HAPPY HOLIDAYS....

I wish all my loyal followers and readers a very Happy Holiday Season.

May the New Year bring you and your loved ones Health, Happiness,

Prosperity and the best life has to offer!


Sincerely,

Doctor Tibor



We'll return refreshed and ready to continue in January 2010.

CARCINOMA ASSOCIATED SYNDROMES

Often asked, will be questions related directly or indirectly to malignant
disorders. Of those, we'll list the most common ones...likely to show-up
on your boards...



Q: HYPONATREMIA is commonly associated with which malignancy?


A: SMALL CELL CARCINOMA of the LUNG. (An easy way to memorize this
is the remember the letter "S"......"S"mall cell carcinoma causes "S"IADH
which leads to a change in "S"odium. (Hyponatremia).
*****Also of importance, SIADH only causes Hyponatremia!!!



Q: What is the most common PARANEOPLASTIC SYNDROME?

A: HYPERCALCEMIA ....especially common in Multiple Myeloma, Metastatic
Breast cancer and Squamus Cell Carcinoma of the Lung.



Q: What is the most common cause of SUPERIOR VENA CAVA(SVC) SYNDROME?

A: SMALL CELL CARCINOMA of the LUNG. The CXR will show a widened mediastinum.



Q: H. PYLORI is a PRIMARY RISK FACTOR for which cancer?

A: GASTRIC CARCINOMA. It is also frequently the cause of MALT Lymphoma.



Q: Which CELL TYPE is the most common cause of TESTICULAR CANCER?

A: GERM CELL...will cause about 95% of the these cancers. They will ususally
cause elevated AFP and B-HCG levels.



We'll be back in a few days....study well!!!!

TIPS IN CLINICAL TOXICOLOGY....continued

More interesting information and tips in Clinical
Toxicology...not covered on the previous blog.


Q: What is a common CHIEF COMPLAINT in CARBON MONOXIDE poisoning?


A: FLU-LIKE SYMPTOMS...It's a red herring. Typically it's winter, the entire
family can be ill with headache/nasal congestion/lightheadedness.
These symptoms tends to improve when patient goes outside.
100 % O2.... decreases half-life of CO from 5hrs. to 1 hr.



Q: What finding correlates most closely with the degree of TCA (Tricyclic antidepressant)
overdose?

A: QRS PROLONGATION on the EKG correlates most closely with the severity of
overdose. TCA's cause tachycardia, along with PR/QT prolongation and V. Tach
and V.Fib as well.



Q: Consumption of which ALCOHOL causes a SWEET ODOR of breath and KETONURIA?

A: METHANOL(Rubbing Alcohol)....is the second most common alcohol to cause OD.
It's chief metabolite is ACETONE, that causes the sweet odor/cns effects and ketonuria.




LIST OF COMMON POISONS AND THEIR ANTIDOTE(S)...


IRON---------------------------------DESFEROXAMINE

ORGANOPHOSPATES---------------ATROPINE, PRALIDOXIME

ETHYLENE GLYCOL----------------ALCOHOL(IV)

BENZODIAZEPINES-----------------FLUMAZENIL (Mazicon)

NITRATES---------------------------METHYLENE BLUE

ACETAMINOPHEN------------------N-ACETYLCYSTEINE



Thanks again for your time...we'll continue soon. STUDY HARD !!!

CLINICAL TOXICOLOGY

We'll describe several clinical toxicology syndromes, that are certainly
favored by the boards...they are the core questions on almost every
exam.


Q: Which acid-base disturbance is most likely in SALICYLATE overdose?


A: A MIXED DISORDER of respiratory alkalosis (due to tachypnea) and
metabolic acidosis (due to uncoupling of oxidative phosphorylation).



Q: What type of acid-base disorder does ingestion of ETHYLENE GLYCOL cause?

A: Severe ANION GAP (AG) METABOLIC ACIDOSIS.



Q: Which medication is used as an antidote for BETA BLOCKER poisoning?

A: GLUCAGON....as this drug will increase HEART RATE, stroke volume and thus
cardiac output. (It is especially useful in a HYPOTENSIVE B-Blocker O.D. patient).



Q What is the metabolic cause of ORGANOPHOSPHATE poisoning?

A: This pesticide used by farms/orchards causes inhibition of the
CHOLINESTERASE ENZYME. (Diarrhea/vomiting/excessive lacrimation/
salivation and brochospasm are typically seen).


Q: What is the treatment of NARCOTIC overdose.

A: NALOXONE (Narcan). 0.4-2.0 mg for adults. Pediatric dose is 0.01 mg/kg.
(There is NO toxic dose for this drug, as it is safe to administer in larger
amounts).



Q: What rate is ALCOHOL metabolized in an acutely ETOH intoxicated patient?


A: Rate of breakdown metabolism is 20mg/dl per HOUR.




Q: What is the treatment of choice of moderate to severe LITHIUM TOXICITY?


A: HEMODIALYSIS. Especially in serum level greater 4.0 mEq/l. (Lithium
is very toxic and the therapeutic-toxic "window" is quite narrow. Level
greater the 2.0 mEq/l is already considered mild toxicity).


Q: In which medication overdose is the RUMACK-MATTHEW
NOMOGRAM used?

A: ACETAMINOPHEN (Tylenol) oversode. Serum acetaminophen (apap)
is measured at exactly 4 HOURS POST INGESTION. If the level is greater
then 150 mg/ml....treatment is initiated. (with N-Acetylcysteine IV or PO).
It is most effective, if given in first 8 hours post ingestion.



Thanks for your time, again. We'll be back soon with more and more challenging topics.

PHYSICAL SIGNS OF INTERNAL DISEASE...

Many times we'll observe a patient with a particular or peculiar physical finding
that can give us important insight...into an underlying pathology.
Needless to say....the boards also like you to know some of these clicinal clues.

I will highlight the MAIN association of a particular illness...the one the boards want you
to answer....as there may be multiple associations.


Q: What illness is associated with CAFE AU LAIT spots?

A: NEUROFIBROMATOSIS (Von Recklinghausen's Disease).



Q: What common disorder causes ALOPECIA AREATA?

A: HYPOTHYROIDISM/hyperthyroidism/pernicious anemia.



Q: What process causes BLUE TOE SYNDROME?

A: CHOLESTEROL/AtheroEMBOLI. (As in recent trauma patient or post angiography).



Q: What malignacy is associated with ACANTHOSIS NIGRICANS?

A: GASTRIC ADENOCARCINOMA.


Q: Which common cardiac medication causes GRAY-BLUEISH discoloration
of the sun exposed areas of the skin. (Light charcoal looking face).

A: AMIODARONE



Q: What condition causes KAYSER-FLEISCHER RINGS of the eyes?

A: WILSON'S DISEASE, especially in patients that have the neurologic complications
of the disease. E.g. personality changes/psychosis.



Q: Which genetic condition causes highly elastic skin(connective tissues)?

A: EHLERS-DANLOS SYNDROME. Patients have lax joints/fragile skin
and are prone to GI bleeding, due to lax vascular tissues.



Q: Which condition causes SADDLE NOSE DEFORMITY?

A: WEGENER'S GRANULOMATOSIS. The nasal bridge collapses due to destruction
of bony cartilage by the granuloma.



Q: Which tick borne illness causes ERYTHEMA MIGRANS rash?

A: LYME'S DISEASE...this finding can be absent in 25% of patients!



Thank you for you time...we'll be back soon.

RANDOM BOARD QUESTIONS...

We'll continue with topics that are frequently asked by the boards
assorted from random disciplines.


Q: What is LUPUS PERNIO?


A: It is a violaceous rash on the tip of the nose in patient with SARCOIDOSIS.
(It has no relation to SLE).



Q: What are common physical findings in Reiter's Syndrome (reactive arthritis)?


A: ONYCHOLYSIS
Painless MOUTH ULCERS
Painless PENILE LESIONS (Balanitis Circinata)
Painless SKIN LESIONS (Keratoderma Blenorrhagicum)
UVEITIS
HEEL PAIN



Q: What is ACOUSTIC NEUROMA?


A: A BENIGN TUMOR causing progressive UNILATERAL hearing loss, with
tinnitus but no vertigo!



Q: What is the BEST test to diagnose MUCOPURULENT CERVICITIS?
(Chlamydia Trachomatis)


A: Ligase Chain Reaction (LCR) Assay




Q: What is the MAIN risk factor for MELANOMA?



A: Excessive exposure to sunlight in CHILDHOOD years.




Be back soon....study hard!

DEMENTIA SYNDROMES...Clues to differentiate

Thank you all for your patience in awaiting this next blog.


The boards love DEMENTIA related topics and questions, so let's cover the

most important ones. Subtle "clues" will have you select the correct

answer....and that is my aim. Remember, the CAPITALIZED words are

the KEY....but you should already know that from the previous blogs!?



Q: What is the MOST prominent feature of ALZHEIMER'S DEMENTIA?


A: Memory impairment of RECENT events.

The MMSE(Mini Mental Status Exam) score is usually 12-24 the first
5 years, then significantly worsens.



Q: What is DEMENTIA with LEWY BODIES?


A: Most prominent clinical feature is VISUAL HALLUCINATIONS.
Other features are disturbed REM sleep with VIVID DREAMS.
The MMSE score is usually 15-28 the first 5 years.


Q: What is FRONTOTEMPORAL DEMENTIA?


A Key clinical feature is APATHY, with a remarkably NORMAL MMSE score of 30!!!



Q: What is VASCULAR DEMENTIA?


A; As the name implies, the problem is vascular with MRI of BRAIN documenting
at least one INFARCT. The more infarcts...the more evident the diagnosis.



Q: What is NORMAL PRESSURE HYDROCEPHALUS (NPH)?


A: It is a TRIAD of SYMPTOMS in elderly patients:

1. DEMENTIA
2. GAIT IMPAIRMENT ("MAGNETIC GAIT"). Think Frankenstein!!!
3. URINARY INCONTINENCE

The CT/MRI in these patients will show enlarged ventricles and normal
CSF pressure, if measured.



Thanks again for your patience....the next blog will be coming soon.

Look forward to some quite interesting topics and cases.

SEROLOGIC TESTING...VIRAL HEPATITIS

Interpreting the serologic tests are always challenging, especially
during the stress of exam taking...but also at the practice setting.

We'll show you an easy method of remembering and diagnosing both
acute and chronic Viral Hepatitis.....JUST MEMORIZE ALL THE CLUES!!!


CLUE No.1 As on the previous posting, remember:

Any positive IgM test equals CURRENT illness. HINT: "M" "M"omentary
Any positive IgG test equals RESOLVED illness. HINT: "G" "G"one

Just knowing this simple clue.....you've won half the battle!!!

-------------------------------------------------------------------------------------------------


CLUE No.2 Always divide illess into ACUTE and CHRONIC.


CLUE No.3 ALL Viral Hepatitis has an ACUTE FORM:
HAV, HBV, HCV, HDV and HEV. (a,b,c,d,e) can it be more simple.


CLUE No 4. ONLY THREE types of Hepatitis has CHRONIC FORM:
HBV, HCV and HDV.


By now, you had won three quarters of the battle....the rest is easy.
Let's put it all together by REMEMBERING ALL THE ABOVE INFORMATION.

-------------------------------------------------------------------------------------------------


ACUTE HEPATITIS SEROLOLGY (IgM)


HEPATITIS A (HAV)........+IgM Anti-HAV

HEPATITIS B (HBV)........+IgM Anti-HBc
This is the BEST and MOST SENSITIVE MARKER!!!!

HINT: Acute HBV infection causes
elevation of ALL elements, thus + results:

"c"-Core: +IgM Anti-HBc (as above).
"e"-Envelope: +HBeAg
"s"-Surface: +HBsAg

DON'T FORGET:

On the exam and in clinical practice, the
BEST TEST is always +IgM Anti-HBc !!!!!


HEPATITIS C (HCV).......+HCV RNA (by PCR)...The BEST TEST!!!
+Anti-HCV

HEPATITIS D (HDV)........+Anti-HDV (Remember, there must be a co-
-existing HBV infection).


HEPATITIS E (HEV).......+ IgM Anti-HEV

-------------------------------------------------------------------------------------------------

CHRONIC HEPATITIS SEROLOGY (IgG)


HEPATITIS B (HBV)......+IgG Anti-HBc

HEPATITIS C (HCV).......+Anti HCV
+HVC-RNA

HEPATITIS D (HDV)......+IgG Anti-HDV (This infection can never outlast HBV)


-------------------------------------------------------------------------------------------------

RECOVERED/RESOLVED PHASES OF HEPATITIS (IgG)


HEPATITIS A (HAV).......+IgG Anti-HAV (Confers Immunity/Prior Infection)

HEPATITIS B (HBV)........+ Anti-HBs (Confers Immunity/Prior Infection)

HEPATITIS C (HCV)........-Anti-HCV-RNA (by PCR) (Resolved Viral Load)
+Anti-HCV (Remains + for life)

HEPATITIS D (HDV)........+IgG Anti-HDV

HEPATITIS E (HEV)........+IgG Anti-HEV


-------------------------------------------------------------------------------------------------


Thanks for your time and attention.....hope it was simple, fun and not hard at all!!!

HEPATITIS FACTOIDS.....Made Simple

We'll review some important generalizations about "HEPATITIS"
while keeping it simple, easy to recall....and fun to memorize.


HINT: the CAPITALIZED words, are the KEY features to remember!!!





IgM ----- implies a CURRENT/ACTIVE process.
IgG------ implies a RESOLVED process. HINT: "G" Gone!!!



Hepatitis A Virus (HAV).....does NOT have a chronic form.

Hepatitis E Virus (HEV).....also does NOT have a chronic form. With PREGNANCY it has
> 20% mortality, in endemic areas, esp. Asia.

Hepatitis B Virus (HBV)....99% patients recover from ACUTE form of infection, without
treatment. Symptoms are usually SERUM SICKNESS-like
with URTICARIA, ARTHRALGIA, ANGIOEDEMA, prior to
jaundice.

Hepatitis C Virus (HCV)....acute form is rarely symptomatic. Thus, most patients are
diagnosed incidentally. GENOTYPE 1 is most common, @ 75%
and also has the WORST PROGNOSIS in USA. No vaccine
available, yet.

Autoimmune Hepatitis.....is non infective, but can cause FALSE positive HCV test.
NO PRURITUS involved. If patient c/o itching, look for
an alternate diagnosis.

Drug Induced Hepatitis....generally causes an ELEVATED LDH and normal hepatitis
profile. Moderate-severe elevated LFT's. Accounts for about
40% cases of hepatitis in USA.


Hepatitis D Virus (HDV)....requires CO-INFECTION with Hepatitis B (HBV).
Thus, cannot diagnose HDV infection without HBV.


Ischemic Hepatitis...........Most common cause is POOR CARDIAC OUTPUT, with
systemic hypotension/hypoxia. AST/ALT elevation in the
THOUSANDS within hours of HYPOPERFUSION injury.


Alcoholic Hepatitis..........Has 10-40% mortality. Patients are usually malnourished
and present with FEVER, jaundice, RUQ pain, modest AST/ALT
elevations (2:1/3:1 ratios) and ELEVATED IgA levels!!!


Glucocorticoids.................are CONTRAINDICATED in any form acute VIRAL Hepatitis.


Chronic Hepatitis............. requires the illness to be present for > SIX MONTHS by definition.



Thanks for you time. Next posting we'll review interpretation of viral hepatitis
laboratory tests......made simple.

Types of Pneumonia....DETECTIVE CLUES...

Knowing the CLUES BY HISTORY, will make all the difference on the exam and in
clinical practice.


1. MYCOPLASMA PNEUMONIA....Seen generally in YOUNG adults. Common in the fall
and spring. Frequently associated with a RASH and BULLOUS MYRINGITIS.



2. CHLAMYDIA PNEUMONIA...Also common to YOUNG adults. E.g. college dorm students,
military recruits/barracks and frequently follows a prolonged SORE THROAT/URI.
The organism responsible is Chlamydia Trachomatis.



3. PSITTACOSIS PNEUMONIA...Occurs in patients who are in contact with BIRDS.
(pigeons/parakeets/parrots/chickens.) Either through occupation or as pets.
Causative organism is Chlamydia Psittaci.



4. STREPTOCOCCUS PNEUMONIA...Is the most common of the CAP's. Usually very
ACUTE/ABRUPT onset, more common in patients with underlying COPD.



5. KLEBSIELLA PNEUMONIA....Especially common in ALCOHOLICS and in patients
with Diabetes Mellitus/Nursing Home populations.



6. LEGIONELLA PNEUMONIA....Associated with WATER VAPORS. E.g. humidifiers,
air conditions, hot tubs, cooling towers and ventilation systems. Clinically, frequently
associated with CONFUSION/DIARRHEA/HYPONATREMIA and pleural effusions.



7. STAPHYLOCOCCUS AUREUS PNEUMONIA....Frequently follows INFLUENZA.
Tends to leave CAVITARY lesions on the CXR.



8. HAEMOPHILUS INFLUENZAE PNEUMONIA....Also, frequently follows a bout of
upper respiratory infection (URI) and especially common in pts. with COPD.



Thanks for your time....remember the clues!

Clinical gems....Infectious Diseases

We'll continue with the "exciting" material from the field of Infectious Diseases.



Q: What are the common communicable diseases causes by Deer Ticks?


A: Lymes Disease / Ehrlichiosis / RMSF(Rocky Mountain Spotted Fever) / Q Fever
Babesiosis and Tularemia.
HINT: Each time you see a patient with a "tick bite" consider all of the above
not just Lyme's, which is the most notable and common.




Q: What disorder is the most common RISK FACTOR for native valve endocarditis?


A: Mitral Valve Prolapse (MVP). Remember, NATIVE valve.
HINT: Risk factors for prosthetic valve endocarditis are usually NOSOCOMIAL
infections.




Q: Which type of organism is most serious occuring from a DOG BITE?

A: CAPNOCYTOPHAGA CANIMORSUS infection. This can be lethal in patients who are
immunocompromised, such as Splenectomized, HIV, Chemotherapy patients, etc.
Sepsis treatment requires: 2 wks. of IV PCN-G antibiotic.





Q: What is the BEST lab test to determine need for continued antibiotic treatment
in a patient with Osteomyelitis?


A: C-REATIVE PROTEIN. Is the single BEST lab test, to determine the "success"
of the antibiotic regimen....not he Sed Rate.





Q: What is the HALLMARK physical symptom of Whooping Cough.

A: PAROXYSMAL cough! Repetitive BURSTS of 5-10 episodes of cough. frequently
followed by post-tussive vomiting. The other symptom is the audible "whoop".
(The organism responsible is Bordatella Pertussis. A Gram negative bacilli).




Q: What is the treatment of a PREGNANT patient with Syphilis?

A: Same as the non-pregnant. PCN-G is the ONLY treatment, whether pregnant or not.
HINT: If patient is allergic to PCN....must DESENSITIZE and still use PCN. This applies
to all patients!!!





We'll continue next week. Study hard.

Topics in Emergency Medicine

This specialty is also well represented on the examination and in
daily practice of emergency medicine-urgent care.



Q: What is a Felon?

A: It is a pyogenic infection of the distal pulp space of the finger. Usually due to
staphylococcal or streptococcal infections. Best therapy: Incision and Drainage
followed by 7-10 days oral antibiotics, against gram-positive organisms.




Q: What is a Fat Embolism Syndrome?

A: It occurs in patient with severe long bone injuries/fractures. The symptoms are due to
dislodged fat globules...causing an embolism, several days after the trauma.
Pts. usually exhibit hypoxia, restlessness, bilateral CXR infiltrates and kidney failure.
Treatment is supportive.




Q: What is Gas Gangrene (Myonecrosis)?

A: It is an infection caused by Clostridium perfringens. It causes rapid necrosis of fascia,
muscle and tendon. It usually occurs in traumatized or diabetic patients. Clinically, there
is palpable gas (crepitations) of the skin (also visible on X-rays) and intense pain.
Treatment: Aggressive IV antibiotics, surgical debridement and hyperbaric oxygen.




Q: What is Erysipelas?

A: It is cellulitis involving the facial structures (cheeks/nose) due to group A Strep Pyogenes.
The lesions is very painful, erythematous and edematous.
Treatment: Oral dicloxacillin. In PCN allergic patients, erythromycin.




Q: What is a External Hordeolum?

A: It's also called a Sty. An infection usually due to Staph. aureus, involving the eyelash
follicles. Treament: Usually self limited, after spontaneous drainage of the abscess.
Warm wet compresses 3-4 times daily for 15-20 mins. helps the healing process.
Bacitracin ointment can be supplemented.




We'll return soon....keep up the good work.

CLUES by ETHNICITY....

Many disoders occur within certain ethnic/racial groups.
This may seem obvious, but we often overlook this fact.
Many questions can be "guessed" based on just being aware.


The list is only partial and overlaps may occur...but on the exam, they
keep it simple and straightforward.



Disorders frequent to ASIANS:

1. Hepatitis E (HEV). It is the oriental equivalent of Hepatitis A. (HAV).

2. IgA Nephropathy (Berger's Disease) Occurs commonly in Asian males.

3. Kawasaki's Disease. Occurs mainly in oriental children.

4. Takayasu's Arteritis. A form of vasculitis mainly in younger women of East Asia.




Disorders frequent to MEDITERRANEANS: (Greeks/Italians/Armenians/Lebanese/Jews)

1. G6PD-Deficiency.

2. Familial Mediterranean Fever (FMF)

3. Beta Thallassemia

4. Tay-Sachs Disease. Occurs predominantly in Jewish populations.



Disorders frequent to CAUCASIANS:

1. Cystic Fibrosis. Especially Northern Europeans.

2. Heredirary Hemochromatosis

3. Wilson's Disease

4. Factor V-Leiden. Has a major Caucasion predominance.

5. Protein 20210 Mutation. Occurs mainly in White populations.

6. Alpha-1 Antitrypsin Deficiency



Disorders frequent to AFRICAN AMERICANS:

1. Sarcoidosis. A disorder of non-caseating granulomas.

2. Focal Segmental Glomerulosclerosis. (FSGS). African Americans have a high predisposition.

3. Sickle Cell Anemia (SSA)



Thanks thanks for your time....we'll continue next week.

Physical diagnosis....

We'll review the "classic" physical signs...that with great certainty, will be asked on the
board exam. Suggest, you memorize all of them.



Q: What is a Kussmaul Sign?


A: It is distention of the neck veins on inspiration. (This occurs in any condition that impedes
right ventricular filling, e.g. RV Infarction/CONSTRICTIVE PERICARDITIS/right heart
failure.


Q: What is Pulsus Alternans?


A: It is alteration in the amplitude (palpable force) of each pulse, due to left ventricular
contractive weakness. Each pulse is regular. Main conditions causing this are CARDIAC
TAMPONADE and severe LV decompensation.



Q: What is Tinel's Sign?


A: It is a common finding in patients with CARPAL TUNNEL SYNDROME. The sign
itself refers to "tapping" of the median nerve at the volar aspect of the wrist. This
causes, paresthesia (pins& needle senation). HINT: "T"apping---"T"inel's !!!!


Q: What is the Drop Arm Sign?


A: It is seen in patients with ROTATOR CUFF TEAR. The patient's arm is abducted
to 180 degrees. When asked to gently let down the arm....it will just suddenly drop
when reaching about 90 degrees....thus confirming the tear.



Q: What is an Iliopsoas Sign?


A: It is a physical finding suggestive of ACUTE APPENDICITIS. It is elicited by asking
the patient to raise the right leg against resistance. The pain...is
is caused by "rubbing" of the inflammed appendix against the inner peritoneal wall.



Q: What is a Cullen's Sign?


A: It is seen with conditions causing hemoperitoneum. Classically, it's associated with
NECROTIZING PANCREATITIS. The finding is a PERIUMBILICAL ecchymotic
like discoloration of the skin.


Q: What is Kehr's Sign?


A: Violent, severe pain in the left shoulder of a patient with RUPTURED SPLEEN.



Q: What is Chvostek's Sign?


A: It is an elicitation of unilateral facial irritability, by gently tapping over the facial
nerve, just anterior to the ear. It will cause facial grimacing, due spasm of the orbucularis
oris or oculi muscles. It is a sign of TETANY (HYPOCALCEMIA).





Keep up the good work!!! Study hard...reap the benefits later.....

Clinical gems...Pulmonary Medicine

We'll continue with interesting topics from the field of Pulmonology. Essentially,

illnesses caused by environmental/occupational factors.



Q: What is the most common cause of Mesothelioma?

A: ASBESTOS exposure-long term. (Of note, it is NOT associated with smoking).



Q: What is Farmer's Lung?

A: A pneumonia like illness, occuring 4-8 hrs. after exposure to MOLDY HAY.
The organism causing the illness is Thermophilic Actinomyces.



Q: What occupational illness causes "monday chest tightness"?

A: BYSSINOSIS...exposure to cotton dust. The release of histamine causes the tightness,
when the patient returns to the cotton processing work, after the weekend.



Q: Which occupational illness causes an markedly increased risk for Tuberculosis?

A: SILICOSIS...an illness due to quatrz exposure in foundry/glass workers.
The CXR actually shows a miliary(seed/millet) like finding, as in T.B.



Q: Which lung disease of coal miners is associated with Rheumatoid Arthritis?

A: CAPLAN'S Syndrome...a form of pneumoconiosis with a poor prognosis.



Thanks again, we'll be back next week. Feel free to post questions and comments.

Clinical gems....Hematology

We'll review some of the likely topics asked on the boards.



Q: What is the BEST diagnostic test for detecting iron deficiency anemia?

A: Serum Ferritin level... (serum iron test is mainly for screening)



Q: What physical SIGNS are highly specific for iron deficiency anemia?

A: Both.... Blue Sclera and Koilonychia...(spoon shaped fingernails)



Q: What infectious agent can cause sudden Aplastic Anemia in a young adult?

A: Parvovirus-B19 infection



Q: What disorder is the most common cause of vitamin B12 deficiency?

A: Pernicious Anemia... (due lack of gastric intrinsic factor)



Q: What peripheral smear finding is associated with Lead Poisoning?

A: Basophilic Stippling...(small granules in RBC's)



Q: What is the BEST test for definitive diagnosis of vitamin B12 deficiency?

A: Serum Methylmalonic Acid...( serum B12 level used mainly for screening).



Q: What is the MOST frequent blood transfusion reaction?

A: FNHTR (Febrile Non-Hemolytic Transfusion Reaction). Use Leukocyte reduced RBC's.



Q: Which type of anemia presents with paresthesias/ataxia/prominent NEURO symptoms?

A: Cyanocobalamin deficiency(B12). Causes demyelination of the dorsolateral portion
of the spinal cord. Foot burning...numbness are often the FIRST symptoms.


Q: Does deficiency of Folic Acid alone cause neurologic abnormalities?

A: No....only B12 deficiency.



More topics soon to follow...

Clinical gems.....Opthalmology

Clinical "gems" are especially helpful for the boards and in our daily practice.

So, let's review some of the important ones, likely to be presented to your on the exam.




Q: Wearing of contact lenses is a risk factor for which type of infection?

A: Pseudomonas...Keratitis (painful condition with photophobia w/o exudate)



Q: Finding of vesicles/dendritic ulcers on the conjunctiva, is associated with which infection?

A: HSV...Keratitis



Q: Finding of dryness and grittyness under the eyelids, is associated with which illness?

A: Sjogren's Syndrome



Q: Which conditions cause sudden PAINLESS visual loss?

A: Both CRAO (Central Retinal Artery Occlusion) & CRVO (Central Retinal Vein Occlusion).



Q: Which ocular condition is PAINFUL....Acute Closed or Open Angle Glaucoma?

A: Acute Closed Angle.....as the word "closed" implies. The pressure has no outlet.




Thanks again...we'll continue shortly.

EXAM TAKING WORD SKILLS.....

We'll return to the PSYCHOLOGY of exam taking. Some you may be familiar with, some may
not. So, it's useful to review a few tools you can use to your advantage. Especially, when you'll
just have to guess an answer.



Exam taking rule # 2. PAY ATTENTION TO THE WORDING !!!!

Whenever you see a sentence containing the following words: NEVER, ALWAYS,
RARELY, UNLIKELY....are most probably NOT the correct answers!!!!





Example: 1. A patients with Hodgkin's Lymphoma RARELY experience fever. (Quite the
opposite is true. One of the key features is, PAL-EBSTEIN FEVER).


Exaample 2. Travelers who receive immune prohylaxis prior to travel to the
Sub-Saharan Africa, NEVER develop malaria. (DRUG RESISTANCE is common
so, even with the best preventive measures, malaria can occur).


Example 3. Patient's with Adult Still's Disease ALWAYS experience a rash. (In fact,
they experience an EVANESCENT (come&go) faint salmon colored rash,
therefore making the diagnosis even more difficult).


Example 4. Patient's with Pseudotumor Cerebri are UNLIKELY to benefit from weight
loss. (Quite the contrary. These patients are usually obese young women, in
in whom, weight loss is often CURATIVE of their recurrent headaches).





Thanks for your time again....we'll continue soon and get into more detail on exam taking.

Physical Signs of Illness

Physical signs of illness is another area well covered by the boards, additionally
we can encounter these at any given day in our clinical practice....may be as soon as
tomorrow!?

So, lets review some of the interesting ones.


Q: What is the HUTCHISON'S SIGN?

A: The appearance of vesicles on the tip or lateral aspect of the nose indicating involvement
of the nasociliary nerve branch by VZV (VARICELLA ZOSTER VIRUS). An opthalmology
referral is warranted, as it is likely to indicate onset of Herpes Zoster Opthalmicus.


Q: What is the sign of LESER-TRELAT?

A: Abrupt onset (eruption) of many pruritic Seborrheic Keratosis (scaly,reddish
lesions) on the face, most commonly associated with imminent dx. of GASTRIC
ADENOCARCINOMA.


Q: What is DARIER'S sign?

A: Eruption of a pigmented salmon-brown lesions with pruritus (Urticaria Pigmentosa)
at the site of stroking of the skin. This is found in MASTOCYTOSIS, a condition
caused by systemic histamine release, due to mast cell proliferation.


Q: What underlying condition does RACOON EYES (non-traumatic) represent?

A: PRIMARY AMYLOIDOSIS. They are peri-orbital "dark circles". Not to be confused
with melasma a normal hyperpigmentation associated with pregnancy.


Q: What is the NIKOLSKY'S SIGN?

A: Refers to superficial seperation of skin with lateral pressure on the lesion.
On the boards mainly associated with ERYTHEMA MULTIFORME.



Thanks again for your time!

Rheumatology Bits...

Rheumatology is a HOT TOPIC on the boards.....as in the past.
So, it's useful to be updated on the subject.

Speaking of updates, I want to share a bit of NEW information regarding the choice
diagnostic testing of RA. I had a great conversation today, about this exact subject
so, it's only befitting to mention it.


The latest test of choice for the diagnosis of Rheumatoid Arthritis, is called... Anti-CCP-Ab.
This test has replaced the previous one, namely the RF (Rheumatoid Factor), which has
become totally outdated.


Having shared that...let's continue with some rheumatology ONE-LINERS.


Q: What is the most sensitive physical exam test for Carpal Tunnel Syndrome?

A: Eliciting weakness of the Abductor Pollicis Brevis



Q: Which blood test is diagnostic of Drug- Induced Lupus?

A: Anti-Histone Ab



Q: What is the hallmark physical finding of Psoriatic Arthtritis?

A: Sausage digits (dactylytis)



Q: What is Anserine Bursitis?

A: Inflammation of the bursa under the sartorius attachement, causing pain about 4 cm below
the MEDIAL aspect of the knee, especially in mid-elderly women with DM.
TX: Acetaminophen


Q: Which spinal fracture can be common in patients with Ankylosing Spondylitis, even with
trivial injuries?

A: C7 (cervical spine) fracture.




Thanks for your time! We'll be back shortly.

Power of ONE-LINERS

We'll continue the one liners, as they are the backbone of any examination, especially the boards.
They take pride in challenging your intellect and years of hard memorization....so, the more you
know, the higher you'll score.

Q: What is the most common cause of death among teenagers?

A: Motor vehicle accidents


Q: Which type of E.Coli causes bloody diarrhea, due to consumption of undercooked beef?

A: E.HE.C. (Entero-Hemorrhagic-Escherichia-Coli).....Serotype O157:H7 !!!


Q: What illness can be a serious complication of O:157:H7 E.Coli infection?

A: Hemolytic Uremic Syndrome (HUS)


Q: What rheumatologic condition is associated Gottron's papules(scaly, light erythema @ MCP
joints).

A: Dermatomyosytis


Q: Which syndrome causes mild, asymptomatic lifelong,unconjugated hyperbilirubinemia?

A: Gilbert's Syndrome. This can be mistaken for chronic hepatitis or other liver disorders.


Thanks for your time...we'll continue soon.

We're moving on to more exciting stuff of medicine....the ONE LINERS which must be memorized,period. There is no alternative but to know these cold, but you can simplify
the process, as we'll show you later.

Many of these questions will be on your exam verbatim...so it will be very worthwhile for you
to memorize them and keep repeating them, until ad nauseum.

Q: What is the most common cause of Bacterial Endocardititis?
A: Streptococcus Viridans

Q: Best therapy for Macular Degeneration?
A: Low vision aids (large unfashionable dark glasses)

Q: Which pathogen is most serious of Human Bites?
A: Eikenella Corrodens (Clenched fist injury, i.e. a skin tear of the hand by the teeth)

Q: What vesicular infection is common in wrestlers?
A: Herpes Gladiatorum (Head and neck skin infection in young "gladiators")

Q: What is Pott's Disease
A: Tuberculosis involvement of the thoracic spine (plain films will show irregular bone
erosion of end plates)

Q: What is the most common cause of sudden death in young adults?
A: HCM (Hypertrophic Cardio-Myopathy) due to paroxysmal ventricular fibrillation.

Q: Which cardiac medication has been shown to be of both short and long term survival
benefit?
A: Beta Blockers (ACE Inhibitors is the other answer, if B-blocker is not a choice)

Q: What is the most common congenital heart disease?
A: VSD (Ventricular Septal Defect)

Q: What particular ethnic group has an increased risk of breast cancer?
A: Ashkenazi Jews (due to increased BRCA-1 mutations)

Q: What is the most common type of skin cancer?
A: Basal Cell Carcinoma (About 70-80% of skin cancers)

Thanks for you participation today....see you soon.

The dynamics of the examination questions...

There is a definite reward in mastering the art of exam taking....you will get the question right!
The trick is to "dissect" each question for clues to the correct/best answer, while remembering
this very important rule:

Rule No.1. Every question must contain the answer!

Think about it. How can a question be asked by the examiner without giving ALL the clues
to the correct answer within the framework of the question itself. It is impossible!!!

The exceptions are the one liners...which you must know cold, pure rote memory. But we'll
show you how to skillfully answer them as well, with confidence.

Example: Which organism is the most common cause of Trench Fever?
Answer: Bartonella Quintana.

An example of a complex question, to "dissect":

A 42 year old white male presents to the E.R. with fever, chills, malaise and generalized body
aches and back pain of 3 days duration. Pt. was well prior to the onset of these symptoms.
PMH: Negative. PSH: Appendectomy SH: Smokes 1ppd. ETOH: Socially. FH: Prostate cancer/ HTN/ Ulcerative Colitis. Occupation: Welder. Married with 2 children.
Current medications: None. Allergies: None.

Physical Exam: T: 100.7 HR: 101 BP: 122/66 mm/Hg RR: 18 Pulse Ox: 98% on room air.

Pt. appears prostrated, but non toxic.
Skin: Warm and dry. No petechiae/purpura/jaundice. Nailfolds show faint vertical lines at tips.
HEENT: Essentially unremarakble, except for small prominent blood vessels on conjuntiva.
LUNGS: Clear to auscultation/percusssion
HEART: S1 S2 audible. No murmur/rub/dullness.
ABDOMEN: Soft, non tender, bowel sounds wnl, no organomegaly.
MUSCULOSKELETAL: No CVA tenderness. No joint effusions/synovitis. No needle tract marks.
Noted are small purplish spots on the tip of fingers, that are reportedly painful.
NEUROLOGIC EXAM: Normal.

LABS: CBC with diff. WBC 12.2 Hb/Hct: 14.4/38.6 Platelets: 244K
Electrolytes: Normal
Blood Cultures: Pending
Sed Rate: 48 mm/hr
ASO Titer: Negative
Urinalysis: RBC's 2 + No wbc/trace bacteria. Normal sediment
CXR: Normal
EKG: Sinus rhytm. 98/min. Normal axis. No acute changes.

What is your diagnosis:

A. Acute Viral Syndrome
B. Acute Urinary Tract Infection
C. Acute Bacterial Endocarditis
D. Fever of Unknown Etiology
E. Adult Still's Disease

Correct anwser: C. Acute Bacterial Endocarditis

The question contained all the clues(answers) to pick the correct diagnosis.

Main clues: Fever/malaise/back pain. Of these, back pain is the most important...because
@ 40% of cases of bacterial endocarditis will manifest this symptom.

Vertical lines at nailfolds: Splinter hemorrhages
Conjunctiva: Conjunctival hemorrhages
Purplish spots on fingertips: Osler's nodes (OUCH) on pads of digits.

Missing are two more prominent findings of endocarditis not seen in this patient:
1. Roth spots. White centered retinal hemorrhages are PATHOGNOMONIC.
2. Janeway lesions. Painless purplish hemorrhagic spots on the palmar/soles.

Incidentally, the back back pain occurs, due to microspopic papillary necrosis of the kidneys,
leading to slight HEMATURIA and back pain, of course.

Remember: ALL THE PHYSICAL FINDINGS OF BACTERIAL ENDOCARDITIS ARE FOUND
ON THE HANDS/FEET AND EYES. There are NO other bodily findings!

You have just dissected your first question, succesfully!

Taking my first steps...

Hi,

I am taking the very first step, in the world of blogging...not even certain quite how to proceed, but bear with me, it will be worth it.

I want to share a bit of my knowledge of medicine, specifically geared towards physician's assistant students...who will be taking their board exams or those already practicing and are due to recertify.

Why am I doing this...well it is a sort of giving back! And I throughly enjoy teaching. It gives me great pleasure and something very worthy to do with my free time...without wanting anything in return.

So, feel free to ask anything related to your board preperation in the hope of your total
success and confidence in passing the exam.

Sincerely,
Doc Tibor