"Valvular Aortic Stenosis in the Elderly"
Wilbert S. Aronow, MD. Cardiology in Review, Volume 15, Number 5, September/October 2007
1. Etiology and Prevalence
a. Calcification of aortic valve increases with age: 28% in 55-71, 48% in 75-76, 75% in 85-86
b. Reduction in aortic valve area 0.11-0.12cm2/y
c. Risk Factors for progression: smoking and hypercholesterolemia
d. Aortic stenosis in elderly(average age 80-81): 15% men, 17% women
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History Taker A free electronic personal electronic health record. Hit the HPI then PMH buttons to answer questions. Questions: HPI Button - History of Present Illness: How old is this patient? What is the sex of this patient? What is this patient's chief compaint? What is the duration? What are the associated symptoms? PMH Button - Past Medical History, Past Surgical History, Medications, Allergies: What is this patient's past medical history? What is the patient's past surgical history? What medications does this patient take? What are this patient's allergies? Please make any corrections below and then press "Generate Final" to get a personal health record page in the new window. To save the file, select "File>Save As>" and save as an HTML file.
Calculates expected CO2 based on HCO3, bicarbonate.
Expected CO2 = HCO3 * 1.56 + 8.36
"Crush Step 2" is an easy book to read. I read this twice before taking the test. I would say it has more detail than "First Aid for Step 2 CK", yet I read both of them. I thought they complemented each other well. |
"NMS Review for USMLE Step 2 CK" provided a 1000 practice questions. I was able to finish the entire book. Its explanations provide a lot of background. Sometimes explanations repeat key points several times over different questions. I did all the questions once and I think it would be pretty hard to do the questions multiple times. Reading and underlining the explanations was probably where I learned the most for Step 2 CK. |
"Boards and Wards" is a good pocketbook for clinical rotations as a medical student. It's also a thorough review book for Step 2 CK. I would say it's more detailed than "Crush Step 2" or "First Aid for Step 2 CK". I was able to read this 1-2 times. |
"First Aid for Step 2 CK" provided good tables for the test. I read this book twice, yet I thought sometimes it provided too little detail in some areas. Reading multiple books will help the most. |
I still think you need access to at least a good medical textbook, either "Harrison's" or "CMDT". Access to Access Medicine is great also. Sometimes the explanations on practice questions will need more background information. |
For example, a hybrid averaging 40 miles per gallon versus
a standard car with 25 miles per gallon will save $9,300 over
200,000 miles when the price of gas is $3.10.
Hybrid Gallons = 5000
Standard Gallons = 8000
Hybrid Gas Price = 15500
Standard Gas Price = 24800
Savings = 9300
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Direct Link:http://www.fepint.org/. Here's the page of benefits for authors, including receiving high royalties, owning copyright, and providing extensive distribution.
Last minute deals on flights are available for residency interviews. Look for better deals during the weekdays. Also, consider alternative airports in larger cities. Combine hotels and flights to save money. Car rentals are also cheaper online.     |
Writing a personal statement for a medical student requires time and effort. Resumes and Personal Statements for Professionals was mentioned in Iserson's Getting Into A Residency.
Both of these books provide a lot of guidance from people who have helped
many medical students apply for residency.
And they will still be able to pursue deadbeats practically into the grave, since people who file for bankruptcy have to keep paying back their student loans — an astonishing exception to the bankruptcy law that lenders lobbied for, and won, in the 1990s. The student loan business will still be, well, a business.
| Subjective |
| 34 year old white male presents with dry patches on his scalp, back of his elbows, and the front of his knees. They have been present for several months. No itching. |
| Objective |
| Vital signs stable. Skin - dry, scaling plaques, well-circumscribed, silver present on scalp, extensor surfaces of elbow and knee |
| Assessment and Plan |
| A- Psoriasis P- topical corticosteroids, other options include ultraviolet light (sunlight), lubricants, and keratolytics |
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| Subjective |
| 75 year old male presents with ulcers in his mouth. Started five months ago. Ulcers have progressed to around his mouth and on his forearms. |
| Objective |
| Vitals signs stable. Oral- multiple bullae in mucosa Skin - multiple bullae Labs - biopsy shows antibody pattern in fish-net immunofluorescence pattern |
| Assessment and Plan |
| A- Pemphigus P- corticosteroids |
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| Subjective |
| 45 year old female presents with painful, red nodules on her shins. Started 1 month ago. Patient was recently diagnosed with ulcerative colitis. |
| Objective |
| Vital signs stable Extremities - pretibial, tender, erythematous nodules |
| Assessment and Plan |
| DDX - sarcoidosis, coccidiomycosis, ulcerative colitis, streptococcal infection, idiopathic A - erythema nodosum due to ulcerative colitis P - treat ulcerative colitis |
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| Subjective |
| 25 year old patient notes a growth on her forehead which is the color of her skin. It started about 2 months ago and has stopped growing. |
| Objective |
| Vital signs stable. Skin - flesh colored lesion on forehead with central crater, crater contains keratinous material |
| Assessment and Plan |
| A - Keratocanthoma P - Lesion will likely resolve in a few months, observation for few months, biopsy if needed. |
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Substance | Intoxication | Withdrawal |
Alcohol | - (1+) Slurred speech - Incoordination - Unsteady gait - Nystagmus - Impairment in attention or memory - Stupor or coma (t) folate 1mg , thiamine 100mg | - (2+) Autonomic hyperactivity - Increased hand tremor - Insomnia - Nausea or vomiting - Transient visual, tactile, or auditory hallucinations - Psychomotor agitation - Anxiety - Grand mal seizures (t) Benzodiazepines - oxazepam, IV; Dilantin; Haldol |
Cocaine / Amphetamine | - (2+) Tachycardia or bradycardia - Pupillary dilation - Elevated or lowered blood pressure - Perspiration or chills - Nausea or vomiting - Evidence of weight loss - Psychomotor agitation or retardation - Muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias - Confusion, seizures, dyskinesias, dystonias, or coma (t) self-limited, anti-psychotics | - (2+) Dysmorphic mood - Fatigue - Vivid, unpleasant dreams - Insomnia or hypersomnia - Increased appetite - Psychomotor retardation or agitation (t) self-limited, observation |
Opiates - morphine - codeine - meperidine - hydromorphone | - papillary constriction (dilation) - (1+) drowsiness or coma - slurred speech - impairment in attention or memory - euphoria > dysphoria - psychomotor agitation or retardation - impaired judgement (t) Methadone 5-20 mg> 60-100 mg | - (3+) dysphoric mood - nausea or vomiting - muscle aches - lacrimation or rhinorrhea - papillary dilation, piloerection, or sweating - diarrhea - yawning (t) Clonidine |
Sources : Diagnostic Criteria from DSM-IV, Blueprints Psychiatry 3rd ed
Ovarian Tumors
1. Introduction
a. Malignant ovarian tumors are the leading cause of death from reproductive tract cancer.
b. Majority of ovarian tumors are benign.
c. General lifetime risk is 1.6% and 5% with a first degree family relative.
d. Lifetime risk with BRCA1 gene is 45% and with BRCA2 gene is 25%.
2. Clinical Findings
a. Symptoms and Signs
i. Most patients are asymptomatic.
ii. Mild nonspecific gastrointestinal symptoms or pelvic pressure
iii. Pelvic exam can detect early disease.
iv. Advanced disease can present with bloating, abdominal pain, ascites, and palpable abdominal mass.
b. Lab Findings
i. CA 125 level greater than 35 units can indicate malignancy.
ii. CA 125 elevated in 80% of epithelial ovarian cancer and only 50% in early disease.
c. Imaging Studies
i. Transvaginal Ultrasound for screening
ii. Ultrasound helps differentiate from benign and malignant neoplasm.
3. Differential Diagnosis for an Ovarian Mass
a. Functional
b. Benign Neoplastic
i. Premenopausal woman, asymptomatic, mobile, unilateral, simple cystic mass less than 7.5 cm
c. Potentially Malignant
d. Predictive factors include age, size of the mass, ultrasound configuration, CA 125 levels, symptoms, and symmetry
4. Treatment
a. Malignant neoplasm – surgical staging, abdominal hysterectomy, bilateral salpingo-oophorectomy
i. Advanced disease
1. removal of all visible tumor
2. post-operative chemotherapy
a. cisplatin or carboplatin with paclitaxel
b. Benign neoplasms – tumor removal or unilateral oophorectomy
5. Prognosis (5 yr survival)
a. Distant metastases – 17%
b. Local spread – 36%
c. Early disease – 89%
Source:
1. Tierney, Jr,
A picture of Old Main, the administrative building at Penn State with snow on the ground. The color picture was changed using the filter photocopy in Adobe Photoshop.
Normal Pregnancy | Preeclampsia | Severe Preeclampsia | |
Blood Pressure | Fall in first 24 weeks, rises to baseline by term | 140/90 after 20 weeks gestation | >160/100 |
Kidneys | GFR increases 50%, renal plasma flow increases serum urea and creatinine decrease; enhanced waste metabolite removal; glycosuria | Vasospasm and capillary endothelial swelling -> reduction in GFR Serum uric acid and creatinine increased Proteinuria > 300 mg in a 24 hour collection | proteinuria > 5 g/24h, oliguria (<500cc/24h) Oliguria <> |
Edema | Normal | Presenting sign but 1/3 don’t have it | |
Hemostatic | Venous stasis from hypercoagulable state | Systemic vasospasm, coagulation system activation, abnormal hemostasis Cycle – endothelial injury, platelet activation, platelet consumption | |
Prostanoid Changes | Both prostacyclin (PGI) and Thromboxane A2 (TXA) elevated, PGI > TXA | TXA > PGI PGI – vasodilator and inhibitor of platelet aggregation TXA – vasoconstriction and platelet aggregation | |
Autonomic | Increased sympathetic state – vasoconstriction | ||
Nitric Oxide | Reduced | ||
Free radical oxidation products | Increased | ||
Hematologic | Plasma vol inc, RBC mass inc à “physiologic anemia” of pregnancy Hgb 11.5 mg/dl WBC count increases Hypercoagulable state – inc fibrinogen, factor VII to X increase – venous stasis | - Thrombocytopenia - <100,000 class="MsoNormal">- fibrinogen decreased - coagulation time increased (PT, PTT) -Can progress to DIC | |
Hepatic | Signs of liver disease Spider angiomata and palmar erythema – elev estrogen Serum – dec albumin, elev alk phos, elev cholesterol Estrogen increased proteins – fibrinogen, thyroid hormone binding globulin, ceruloplasmin Hepatic enzymes – AST/ALT, PTT unchanged | 10% - transaminase elevation | impaired liver function (AST/ALT >70) |
Pulmonary | pulmonary edema | ||
Neurological | Cerebral or visual disturbances Headache | ||
GI | Epigastric pain - hepatic subcapsular hemorrhage -stretch or rupture of liver capsule | ||
Seizures | Severe cases -> Eclampsia |
HELLP Syndrome - hemolysis, elevated liver enzymes, low platelets - severe preeclampsia.
Sources:
1. Rubin, Emanuel . Rubin's Pathology: Clinicopathologic Foundations of Medicine. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2005 : 986-7.
2. Tierney, Jr, Lawrence M., Stephen J. McPhee, and Maxine A. Papadakis. Current Medical Diagnosis & Treatment 2005. 44th ed. New York: McGraw Hill, 2005: 747-9.
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