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STD's with Ulcers and No Ulcers


With Ulcers :

Syphilis (Painless)
Genital herpes (Painful)
Granuloma inguinale
Chancroid (Painful)


Hepatitis B

Early vs Late Congenital Syphilis

Early congenital syphilis :

  • Non - immune hydrops
  • Macerated skin 
  • Thrombocytopenia

Late congenital syphilis :

  • Hutchinson teeth
  • Mulberry molars
  • Saber shins

Clinical Manifestations of Congenital Infections

Clinical Manifestations of Congenital Infections 

Highlight on 

CMV : Petechiae
Toxo : Chorioretinitis & Cranial Calcifications

Couvelaire uterus - (Abruptio Placenta)

It is pathological entity in association with severe form of concealed abruption placenta
There is massive intravasation of blood into the uterine musculature upto the serous coat.
The condition can only be diagnosed on laparotomy

Difference Between Osler's Node and Janeway Lesions (Infective Endocarditis)


Osler's Nodes : Painful Nodules on Finger tip and Toes (Immunologic phenomena)

Janeway Lesions : Macular Erythematous non tender lesion on Palms and Soles . (Vascular phenomena)

Mechanical Ventilation in ARDS - USMLE

FiO2 and PEEP both use to improve oxygenation, in ARDS, in the beginning you give high FiO2 and PEEP to improve oxygenation, once PaO2 is normal

then you first decrease FiO2 and keep it below 60 and then decrease PEEP, to wean off your target FiO2 should be less then 40

Note :

  • Increasing FiO2 depresses respiratory drive
  • PEEP keeps alveoli open at the end of expiration and it improves ventilation and gas exchange
  • FiO2 should not be more than 60 for more than 48hrs it will cause oxygen toxicity, which will further destroy the lung.

Immunodeficiency Disorders - ( Easy way to Remember ) - USMLE


B cells normal in numbers ; but decrease in IgG IgM and IgA

  • Recurrent sinopulmonary infections in adults 
  • Decreased response to Antigen stimulation of B cells .
  • NORMAL amount of lymphoid tissues 

Rx : IV immunoglobulins

X-linked (Bruton) Agammaglobulinemia :

  • Male Children 
  • B cells and Lymphoid tissue are diminished 
  • Absence of the tonsils, adenoids , lymph nodes . T cell NORMAL 



Combined so Both B and T cells - related to both : B cells : recurrent sinopulmonary infection as early 6 month. T cells : Candida , AIDS , PCP

Rx : BMT

IgA deficiency :

  • sinopulmonary infections : Difference it also have Atopic diseases , Anaphylaxis to blood tranfusion when blood is given from a patient who has normal levels of IgA
  • Sprue like condition with fat malabsorption 

Rx : infections and use blood from igA-deficient donors or that has been washed.

Hyper IgE: skin infections with staph.

lymph nodes with purulent material leaking out . Abnormal NBT testing .

Hepatitis C associated problems

Bacillary angiomatosis vs Kaposi sarcoma

Bacillary angiomatosis also known as Cat scratch disease

by : Bartonella spp.

Transmission : Cat scratch

Lesions : Red color

bacillary angiomatosis-its a superificial vascular proliferation,biopsy shows neutrophilic inflammation

Kaposi sarcoma : HHV-8

lesions violaceous color

Kaposi's sarcoma(HHV-8)- its the neoplastic proliferation of vasculature, biopsy shows lymphocytic inflammation.

Being a Doctor what do you know about Zika Virus ?

Zika Virus is trasmitted by mosquitos of the Aedes genus

Affected countries : Brazil , Bolivia , paraguay , Ecuador , Colombia , Mexico
Haiti , Dominican Republic , Panama , Costa Rica , El salvador

Clinical features :

Vague last for upto a week

Dx : Serology

Symptoms :
  • Fever , Rash , Joint pain , Conjunctivitis , Myalgia , Headaches , Pain behind the eyes and Vomiting
  • Only 1 in 4 develop symptoms 
  • Mostly seen in pregnant women --- lead to infant microcephaly

Prevention :
  • Insect repellent , wear long sleeved , long pants - covered extremities 
  • Rest 
  • Hydration 
  • Antipyretic and analgesics : Tylenol  (acetaminophen)

USMLE Step 2 CK Flashcards

Nikolsky sign positive in :

1. PV - pemphigus vulgaris
2. SJS - stevens johnson syndrome
3. TEN - toxic epidermal necrolysis
4.SSSS - staphylococcal scalded skin syndrome

D for DC : Dapsone - Dermatitis herpetiformis - Celiac disease

Double bouble sign : Duodenal atresia

Triple bouble sign : Jejunal atresia

Contrast enema for : Hirschsprung's disease and Meconium ileus

Upper GI series : Malrotation / Midgut volvulus 

Erb-Duchenne palsy:  C5, C6. waiter's tip, absent Moro but intact grasp

Klumpke's paralysis:  C7, C8, T1. hand paralysis, Horner's syndrome (ptosis, miosis, anhidrosis)

C.difficile : Cytotoxin assay of stool

Seminoma - High HCG and normal AFP

Non-Seminomatous germ cell tumor - Both HCG and AFP high

  • Urine Anion gap:  is positive for RTA
  • Urine Anion gap:  is -ve for Diarrhea
PCP prophylaxis : bactrim : CD4 less than 200 : if question tell G6PD suspect Dapsone and switch to Atovaquone

HIV newborn prophylaxis : AZT within 12 hours of delivery x 6 week

Non-megaloblastic drugs : AZT(zidovudine), 5 FU and Cytarabine

Contraindications of LP : mnemonic : FAILS : Focal neurological deficit , Altered Mental Status , Immunosuppressed , Lesions and Seizures 

Bacterial meningitis : mnemonics : CVS pharmacy : Ceftriaxone , Vancomycin , Steroids +/- Ampicillin

Syphilis : rash spread palms and soles

Lyme disease : Connecticut (tic usually not seen)

Atypical bacterial meningitis : Rocky mountain spotted fever , Lyme disease , Cryptococcal meningitis , TB , Syphilis

Microorganisms : Risk factors : 
  1. Staph Aureus : Most common always , 
  2. Salmonella : Sickel cell 
  3. Pseudomonas : Penetrating Shoe
  4. Strep Pyogenes : Erysipiloid
  5. Poly Microbial : PVD/ DM
Standing/ Valsalva maneuver: INCREASES -- HOCM, MVP MURMURS - decrease All other murmurs
Squatting / Sitting maneuver: DECREASES -- HOCM, MVP MURMURS - increase All other murmurs

Hand grip : INCREASES Other including MR , MVP (intensity )  DECREASES HOCM, AS and MVP (duration) 


INSPIRATION : INCREASES : Right sided murmurs So it DECREASES Left sided murmurs

EXPIRATION :  INCREASES : Left sided murmurs So it DECREASES Right sided murmurs

Torsade de pointes : Quinidine , Procainamide , Disopyramide , Sotalol , Ibutilide , dofetilide , Amiadrone , Haloperidol , Chlorpromazine, Methadone, TCA , Chloroquine, Pentamidine , Domeperidone, Cisapride, Terfenadine Antibiotics such as Macrolides(Erythromycin, Clarithromycin) , fluroquinolones-Moxifloxacin Anti-fungal - Fluconazole

Long acting injectable (Depot injection) : Nandrolone , Fluphenazine , Bromperidol , Haloperdol and vanoxerine.

Check for LFT's for the Drugs : Statins , Terbinafine

Failure to pass catheter through the nose into the oropharynx : Choanal atresia

Fetal tachycardia can be due to maternal fever in chorioamnionitis. Therefore chorioamnionitis is not indication of C-section. But fetal distress associated with deceleration is indication of C-section.

Both papillary muscle rupture and ventricular wall rupture can occur post-MI after 3-5 days but ventricle wall rupture has signs of hypotensive shock where as papillary muscle rupture has an MR murmur with less severe hemodynamic derangements. 

Typical signs of Pericarditis : murmurs are absent in uremic pericarditis which is indication of dialysis

Cause of Delayed hemolytic reaction : Anamnestic antibody response.

Rx of Subclinical hypothyroidism : When TSH greater than 10

Seizures : VITAMINS mnemonic : Vascular, Infection , Trauma , Autoimmune , Metabolic , Ingestion/ Withdrawal , Neoplasm , pSychics

Differential diagnosis of Child abuse : Osteogenesis imperfecta

ADHD also think about differential Absence Seizures - depend on the Vignette

Myoclonus and Atonic seizures : Rx : Valproate

CBT - cognitive behavioral therapy first-line Rx : Specific phobia , GAD (generalized anxiety disorder) - for GAD also think about SSRI's

Absence Seizures : Rx : Ethosuximide

Tic-Do-Le-rux : Rx : Carbamazepine

Drug induced lupus : mnemonic : SHIP : Sulfasalazine , Hydralazine , Isoniazid , Procainamide

Secondary causes of HTN : Renal : RAS , Adrenal ( Primary hyperaldosteronism) , Cushing syndrome , Pheochromocytoma, Thyroid : Hyperthyroidism , Parathyroid : Hyperparathyroidism  Heart : COA

Systolic-Diastolic Bruit : RAS - (renal artery stenosis)

Systolic Bruit : AAA - Abdominal Aortic Aneurysm

Idiopathic intracranial HTN = aka = Benign intracranial HTN = Pseudotumor cerebri : Obese women , Besides OCP's the other '' non-idiopathic '' cause is Vitamin A overdose

Trigeminal Autonomic Cephalgias involve segments of V1 (headache, eye pain) are associated with autonomic syndrome ( horner's syndrome, lacrimation, rhinorrhea) Intracranial imaging required

Trigeminal neuralgias involve segments of V2, V3 (lancinating pain to the jaw, and lower half of face ) have NO autonomic syndrome No intracranial imaging required Rx : Carbamazepine

Trigeminal Cephalgias : the Cluster headache

Trigeminal Neuralgias : The Tic Douloureux

Primary Headaches : 1. Migraines 2. Cluster 3. Analgesic 4. Tension

Secondary Headaches : 1. SAH 2. Meningitis 3. Abscess 4. Tumor 5. Temporal Arteritis

Temporal arteritis : First Steroids to prevent irreversible blindness then get Biopsy

Triptan's : Contraindicated : in case of Coronary Artery Disease because it leads to vasoconstriction

Cluster heaches Rx : Oxygen important then Ergot or if Triptans fails can be prevented by Verapamil

Follow up : Vascular headaches such as Cluster and Migraine -- with Brain imaging

Pseudotumor cerebri : Dx by LP  Rx : LP repeat - VP shunting (Important to stop OCP's if women age 20-30's taking OCP's -- then go for LP

Spinal Stenosis : present like Claudication but improves with leaning forward

AAA - big enough -- back pain do USG to fix it

Visceral organ pain -- Differential for back pain : case would be like someone get constipation or diarrhea (women with menstrual) without typical presentation of back pain

LP - improves - think NPH 

Schizoaffective disorder : predominant mood symptoms with minimum duration of depressive / anxiety symptoms of 2 weeks with psychotic symptoms

Mid diastolic rumble at the apex -- MS and intracardiac tumor

Asystole/ PEA - do CPR - Atrial fibrillation when hemodynamically unstable then -- synchronized cardioversion

Ventricular fibrillation : Unsynchronized cardioversion

Palpable Bilateral Abdominal masses : ADPKD

Multifocal Atrial Tachycardia : COPD

Rotatory nystagmus : BPPV

BPPV ---- vs ----- Menier's disease :

BPPV : Otolith : Reproducible , recurrent vertigo , last less than 1 minute Dx : Dix halpike Rx : Epley maneuver

Menier's disease : Tinnitus , Fullness lasts less than 1 hour goes greater than 30 minute Rx : salt restriction and Diuretics , Meclizine

Labyrinthitis : Duration is in between of above problem its weeks  with URI , hearing loss , tinnitus , Nausea , Vomiting without brain stem ( Central lesions) Rx : early Steroids and meclizine.

Peripheral vertigo : (BPPV, Menier's , Labyrinthitis) - Central vertigo : ( CVA, Post. Fossa tumor, Multiple sclerosis , Medications)

Coloric test : COWS : (Cold opposite warm same)

ALS : Rx : Riluzole

Rx : for Multiple sclerosis : Acute - Steroids , Chronic : IFN , Symptomatic Rx : if Urinary retention : Bethanecol if Urinary incontinence : Amitriptyline , If spasm : baclofen

Best test is EMG : 1. Mysthenia gravis 2. Eaton lambert syndrome 3. ALS

Must do CT scan in Mysthenia to check thymoma and in Eaton lambert to check Lung ca. i.e. Small cell carcinoma

Done LP : lots of protein and few cells suspect Guillain Barre syndrome

Raloxifene increases your risk of DVT less than Tamoxifene. The organizer is to Keep Raloxifene separate from Tamoxifene.

Ventricular free wall rupture : PEA associated

Ventricular aneurysm : akinesis of the ventricular wall on Echo

Pericarditis : EKG : PR segment depression

PSVT : narrowed complex - wide complex : hemodynamically unstable -- Rx : immediate cardioversion / Defibrillation

Cold water -- increases vagal tone like carotid massage --- decreases AV nodal conductivity

Stroke from Vertebral artery dissection -- Rx -- is heparin instead of alteplase

High Output cardiac failure : Paget disease , Beriberi , Pregnancy , Hyperthyroidism , Anemia

Remember LV free wall rupture presents like Cardiac tamponade

Inter-ventricular wall rupture : VSD : holosystolic murmur left sternal border as compared to papillary muscle rupture which is on apex

Inability to palpate to the point of maximal apical impulse is consistent with large pericardial effusion

Ursodeoxycholic acid DOC for PBC

Antibody and its Disease : ANA (lupus) , Anti-CCP (RA) , RF (RA) , Anti-Histone (Drug induced lupus) , Anti-dsDNA (Lupus and renal disease) , Anti-Centromere (Scleroderma - CREST) , Smooth muscle ( Autoimmune Hepatitis) , Ro + La (Sjogren's) Jo (Polymyositis) , Anti-mitochondrial (PBC) , Topoisomerase (Systemic Sclerosis)

Asymptomatic gallstones : No treatment is needed 

Sildenafil is Contraindicated if patient is on nitrates 

[HEPARIN + WARFARIN(Bridge)]  After 5 days Discontinue HEPARIN -- WARFARIN for 6 months (inital venous thromboembolism)  if its second time -- Life time anticoagulant .

Malignant hyperthermia : Halothane and Succinylcholine

HBV infection associated with : PAN , Membranous glomerulonephritis , Membranoproliferative glomerulonephritis

P450 Inducers and P450 Inhibitors Mnemonics

Extrinsic intrinsic pathway coagulation (Easy to memorize)

Secondary causes of Hypertension

Secondary causes of HTN 

1. Renal : Renal Artery Stenosis
2. Adrenal : Primary Hyperaldosteronism , Cushing syndrome , Pheochromocytoma
3. Thyroid : Hyperthyroidism
4. Parathyroid : Hyperparathyroidism .

Torsade de pointes

Drugs list Torsade de pointes :

  • Class 1 Anti-Arrhythmia : Quinidine , Procainamide , Disopyramide
  • Class 3 Anti-Arrhythmia : Sotalol , Ibutilide , dofetilide

  • Combination of Class 1 and Class 3 : Amiadrone

  • Antipsychotic : Haloperidol
  • Antidepressants : TCA 

Skin conditions and important associations

Acanthosis nigricans -- Insulin resistance (Polycystic Ovarian Syndrome), Gastrointestinal malignancy

Multiple skin tags   -- Insulin resistance , Pregnancy and Crohn disease (perianal)

Porphyria cutanea tarda
Cutaneous leukocytoclastic vasculitis (palpable purpura) secondary to cryoglobulinemia, Lichen planus --
Hepatitis C

Dermatitis herpetiformis  -- Celiac disease

Sudden-onset severe psoriasis 
Recurrent herpes zoster 
Disseminated molluscum contagiosum   -- HIV infection

Severe seborrheic dermatitis  -- HIV infection and Parkinson disease

Explosive onset of multiple itchy seborrheic keratosis -- GI malignancy

Pyoderma gangrenosum -- IBD (inflammatory bowel disease)

Vitiligo -- other autoimmune conditions such as Celiac disease, Pernicious anemia , autoimmune thyroid disease, type 1 diabetes mellitus, primary adrenal insufficiency, hypopituitarism, and alopecia areata.

Types of Personality Disorders