa → acid induced bleedingCroup: parainfluenza. moderate: IM steroid single dose (help with glottic edema)Epiglottis: Hib, Strep or viralPertussis incidence is ↑ in CanadaTx: Erythromycin or azithromycin; TMPSMZ 2nd lineHand-foot-and-mouth disease: Coxsackie A; supportive careSerum bilirubin:Age(hrs) Consider photox photox exchange transfusion if photox fails25-48 >=12 >=15 >=2049-72 >=15 >=18 >=25>72 >=17 >=20 >=25

Newborn mass:50% renal origin, usu. benignmyelomeningocele - anaphylactic shock from latex allergyRDS tx: L/S <2:1 maternal corticosteroidsCerebral palsy: frequent seizured perinatal period - asphyxiaReye’s syndrome: rash, vomiting and liver diseaseMost common posterior mediastinal tumor in children: neuroblastomaOsteosarcoma: no radiationLead poisoning: wobbling gait. Normal blood lead <10ug/dlAsymptomatic proteinuria in children/adolescent: 60% orthostaticHenoch-Schonlein purpura (HSP): generalized acute vasculitis of unknown cause involving smal blood vessels. Purpura + arthritis of large joints, gastrointestinal symptoms, colicky abd. pain vomit melena

PSYCHIATRY

Psy functional inquiry: MOAPS: Mood, Organic(substances), Anxiety, Psychosis, SafetyFluoxetine less likely to cause discontinue symptoms - long t1/2 long-acting metabolismFluoxetine early side effect: loss of appetiteFluoxetine is the only FDA approved med for 8-17 yoNight terror: No nightmare, (-) REM, Tx. Diazepam improves conditionOCD - Tx SSRI, SNRI (venlafaxine) not the choice. TCA (clomipramine) can be usedAcute stress disorder <4wksPTSD: SSRI (Quetiapine)HIV+ dementia: usu CD4<200Pick’s disease - 25% of dementias early personality changes, social improper mood changespick body (intracellular inclusion) and pick cells (swollen neurons)Benzodiazepine in elderly - potential for delirium

Page 11: Notes From MCQs for MCCEE

Major depression Disorder - depletion of norepinephrine and serotoninTx: last >6mo after first episodeECT: methohexital (anesthetics), complication ↑ w recent cerebral Hemorrhage, stroke or ↑ ICPECT safe in pregnancySwitch phenelzine to paroxetine (MAOI to SSRI) - allow 2 weeks wash off time avoid serotonin +cyproheptadine for serotonin syndromeSSRI withdrawal 2d lightheadedness, headacheNortriptyline: curvilinear Imipramine: sigmoidal (pharmacodynamics)Citalopram is least involved in P450 systemMAOI - avoid tyramine metabolismDysthymia: strongly associate with other disorders,(major depression, personality disorder, social phobia, MS, AIDS, CVS, premenstrual, hypothyroidism)Tx: mood stabilizer(lithium), anticonvulsive med. (valproic acid), antipsychotics, antianxiety (benzo) CBT, IT, Group TxValproic acid: carnitine to prevent increase ammonia levelLithium most common side effect: tremor.Maintain bipolar: lithium, lamotrigine, aripiprazole or olanzapineNarcissistic: medicine Tx no use. Psychodynamic psychotherapyPsychosis: loss contact with realitySchizophrenia: 20% drink excessive waterPhenobarbital - likely to cause Tardive dyskinesiaChildhood disintegrative disorder: apparent normal development <2yo clinically sig. loss of prev acquired skills before 10 yoRett’s disorder: By age of 5, microcephaly or disordered gaitFetal alcohol syndrome: small eyes, short palpebral fissures, thin upper lip and a smooth philtrumSleep disorders: cognitive-behaviour therapyzaleplon is short acting vs. zolpidemzaleplon may induce sleepwalking, binge eating aggressive outbursts night driving etcNarcolepsy modafinil → ↓ sleep attacksSomatoform disorder → Don’t need to have Hx of depression / anxietyConversion disorder: “la belle indifference” - don’t concern regarding apparent extreme decline of healthTriazolam (benzodiazepines) → short term (<10d) tx for insomnia, may cause amnesia

PULMONARYAcute asthma: ipratropium added to b2 blocker better than b2 blocker alonesystemic steroids recommended to all admission to hospital pts.COPD inhaled steroids - controversial review (+risk of pneumonia, improve quality of life, no effect on mortality)Non-caseating granulomas can be seen in Crohn’s but not UCNitrofurantoin - may cause acute hypersensitivity pneumonitis, fever, chills, cough, bronchospasm. CBC leukocytosis with ↑ @ of eosinophilsPleural effusion: CHF usu. right sideEchinacea - used to treat upper resp. infection - no proven effectAir-fluid level in superior segment of right lower lobe - pulm. abscess - anaerobesPneumonia 23 valent vaccine: 2-64 yo-DM, cirrhosis, CHF, Chronic lung dis.(COPD),- not AsthmaPulmonary hemosiderosis: X-ray, diffuse fluffy infiltrates, may assos. w milk allergy (heiner syndrome)

Page 12: Notes From MCQs for MCCEE

RENAL/GENITOURINARYUTI in childhood - 80-90% E ColiThiazides may decrease renal clearance of Ca2+ → exacerbate hypercalcemia asso. w hyperparathyroidismFanconi syndrome: proximal renal tubules do not reabsorb back → excessive drinking, excessive urination, glucose in urine, untreated: muscle wasting, acidosis, poor conditionKidney stone (ureteral stone) adequate analgesia is criticalAcute tubular necrosis ATN: FeNa>2Atheroembolic renal failure warfarin → risk factor,CF: derm findings, digital cyanosis, refractile plaque in retinal arteryNephritic syndrome: PRO<1.5g/dNephrotic syndrome: PRO>3.5g/dInguinal hernia in child - don’t close spontaneouslyHydrocele - usu resolve itself<12-18moEpididymitis: if MSM, or >35yo, E Coli is most comonTx: ofloxacin 10d or ceftriaxone 1 dose + doxycycline 10dOrchitis is viralFinasteride(proscar) falsely decrease PSA levelTesticular cancer don’t FNA!!! can cause spread. Use ultrasoundIncontinence:Urge - detrusor instability ↑, anticholinergic: oxybutynin(ditropan)/tolterodine(detrol)side effect - retention, delirium, etc.Overactive bladder - Kegel exercisesStress - pseudoephedrine(sudafed) weight loss, surgeryOverflow - residual >200ml, (normal <50) life style, catheterization, Tx underlying cause, cholinergic drugs (bethanechol)

SELECTED EMERGENCY MEDICINEUnstable cardiac Pt: chest pain, shortness of breath, confusionAsystole - vasopressin better than epinephrineBlumberg’s sign - rebound painMethamphetamine addiction Tx: Cognitive Tx (difficult to treat)Flumazenil - don’t give on benzo overdose, may cause status epilepticus in dependentsCommon symptom caffeine discontinue - headacheCocaine withdrawal - crushHeroin withdrawal - cravingAlcohol dependence relapse prevention: Naltrexone/ disulfiramCharcoal : not useful for iron, hydrocarbon, acid/alkali erosionPerioperative cardiovascular risk: elective operation, 6mo after acute MIPostoperative fever: 1d atelectasis 3d UTI 5/7d DVT 5/7d wound infection 7-10d abd abscessSigmoid volvulus: sigmoidoscopy decompression (tx)Activated protein C (APC) ↑ survival in septic shockGCS: Eye Open 4 verbal 3 pain 2 no 1Verbal oriented 5 confused 4 inappropriate 3 incomprehensible 2 no 1Motor obey 6 local pain 5 withdraw 4 flexion 3 extension 2 no 1Sepsis - norepinephrine is preferred vasopressorBariatric surgery leading cause of death: PE

Page 13: Notes From MCQs for MCCEE

RAPID REVIEWMurmur VSD: holosystolic at mid left sternal borderMurmur Aortic Insuf mid left sternal borderImpetigo - S Pyogenes and S aureusEchovirus - cause aseptic meningitis


Recommended