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USMLE Step 2 CK Bits & Pieces High yield short focused points, monographs, charts, illustrations, tables, and other stuff related to the USMLE Step 2 CK Exam.


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  #1  
Old 01-28-2013
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Star Collection of Best Intial, Most Accurate Test, Best Next Step, Best Treatment!

Hello everyone,
CK basically revolves around the questions asking us about the best initial test, most accurate test, appropriate next step and Best treatment. I would try to make as many post I can and I would hope that other people would contribute in this thread too.

I would start with the Aortic Dissection

Best next step if BP is given: Control BP (a) Beta Blocker (b) Nitroprusside
Best Initial test: Chest X-ray
Accurate test: Angiogram
Rx: Surgical correction

Note: TEE=Constrast CT=MRA. Between TEE and TTE, choose TEE

* Please correct me if I make any mistakes. Thanks.
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Old 01-28-2013
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MS:
Best indicator of severity is A2 to OS
Best initial test is TTE; more accurate is TEE and most accurateis Cathertization
If asymptomatic= follow up
If mild sym= medical ttt
If failed medical ttt= Valvoplasty
If unsuccessful Valvoplasty= valve replacement
In pregnancy manage with Valvoplasty
Indication of replacement:
1- Symptomatic pt with MR
2- Sever calcified MV
3- Failure of Valvoplasty
4- CHF with sever symptoms
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Peripheral Artery Disease

Best Initial Test- Ankle Brachial Index(<0.9 is diagnostic)
Most Accurate Test- Angiogram
Rx- Aspirin, Stop Smoking, Cilastazol(Single most effective)
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  #4  
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MI:

#Diagnostic tests:

*Best initial test= ECG= elevation in 1 or > 1 mm in to consequent leads
#In posterior MI looks to ECG paper from up side down to see ST elevation
*Most accurate method= Angiography
*Confirmatory test= CK-MB is dx of choice,, Troponin is most specific
*Stress test= done when etiology of chest pain is uncertain and EKG is not diagnostic and it limited by:
#If pt can’t able to exercise= (1) Dobutamine + Echo OR (2) Dipyridamole or (adenosine= C/I in Reactive airway Dz coz provoke bronchospasm) + thallium or sestamib
# If can’t able to read ECG= (1) thallium or sestamib {decrease uptake} OR (2) Echo for detection of motion abnormalities

*Treatment of ACS:


#
Treatment of stable A:
*Best initial= NG + ASP
* BB= start at any time

# Treatment of ST elevation:

* Best initial= O2 + morphine + NG + ASP(Clopidogrel if allergy to ASP)
* PCI Angioplasty within 90 min
* Immediate Thrombolytic (TPA)= within 2 hrs If Angioplasty delayed
*Heparin= after thrombolytic or PCI
*BB= start at any time and if not tolerate BB {in asthmatic pt} can use CCB (Verapamil or Diltiazem)
*Statin= if LDL> 100
*ACEI= if low EF
*CABG

#
Treatment of ST depression or unstable A or posterior MI:

· Best initial= O2 + NG + ASP
· Next step= Heparin
· BB= start at any time
· Gp 2b/3a {Abciximab, tirofiban}=

#
Rt side heart failure:

· Best initial= I.V fluids + prepare pt for revascularization
· If BP not maintain with I.V fluid add Dopamine

*Mortality benefit
:

#ASP
#Angioplasty
#BB= start at any time
#tPA= mortality benefit within 2 hrs
#Statin= if LDL> 100
#ACEI= if EF < 40%

Last edited by heartbeat; 01-28-2013 at 11:14 PM.
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  #5  
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Acute Pulmonary Edema

Next Appropriate step: Loop Diuretic
Best Initial Test(s):1- ECG,2- X-ray,3- TTE
Rx- LMNO (Loop, Morphine, Nitrate, O2)
Preload Reducers like Dobutamine, amrinone and milrinone
(Digonxin not used since it takes weeks)
Afterload Reducers: Acute setting> Hydralazine, nitrates
chronic setting>ACEI/ARBS
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Quote:
Acute Pulmonary Edema

Best Initial Test(s):1- ECG,2- X-ray,3- TTE
Or Best Initial Test(s):1- X-ray, 2-ECG
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Management of acute asthma:
1- Best initial management are O2 + Inhaled albuterol (SABA), if pt respond continue ttt and close observation
2- If no response add low dose inhaled corticosteroid (ICS) (beclomethasone)
3- If no response add salmertrol or increase dose of ICS
4- If no response add max dose of ICS
5- If no response add Omalizumab
6- If no response add oral corticosteroid (prednisone)
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  #8  
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Quote:
Originally Posted by heartbeat View Post
Or Best Initial Test(s):1- X-ray, 2-ECG
It depends on the cause I think. I wrote ECG first because it would help us in ruling out any Arrhythmias during Heart Failure. I am not sure though..
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  #9  
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ASTHMA

Best Initial Test
: ABG(increased A-a Gradient) or PEF(Decreased)

Accurate test: PFT ( decreased FEV1/ FVC, Increased DLCO, Obstructive disease pattern)

Rx- ET for Mechanical Ventilation is used when patients PCo2 is very high
(rest of treatment in the previous post)

P.S:sorry: People come on Contribute. In the end, we can make a huge PDF file so that people would actually benefit from this.
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  #10  
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Quote:
Originally Posted by Nouman View Post
ASTHMA
Rx- ET for Mechanical Ventilation is used when patients PCo2 is very high
(rest of treatment in the previous post)
Interpretation of Arterial Blood Gases in Asthma and when to intubate the patient:
During an Asthma Attack at the start of an asthma attack the PaO2 falls(e.g. to 60mm Hg), the PaCO2 falls (e.g. to 30 mm Hg) and increase the pH (e.g. to 7.50).
Slowly but surely the PaO2 and the PaCO2 continue to fall and the pH continues to rise as the disease worsens. Eventually, a state is reached wherein the lungs are unable to blow off more carbon dioxide. At this point the PaCO2 starts to rise and the pH starts to fall, but the PaO2 continues to fall. As the asthma attack gets worse and worse the low PaCO2 and the high pH start to move back toward their normal values.
Eventually as the asthma attack becomes extreme, the PaCO2 rises above 40 mm Hg and may reach for example 50 mm Hg or more and the pH falls below 7.40 and may reach for example 7.30. The PaO2 continues to fall and may reach for example 20 mm Hg.At this point patient is candidate for Intubation.
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  #11  
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COPD

Initial test- X-ray(increase in the AP diameter)
Accurate test- PFT ( Obstructive lung disease pattern)
Note: Bicarbonate to assess for disease progression

Rx- Short Acting Bronchodilators [B-agonist/ or Short acting Anticholinergic agents(eg Ipratropium)] for intermittent/mild symptoms

Persistent symptoms/moderate- Tiotropium(long acting)+ Albuterol >>>> Tiotropium+salmeterol

Frequent Exacerbations/Severe--Tiotropium+Formoterol or salmeterol+Inhaled Corticosteroids

Respiratory Failure/V. Severe-- Supplemental O2, Lung Volume Reduction surgery, Lung transplant

*Antibiotics if necessary: macrolides, Cephalosporin, Augmentin, Qunolones, Doxycycline, TMP/SMX

Criteria for O2 use:

pO2 less than or equal to 55 mmHg, 02 Saturation below 88%, Hct> 55, Evidence of Cor pulmonale
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Contrictive Pericarditis >>> Signs of RHF, Kussmaul Sign, Knock

Best Initial Test: X-ray shows calcification n Fibrosis
Accurate Test: CT or MRI *after* X-ray
Treatment: Diuretics, Surgery

Pericarditis:

1-History and Physical Exam- Sharp pleuritic chest pain that improves leaning forward
2-TESTS:
(a) ECG in all cases- ST segment elevation in all leads, most specific is PR segment depression
(b) X-ray in all cases
(c) Echocardiography in All cases

3- Find the underlying cause(eg. TB, ANA etc), if suspected

Combination of above lead to the diagnosis of pericarditis.

Rx:
NSAIDS, if fails use Steroids.
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Allergic interstitial nephritis(AIN)

best initial test------> urinalysis (WBC in urine)......hematuria is neither sensitive nor specific

more accurate(next step)----> hansel stain/ wright stain (eosinophils in urine)

most accurate-----> kidney biopsy

best management----> stop the drugs causing(e.g- pencillin).

thanks for the post
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COPD:I WILL ADD THESE CONCEPTS

Improve mortality:
1- - O2 with titration of 90 % sat and the goal is to maintain pO2 of 60 mmHg
2- Smoking cessation slow progression
3- Influenza and Pneumococcal Vaccine
Improve symptoms:
1- first line = ipratropium MDI + inhaler B agonist (metoprotrenol)
2- If pt have tachyarrhythmiause ipratropium as first line
3- If first line failedadd theophylline
4- Inhaled steroid= use for short term exacerbation but have no role in long term
5- LABA
6- Postural drainage

Criteria of intubation:
1- pO2 < 50
2- Alter mental status
3- Profound academia
4- Cardiac dysfunction
Acute exacerbation of COPD:
defines as an acute increase in symptoms beyond normal day-to-day variation. This generally includes an acute increase in one or more of the following cardinal symptoms:
  • Cough increases in frequency and severity
  • Sputum production increases in volume and/or changes character
  • Dyspnea increases
Management:
1- Admission
2- If alter mental status or unstable HD= Intubation
3- O2 supplementation
4- Ipratropium
5- Systemic steroid I.V
6- Antibiotics despite normal X- ray
7- Don’t stop theophylline if pt take it and not start it if pt not take it
8- Complete all investigation= CXR, ABG, O2 sat, ECG, CBC, theophylline level
Best prognostic indicator of survival is FEV1
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Old 01-31-2013
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ok i like this topic, but since i just started studying i dont have anything to contribute so far

i will also do once i start things up.
I am typing this in here, so that i get frequent emails saying that this topic is still active and its good to keep reading it, atleast 1 day it might stick in my brain. lol

Keep going guys
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  #16  
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Hi friends
Could we discuss Cervical Neoplasia (Screening, workup, and management)? cuz this is most important and controversial topics in GYN so we should mastered it.

Thanks
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Id love to contribute to this thread but I dont feel too confident about my knowledge right now :-/ But you all are doing great. Thanks a mil
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  #18  
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MYASTHENIA GRAVIS

Best Initial: Acetylcholine Receptor Antibodies (NOT tensilon test)
Most Accurate: Electromyography

BEST INITIAL Tx: Pyridostigmine or Neostigmine

Tx if Pyridostigmine dont work (Chronic):
Steroids if pt above 60y ; Thymectomy if pt below 60y.

ACUTE MYASTHENIC CRISIS:

Best Initial Tx: Intravenous Immunoglobulins OR Plasmapheresis
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Screening for Cervical Cancer

Current Recommendation

Release Date: March 2012
These recommendations apply to women who have a cervix, regardless of sexual history. These recommendations do not apply to women who have received a diagnosis of a high-grade precancerous cervical lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised (such as those who are HIV positive).
  • The USPSTF recommends screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. See the Clinical Considerations for discussion of cytology method, HPV testing, and screening interval.
    Grade: A Recommendation.
  • The USPSTF recommends against screening for cervical cancer in women younger than age 21 years.
    Grade: D Recommendation.
  • The USPSTF recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer. See the Clinical Considerations for discussion of adequacy of prior screening and risk factors.
    Grade: D Recommendation.
  • The USPSTF recommends against screening for cervical cancer in women who have had a hysterectomy with removal of the cervix and who do not have a history of a high-grade precancerous lesion (i.e., cervical intraepithelial neoplasia [CIN] grade 2 or 3) or cervical cancer.
    Grade: D Recommendation.
  • The USPSTF recommends against screening for cervical cancer with HPV testing, alone or in combination with cytology, in women younger than age 30 years.
    Grade: D Recommendation.
Quote:
Screening recommendations for specific patient age groups are as follows[4, 3] :
  • < 21 years – No screening recommended
  • 21-29 years – Cytology (Pap smear) alone every 3 years
  • 30-65 years – Human papillomavirus (HPV) and cytology cotesting every 5 years (preferred) or cytology alone every 3 years (acceptable)
  • > 65 years – No screening recommended if adequate prior screening has been negative and high risk is not present
Quote:
Women who have had a total hysterectomy may stop undergoing cervical cancer screening. Exceptions are as follows:
  • Women who had a hysterectomy without removal of the cervix
  • Women who have had a CIN grade 2 or 3 lesion treated in the past 20 years
  • Women who have had cervical carcinoma at any time
Quote:
The treatment of cervical cancer varies with the stage of the disease, as follows:
  • Stage 0: Carcinoma in situ (stage 0) is treated with local ablative or excisional measures such as cryosurgery, laser ablation, and loop excision; surgical removal is preferred
  • Stage IA1: The treatment of choice for stage IA1 disease is surgery; total hysterectomy, radical hysterectomy, and conization are accepted procedures
  • Stage IA2, IB, or IIA: Combined external beam radiation with brachytherapy and radical hysterectomy with bilateral pelvic lymphadenectomy for patients with stage IB or IIA disease; radical vaginal trachelectomy with pelvic lymph node dissection is appropriate for fertility preservation in women with stage IA2 disease and those with stage IB1 disease whose lesions are 2 cm or smaller
  • Stage IIB, III, or IVA: Cisplatin-based chemotherapy with radiation is the standard of care[8]
  • Stage IVB and recurrent cancer: Individualized therapy is used on a palliative basis; radiation therapy is used alone for control of bleeding and pain; systemic chemotherapy is used for disseminated disease[8]
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Last edited by Novobiocin; 01-31-2013 at 09:52 AM.
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Old 01-31-2013
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Thanks Novobiocin
Appreciated that .
Excellent covering of Cx screening and management of Cx carcinoma.

Ok what about the workup in patient with CIN1, CIN2, or CIN3 either pregnant or non pregnant?
who can help in that ?
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Hemochromatosis

Best Initial: Transferrin saturation

Most Accurate: Liver biopsy

Prognostic Indicator: Liver biopsy

Quote:
Currently, the diagnosis can be confidently based on genetic testing for the C282Y mutation; thus, liver biopsy is no longer essential for diagnosis in many cases. However, liver biopsy may not only be useful to identify liver disease and to determine the presence or absence of cirrhosis, which directly affects prognosis, but it may also be helpful in patients with cirrhosis, which is the primary risk factor for hepatocellular carcinoma.
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Management of Cervical Dysplasia According to Histology:

CIN1: three options:
a-Observation and follow-up:
reapeat Pap in 6 and 12 month or colposcopy and repeat Pap in 12 months or HPV DNA testing in 12 months.
OR
b-Ablative therapy:
cryotherapy,lazer,electrofulguration.
OR
c-Excisional procedure:
LEEP,cold-knife conization.

CIN2 & CIN3:NO observation:
a-Ablative therapy OR b-Excisional procedure.

*For biopsy confirmed,recurrent CIN2 & CIN3 Hysterectomy is acceptable.
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Management of cervical dysplasia/neoplasia in pregnancy:

CIN lesions during pragnany(=no breakage of basal membrane) .all CIN1,2&3 have same management in pregnancy):
follow by Pap smear and colposcopy every 3 months during pregnancy.delivered vaginally if appropriate .at 6-8 weeks postpartum any persistent lesions treated.

Microinvasion:
cone biopsy to ensure no frank invasion(NB:ECC not performed durig pregnancy)also follow ,vaginal delivery,reevaluate and treat 6-8 weeks postpartum.

Invasive cancer:
1)before 24 weeks of pregnancy,ignore pregnancy treat as in non pregnant as appropriate according to the stage.
2)after 24 weeks, conservative management till 32-33weeks(to allow fetal maturity) c section delivery and begin definitve treatment.
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Quote:
Originally Posted by Novobiocin View Post
Hemochromatosis

Best Initial: Transferrin saturation
Thanks Novo
I see you are bold the best initial test of hemochromatosis (Transferrin saturation) inspite you know that in UW the initial evaluation is serum iron study. I think you are right but i would like to know your explanation.

Last edited by heartbeat; 01-31-2013 at 08:54 PM.
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Well done sonami
Thanks bro
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you are welcome heartbeat.
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Back pain:

# Evaluate immediately any patient with new onset back pain and history of cancer, for possible spinal cord compression.
# As soon as you suspect spinal cord compression the best next step is to give dexametasone.
# MRI is the test of choice (whole spine )
# Radiation for lymphoma and MM.
# Surgery for most solid tumors.
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Heartbeat,
MTB says its both Transferrin saturation and serum iron. And in the next line TIBC. I believe all of these are considered part of serum iron studies.
Please correct me If I'm wrong.
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Quote:
Originally Posted by Brainiac View Post
Heartbeat,
MTB says its both Transferrin saturation and serum iron. And in the next line TIBC. I believe all of these are considered part of serum iron studies.
Please correct me If I'm wrong.
That's correct.

Transferrin saturation (ratio of serum iron and total iron-binding capacity, multiplied by 100) is part of the iron studies along with serum iron and transferrin. However, among all these iron studies Transferrin saturation is most specific since serum iron and transferrin can be raised in other conditions being acute phase reactants. It also detects hemochromatosis in earlier stages as compared to the others.

Quote:
Transferrin saturation, abbreviated as TSAT and measured as a percentage, is a medical laboratory value. It is the ratio of serum iron and total iron-binding capacity, multiplied by 100. Of the transferrin that is available to bind iron, this value tells a clinician how much serum iron is actually bound. For instance, a value of 15% means that 15% of iron-binding sites of transferrin is being occupied by iron.
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Stroke
Best intial test:CT scan without contrast
Most accurate test:MRI (only done if CT is negative)

Best initial therapy for ishemic stroke:
Less than 3 hours of onset of symptoms:thrombolytics(tPA) which is associated with better outcome.
More than 3 hours:Aspirin for secondary prevention.
If recurre while on aspirin or the patient already taking aspirin add dipryidamole or witch to clopidog.

Search for the source of embli and manage it:
Echo:Valvular damage:surgery,thrombi:heparin and warfarin
EKG:A fib:warfarin and rate control.
Holter monitor:to look for Afib if EKG is negative.
Carotid douplex:if more than 70% stenosis and patient has sypmtomatic cardiovascular disease:carotid endartrectomy.
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Quote:
Originally Posted by Novobiocin View Post
Transferrin saturation (ratio of serum iron and total iron-binding capacity, multiplied by 100) is part of the iron studies along with serum iron and transferrin. However, among all these iron studies Transferrin saturation is most specific since serum iron and transferrin can be raised in other conditions being acute phase reactants. It also detects hemochromatosis in earlier stages as compared to the others.
Correction-- It should read Ferritin and not transferrin.

Quote:
The level of transferrin decreases in inflammation. Ferritin is an acute-phase reactant, it is often elevated in the course of disease.
Quote:
High transferrin saturation is the earliest evidence of hemochromatosis; a value greater than 60% in men and 50% in women is highly specific.
Quote:
Transferrin saturation corresponds to the ratio of serum iron and total iron-binding capacity (TIBC). The screening threshold for hemochromatosis is a fasting transferrin saturation of 45-50%. If transferrin saturation is greater than 45%, the presence of the C282Y or H63D mutation may be evaluated to confirm the diagnosis of hemochromatosis.
Quote:
Hemochromatosis is suggested by a persistently elevated transferrin saturation in the absence of other causes of iron overload. This is the initial test of choice.
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Last edited by Novobiocin; 02-01-2013 at 08:24 AM.
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Novobiocin

You're right. Thats true. Thanks.
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Quote:
Originally Posted by Brainiac View Post
Novobiocin

You're right. Thats true. Thanks.
You are doing great...........keep it up.
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Thanks everyone for the contributions.. Keep it UP !!
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OSTEOARTHRITIS

Good History and Examination. Lab tests are normal
Most accurate test: X-ray Joint space narrowing, osteophytes, Dense subchondral bone, Bone cyst

Rx:

Best initial medicine: Acetaminophen,
then NSAIDS,
hen Intraarticular steroids joint. finally joint replacement if all else fails.


if Some of you guys are planning to review this THREAD in the end. Let me tell u something here. You are not going to find any time to do so in the end.I am sure of that. Try to review this thread every day. The people who are contributing here are taking the stuff out of your MTB and UWORLD. This thread will definitely help you to consolidate the important stuff.

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Wow! This thread has become my all time favourite!
Great work guys! And hopefully, I'll be able to contribute to it soon.
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Polyarteritis nodosa

- every organ can be affected in the body, except the lung
- can be associated with hepatitis B

Symptoms:

- fever, malaise, weight loss, myalgias and arthralgia;

- GI: abdominal pain, bleeding, vomiting; Pain can be worsened by eating (mesenteric vasculitis);

- neurologic: mononeuritis multiplex; stroke in a young person!!!

- skin: purpura, petechiae, digital gangrene, livedo reticularis

Best initial test: ANGIOGRAPHY of renal, mesenteric or hepatic artery (aneurysmal dilatation)

Most accurate diagnostic test: Biopsy of symptomatic site

Treatment: Prednisone and Cyclophophamide and treat hep B
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G6PD deficiency: X-linked recessive- Anemic males with normal Spleen

Initial test
: Heiz Body and Bite cells on peripheral smear
Accurate test: G6PD levels after 1-2 months of the Hemolytic crisis. G6PD levels are normal during the acute hemolysis(High yield tested point).
Treatment: Avoid oxidative stress n stop precipitating agent eg. medications. No specific therapy.
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Pemphigus vulgaris:

young patients (30s & 40s).
predominently mouth lesions(painful erosions ).
Nikolsky sign.

Bullae break easily>infection and dehydration.

Most accurate test:skin biopsy;immunofluorescent epidermal antibodies.

Teatment:systemic steroids if ineffective or not tolerated: azathioprine,mycophenolate or cyclophosphamide.
Rituximab and IVIG for refractory cases.
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SARCOIDOSIS

Best Initial. CXR
Most Accurate. Lymph Node Biopsy
Tx. Nothing if asymptomatic. Prenisone if symptomatic.

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Indications for Erythropoietin:

1. Anemia due to chronic kidney disease

2. Anemia due to treatment for cancer when Hb<10 (NOT in Anemia due to Cancer)

3. Anemia due to Zidovudine use in HIV/AIDS

Increased risk of thrombosis when Hb >12

Contraindication: Lance Armstrong
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Quote:
Originally Posted by Nouman View Post
I would start with the Aortic Dissection

Best next step if BP is given: Control BP (a) Beta Blocker (b) Nitroprusside
Best Initial test: Chest X-ray
Accurate test: Angiogram
Rx: Surgical correction

Note: TEE=Constrast CT=MRA. Between TEE and TTE, choose TEE

* Please correct me if I make any mistakes. Thanks.
Most accurate test for aortic dissection is echo.

Read here:

Most accurate test for Aortic dissection?
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Thumbs Up Pulmonary diagnostic tests

DISEASE
BEST INITIAL TEST(No 1)
MOST ACCURATE TEST( No 2)

Asthma
1.Arterial Blood Gas
2.Pulmonary function test

COPD
1.CXR
2.PFT

Bronchiectasis
1.CXR
2.HRCT

Cystic Fibrosis 1.Pilocarpine sweat chloride test(genotype is not accurate) and Increased serum Immunoreactive Trypsin is an excellent screening at birth.2. Pilocarpine sweet chloride test
>60 meq/l an children
>80 meq/l in adult

Pneumonia
1.CXR
2.In general sputum culture but there is specific test fr each disease….
1.Mycoplasma-cold agglutinins,PCR
2.chlamydophla pneumonia,chlamydia psittaci,coxiella burnetti-Rising serological titres
3.Legionella-Urine Antigen, Charcoal yeast extract culture
4.PCP-Broncho alveolar lavage


Ventilator associated pneumonia
1.Tracheal Aspirate (ET tube aspirate and sputum culture is worthless)
2.Open lung biopsy

Lung Abcess
1.CXR(Air fluid level)
2.Lung Biopsy(sputum culture is wrong anaerobes are commensals of mouth)


PCP
1.CXR –b/l interstitial infiltrates
2.Bronchoalveolar lavage,A normal LDH rules out PCP pneumonia

TB
1.CXR
2.Pleural Biopsy

Interstitial lung disease
1.CXR –Best Initial but HRCT is more accurate
2.Lung Biopsy


Sarcoidosis
1.CXR
2.Hilar LN Biopsy

Pulmonary Embolism 1.CXR,EKG,ABG
a.CXR-usually normal but the most common abnormality is Atelectasis
b.EKG-usually Sinus Tachycardia but the most common abnormality is ST-T wave changes
c.ABG- Hypoxia and Respiratory Alkalosis with a normal CXR is highly suggestive of PE but large PE may cause Respiratory acidosis
2.Angiogram(But rarely done bcoz of 0.5 % mortality)
a.If CXR is normal proceed with V/Q Scan
b.If CXR is abnormal proceed with Spiral Ct Scan
c.If v/q scan and Spiral Ct is Equivocal proceed with Doppler legs

Pulmonary Hypertension
1.CXR-Palla’s sign
2.Swan Ganz catheterization(Right Heart Cathetherization)
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wow! awesome guys...thanks so much..just started studying..will join you soon
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Sorry Guys I was a sick and could post any new posts. Plus this post has been moved..But I hope that you guys will keep on contributing...

Spontaneous Bacterial Peritonitis: E.coli, Pneumococcus.

Best initial test: Diagnostic paracentesis showing 250 neutrophils is the basis to start therapy

Accurate test: Fluid obtained from paracentesis and culturing it.

Rx: Cefotaxime(Third generation cefphalosporin after cell count.

Prevention: When the ascites fluid albumin level is quite low, prophylactic norfloxaxin or TMP/SMX is used to Prevent SBP
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Acute Edematous Pancreatitis :-
Investigation : best initially test: S. lipase and S.amylase
* Most accurate test is CT abdomen .
Management : NPO + NG suction + I.V fluid + observe for complications .

Acute Hemorrhagic Pancreatitis :-
Investigation : best initially test: S. lipase and S.amylase
Management : very intensive support bcz it's fatal and daily serial CT abdomen required to diagnose pancreatic abscess .

Acute biliary
Pancreatitis :-

Investigation : Best initial step is abdominal U/S
Management: fluid + analgesia + NG suction + antibiotics

Chronic Pancreatitis :-

Investigation : best initial step is CT abdomen
*Most accurate test is ERCP
*further investigations = plain X-ray (calcification) , R.B.S .
Management: stop alcohol intake (if pt is alcoholic) + replace pancreatic enzymes + control DM (with high R.B.S)


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Quote:
Originally Posted by heartbeat View Post
Acute Edematous Pancreatitis :-
Investigation : best initially test: S. lipase and S.amylase
* Most accurate test is CT abdomen .
Management : NPO + NG suction + I.V fluid + observe for complications .

Acute Hemorrhagic Pancreatitis :-
Investigation : best initially test: S. lipase and S.amylase
Management : very intensive support bcz it's fatal and daily serial CT abdomen required to diagnose pancreatic abscess .

Acute biliary
Pancreatitis :-

Investigation : Best initial step is abdominal U/S
Management: fluid + analgesia + NG suction + antibiotics

Chronic Pancreatitis :-

Investigation : best initial step is CT abdomen
*Most accurate test is ERCP
*further investigations = plain X-ray (calcification) , R.B.S .
Management: stop alcohol intake (if pt is alcoholic) + replace pancreatic enzymes + control DM (with high R.B.S)



MTB 2 says: (page # 257 )


Chronic pancreatitis : most accurate test is secretin stimulation test ??
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Quote:
Originally Posted by aknz View Post

MTB 2 says: (page # 257 )

Chronic pancreatitis : most accurate test is secretin stimulation test ??
I read different articles from different trusted website and i found that there controversial in the the most accurate and gold stander test for diagnosing chronic pancreatitis

Quote:
Traditionally, ERCP has been considered the gold standard for pancreatic ductal structure, and the secretin stimulation test has been viewed as the gold standard for pancreatic function. Both ERCP and the secretin test have distinct disadvantages. The main problem with ERCP is that, overall, it carries a relatively high risk (6.7%) of post-ERCP pancreatitis. On the other hand, the secretin test tends not to be very well tolerated by patients. This test requires passing a duodenal tube and collecting pancreatic secretion for 1 hour in an unsedated patient. An informal survey conducted during the 1998 American Gastroenterologic Association postgraduate course found that secretin testing was available to only about 40% of the physicians in the audience.

http://www.medscape.com/viewarticle/445105_4
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good job guys..
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Quote:
Originally Posted by heartbeat View Post
I read different articles from different trusted website and i found that there controversial in the the most accurate and gold stander test for diagnosing chronic pancreatitis


http://www.medscape.com/viewarticle/445105_4
UW says fecal elastase study is the most senstive and specific for chronic pancreatitis
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The most sensitive and specific test for (chronic) Pancreatic insufficiency is the Fecal elastase measurement(UWorld). Amylase and Lipase levels r low in chronic pancreatitis due to Fibrosis of the glands. An extremely fibrosed organ loses the ability to make new enzymes. The same hold true for some other organs of the body!!

Best initial test for acute pancreatitis is Amylase and Lipase levels. It should be followed by CT scan to evaluate the Pancreatic Necrosis.

Pancreatic Laceration in Blunt Trauma: Serial CT scans
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Anemia due to Chronic Kidney Disease

First do Iron Studies to rule out Iron deficiency anemia. If iron deficient, first give Fe and treat the iron deficiency and then give erythropoietin. If not, give erythropoietin only.

Celiac Disease:
Do NOT forget that Iron Deficiency is due to lack of absorption in the GIT! Replace Iron by other means!
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guys

as there is active posting here ,i'm adding my doubt

1)in primary hyperaldosteronism------>most accurate?

according to mtb2 ---most accurate is adrenal venous sampling

according to uworld---most accurate is giving IV/oral NS and measuring aldosterone level in plasma or urine....

are they both same..? if not which one is correct...?


2) @nouman---thanks for post ----in anemia of chronic disease due to renal failure ----wouldnt we start first with erythropoeitin followed by iron supplementation...... or we have to follow according to your post..?


thanks
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Quote:
Originally Posted by venky2600 View Post
guys

as there is active posting here ,i'm adding my doubt

1)in primary hyperaldosteronism------>most accurate?

according to mtb2 ---most accurate is adrenal venous sampling

according to uworld---most accurate is giving IV/oral NS and measuring aldosterone level in plasma or urine....

are they both same..? if not which one is correct...?


2) @nouman---thanks for post ----in anemia of chronic disease due to renal failure ----wouldnt we start first with erythropoeitin followed by iron supplementation...... or we have to follow according to your post..?


thanks
Primary Hyperaldosteronism:
Best initial test: Plasma Aldosterone/Plasma Renin ration after stopping the drugs which effect aldosterone and renin activity before measuring it.
Accurate test: Aldosterone suppression test: Give IV or Oral NaCl. If levels of aldosterone >14mg/24 hrs)> Hyperaldosteronism confirmed.
Accurate test followed by: CT scan of the Abdomen. If you cant find anything on CT scan, then you will do Adrenal vein sampling. (if found positive CT or sampling, then Primary confirmed)

UWORLD is the Holy Book of STEP 2 CK !!!

@IRON AND ERYTHROPOIETIN in CKD: Let me ask a relevant question. How can Bone marrow make RBC without Fe?! Without Fe, do not expect Bone marrow to make Normal Cells. Hope I have answered ur question!
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Quote:
Originally Posted by Nouman View Post
Primary Hyperaldosteronism:
Best initial test: Plasma Aldosterone/Plasma Renin ration after stopping the drugs which effect aldosterone and renin activity before measuring it.
Accurate test: Aldosterone suppression test: Give IV or Oral NaCl. If levels of aldosterone >14mg/24 hrs)> Hyperaldosteronism confirmed.
Accurate test followed by: CT scan of the Abdomen. If you cant find anything on CT scan, then you will do Adrenal vein sampling. (if found positive CT or sampling, then Primary confirmed)

UWORLD is the Holy Book of STEP 2 CK !!!

@IRON AND ERYTHROPOIETIN in CKD: Let me ask a relevant question. How can Bone marrow make RBC without Fe?! Without Fe, do not expect Bone marrow to make Normal Cells. Hope I have answered ur question!

thank you...

regarding CKD---->ya you're right at one aspect--->i mean if iron levels are abnormal we should give iron too along with erythropoetin
but when iron levels are normal ,we should give only erythropoietin..?-----in uworld they gave ,if we give erythropoetin alone then certainly after few days
only RBC are produced in excess when compared to iron ---so iron supplement is started...
--------------so i thought 1st we should start on EPO then followed by Fe....anyways your explanation seems true....
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If iron levels r normal, only EPO(erythropoietin) is given!

If a CKD patient has anemia, we need to do Iron studies First. We ALWAYS check serum Iron(Iron studies) no matter what!!
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Quote:
Originally Posted by Nouman View Post
If iron levels r normal, only EPO(erythropoietin) is given!

If a CKD patient has anemia, we need to do Iron studies First. We ALWAYS check serum Iron(Iron studies) no matter what!!
thank you

for anemia---your statement is correct(checking iron studies and giving)

but regarding only EPO given for normal iron studies---->can you provide me details for it....coz i did a question 2 days back in uworld that after starting EPO therapy for few months----iron supplement is started due to the production of RBC alone than compared to iron----->i'm little confused here..?

thanks
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Quote:
Originally Posted by venky2600 View Post
thank you

for anemia---your statement is correct(checking iron studies and giving)

but regarding only EPO given for normal iron studies---->can you provide me details for it....coz i did a question 2 days back in uworld that after starting EPO therapy for few months----iron supplement is started due to the production of RBC alone than compared to iron----->i'm little confused here..?

thanks
As far As I remember about EPO and Iron. Iron is given when Iron studies r abnormal. It does not matter whether the person receives EPO or not! If iron studies are abnormal any time during the EPO therapy, you WILL have to give Iron! Whether Iron should be given to a patient on EPO therapy and he has normal iron levels,I don't think that Iron is given. But I am not 100 percent sure about it! Probably someone else can help us in this regard.
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also i've doubt in follow up of LEEP for cervical dysplasia

---correct me if i'm wrong

following LEEP---> follow up pap smears every 6 months till 3 consecutive negatives......later follow up by annual pap smears(according to uworld) till 3 consecutive negatives if monogamous,(if different sexual partners exist then again annual screening performed from the start even if she had 2 negative pap consecutively before)------------>later follow up general cytology screening (every 3 yrs)


i'm not sure abt annual screening criterion...


thanks
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yeah, fecal elastase most specific for chronic pancreatitis

ERCP--investigation of choice for recurrent pancreatitis
(source---uworld)
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@nouman-----sorry for posting here but....
can you tell me the follow up of thyroid nodule and pulmonary nodule please....?

thanks
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I would like to admit here to the world that I really really suck in Gynae/Obs..It is one of my weakest areas. I wont be able to help regarding that. Please do not ask me those questions. I really suck at it !!

Regarding Pulmonary Nodule
.A simplified approach made by me. There may be a mistake in this scheme. If i am wrong here, someone should correct me. But I have followed this approach to solve a lot of questions.
Any question on pulmonary nodule will always have an X-ray done on the patient. First thing you need to ask from any patient with a nodule is the OLD X-ray. if the old x-ray is not one of the options, choose CT scan. For low probability nodule on CT (repeat CT every 3 months for 2 years) and High probability lesion gets a resection.
There r two different approaches for indeterminate lesion, you get a BIOPSY or PET scan if the lesion is >1cm and serial CT monitoring for 2 years if the lesion is <1cm. The second approach is that Indeterminate gets a biospy(through bronchoscopy in central indeterminate lesion and through chest for peripheral indeterminate lesions) or a PET scan. If u combine the two approaches for indeterminate lesion, then all malignant looking lesions must b biopsied and benign looking lesion needs to be followed up by serial imaging!
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Thyroid nodule
1- Check TSH, Thyroid hormones
2- if TSH is high (it can be hashimoto)
3- Check Antiperoxidase antibodies
4- if positive Ab, give thyroxine(nodule will disappear)
5-if negative Ab(TSH is High) or normal TSH(skip step 3) get an Diagnostic US
6- Nodule appears benign> routine follow up and surveillance
7- Nodule appears malignant> FNA

I added step 3 after reviewing two similar questions of UWORLD.

1-Check TSH
2- TSH is low
3- Thyroid scan > if hyperfunction > Evaluate for hyperthyroidism
> if nonfunctioning > Diagnostic US > If benign= followup
> if malignant=Biospy
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This THREAD is slowly dying. Why r all the Good people!?
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Quote:
Originally Posted by Nouman View Post
This THREAD is slowly dying. Why r all the Good people!?
because....many ppl above posted already did complete their exam and moved to either step3 or cs forum......
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I am done with my exam too.But I am still helping as much as I can!!!
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Quote:
Originally Posted by Nouman View Post
I am done with my exam too.But I am still helping as much as I can!!!
okay..that's gr8 of you..it's may be coz of notification you'll get everytime a post is created here....some may not activate notification or may not be available to help or may not be gr8 as you to help....thank you..

i found guidelines for cervical screening
http://www.cdc.gov/cancer/cervical/pdf/guidelines.pdf
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Originally Posted by venky2600 View Post
okay..that's gr8 of you..it's may be coz of notification you'll get everytime a post is created here....some may not activate notification or may not be available to help or may not be gr8 as you to help....thank you..

i found guidelines for cervical screening
http://www.cdc.gov/cancer/cervical/pdf/guidelines.pdf

Great! Ask your friends to participate in this as well !!
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SUBARACHNOID HEMORRHAGE (SAH)

S/S- sudden onset of severe headache+ meningeal irritation( stiff neck, photophobia), fever( due to blood irritating the meninges), loss of consciousness( due to sudden increase in ICP)

Best Initial Test - CT without contrast
Most Accurate Test - Lumbar Puncture showing blood

CSF in SAH- WBC:RBC ratio is NORMAL (500-1000)
VS
CSF in meningitis- WBC exceeds the normal WBC:RBC ratio

The ONLY WAY to know which vessel ruptured in order to guide repair of lesion- CT angiography or standard angiography with catheter.

TREATMENT-
1.Embolization (coiling) is superior to surgical clipping. ( if embolization not in the choices, choose clipping)
2. Nimodipine (CCB)- to prevent subsequent ischemia stroke( this happens after SAH)
2. If hydrocephalus develops-- do Ventriculoperitoneal shunt
3. Seizure prophylaxis- Phenytoin
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Default Subarachnoid Hemorrhage

Subarachnoid Hemorrhage is associated with a cerebral salt wasting syndrome resulting in hyponatrnemia. Reasons:
1- Increased ADH secretion
2- ANP/BNP secretion > Lead to salt wasting
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PLACENTA PREVIA

Painless Vaginal bleeding after 28 weeks ( 3rd trimester)

Next Best step ( also Most Accurate Test) : TRANSABDOMINAL ULTRASOUND

Contraindication: TransVaginal Ultrasound and Digital Vaginal Exam ( both can cause placental separation resulting in severe hemorrhage when done in 3rd trimester)

Treatment :
Strict pelvic rest; if delivery should occur, C-section is the mode of delivery.
If pre-term baby, give betamethasone to mature the lungs.

Indications for immediate c-section:
1. Unstoppable labor ( cervix dilated more than 4cm)
2. Severe Hemorrhage
3.Fetal distress
Prepare for life threatening bleeding by type & screen of blood, CBC & Prothrombin time.
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Default Ischemic bowel disease

BEst Initial test : CT scan of abdomen
Most Accurate test : Angiography
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Default Gastric Perforation

Best Initial test : Upright chest xray which shows free air under diaphragm

Most accurate : CT

Treatment :
1.npo
2.ng tube for suction of gastric juices
3. iv ns + broad spectrum antibiotics
4.Surgically repair the perforation
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Default Syringmyelia

cf : Cape like distribution of deficits !!
loss of pain and temperatur bilaterally across the upper back and both arms

Most accurate test ? MRI
Best treatment : Surgical removal of tumor if present and drainage of fluid from the cavity
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Correct Answer Brain Abscess

BEst initial test : Head CT/MRI
ring or contrast enhancing lesion , with surrounding mass effect or edema.

Most accurate : Brain biopsy
to distinguish cancer and infection , need biopsy !!
for culture and sensitivity also

Empiric therapy : Penicillin + Metronodazole + Ceftriaxone
if recent neurosurgry , then use vanco instead of peniciliin !
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Smile let us make this thread active !!

this s a very useful thread!!! Thank you to those who started it..but looks like its dying..we need to make this thread active again !!

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Arrow Acromegaly

Work up and management of Acromegaly

Do IGF levels:
IGF levels = NL --> R/O Acromegaly.
high --> Do Oral glucose suppression test:
GH suppressed>> R/O acromegaly
GH not suppressed -->
Do MRI of brain:
Pituitary mass?? Medical and surgical management
Normal pituitary?? Look for extra pituitary causes: ectopic GH / GHRH producing tumors
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Thanks to everyone...very useful thread..Will start posting soon.
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I am ready to help you guys revive this again. These days I am preparing for the Step 3 exam.
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