2014 Edition

ORAL REVALIDA REVIEWER

ACUTE APPENDICITIS
SURGERY

Etiology
o E.coli & Bacteroides fragilis

Clinical Manifestations
o Abdominal pain cramping, severe, steady at the lower epigastric, within 4-6hrs localizes at RLQ (may vary from different
locations of pain of the appendix)
o Anorexia
o Vomiting

Signs:
o Direct and Indirect tenderness
o Rovsing's signpain in the RLQ when palpatory pressure is exerted in the LLQ (indicates site of peritoneal irritation)
o Psoas sign have patient lay on the left side as the examiner slowly extends the right thigh, thus stretching the iliopsoas
muscle (indicates an irritative focus proximal to that muscle)
o Obturator sign passive internal rotation of the flexed right thigh with the patient supine

Laboratory Findings:
o CBC mild leukocytsis, 10,000-18,000 cells/mm3 (acute uncomplicated AP)
o Urinalysis to rule out UTI

Imaging Studies
o Barium Enema if barium fills the appendix, it is excluded
o Plain films
o Chest radiograph if referred pain for right lower lobe pneumonic process
o CT scan has minimal advantage (dye in the presence of vomiting)
o Laparoscopy in lower abdominal complaints; in differentiating gynecologic problem

The Avogardo Scale for Diagnosing Appendicitis

Manifestations
Value
Migration of pain
1
Symptoms
Anorexia
1
Nausea/vomiting
1
RLQ tenderness
2
Signs
Rebound
1
Elevated temperature
1
Leukocytosis
2
Laboratory values
Left shift
1
Total: 10
3
o Note: Rupture should be suspected in the presence of elevated temperature (>39C) and a WBC of >18,000cells/mm

Differential Diagnosis:
o Acute Mesenteric Adenitis URTI is present, pain is diffuse, tenderness is not sharply localized as in AP; voluntary guarding
and diarrhea are present; laboratory values are normal
o Pelvic Inflammatory Disease right tube inflammation may mimic AP; nausea and vomiting are present in 50% of PID
o Ovarian Cyst ruptured right sided cyst may have similar manifestations of AP, patients develop RLQ pain, tenderness,
rebound, fever and leukocytosis
o Ruptured Ectopic Pregnancy rupture of right tubal and ovarian pregnancies can mimic AP, development of RLQ pain may
be the first symptoms, hematorcit falls due to internal abdominal hemorrhage
o Urinary Tract Infection Acute pyelonephritis, on the right side particularly, may mimic a retroileal acute appendicitis.
Chills, right costovertebral angle tenderness, pyuria, and bacteriuria are usually sufficient to
make the diagnosis.
o Peptic Ulcer Disease Perforated peptic ulcer closely simulates appendicitis if the spilled gastroduodenal contents
gravitate down the right gutter to the cecal area and if the perforation spontaneously seals,
minimizing upper abdominal findings

Treatment Plan:
o For possible operation, Adequate hydration should be ensured; electrolyte abnormalities corrected; and pre-existing
cardiac, pulmonary, and renal conditions should be addressed
o Administer antibiotics to all patients with suspected appendicitis. If simple acute appendicitis is encountered, there is no
benefit in extending antibiotic coverage beyond 24 hours. If perforated or gangrenous appendicitis is found, antibiotics are
continued until the patient is afebrile and has a normal white blood cell count.
o Open Appendectomy

McBurney (oblique) or Rocky-Davis (transverse) incision

o Laparoscopic Appendectomy

Under general anesthesia, use of 3-4 ports

Advantages: decreased operative pain, shorter duration of hospital stay, good wound healing, minimal incision

2014 Edition

ORAL REVALIDA REVIEWER

ACUTE and CHRONIC CHOLECYSTITIS

SURGERY

ACUTE CHOLECYSTITIS
Charcots Triad:
1. Fever

Clinical Manifestations:
2. RUQ Pain
o RUQ or epigastric pain that may radiate to the right upper part of the back or the
3. Jaundice
interscapular area
Reynolds Pentad:
o It is usually more severe than the pain associated with uncomplicated biliary colic
1. Fever
o Fever, anorexia, nausea, vomiting are present; patient is reluctant to move, as the
2. RUQ Pain
inflammatory process affects the parietal peritoneum.
3. Jaundice
o On PE: focal tenderness and guarding at the RUQ; a mass, the gallbladder and adherent
4. Shock
omentum, is occasionally palpable; however, guarding may prevent this.
5. Changes in
sensorium
o Murphy's sign, an inspiratory arrest with deep palpation in the right subcostal area, is
characteristic of acute cholecystitis.

Laboratory Findings:
3
o mild to moderate leukocytosis (12,000 to 15,000 cells/mm ); but some patients may have a normal WBC
o high WBC (>20,000) is suggestive of a complicated form of cholecystitis such as gangrenous cholecystitis, perforation, or
associated cholangitis
o Serum liver chemistries are usually normal, but a mild elevation of serum bilirubin, < 4 mg/mL, may be present along with
mild elevation of alkaline phosphatase, transaminases, and amylase.
o Severe jaundice is suggestive of common bile duct stones or obstruction of the bile ducts by severe pericholecystic
inflammation secondary to impaction of a stone in the infundibulum of the gallbladder that mechanically obstructs the bile
duct (Mirizzi's syndrome).

Differential Diagnosis:
o peptic ulcer with or without perforation, pancreatitis, appendicitis, hepatitis, pleuritis
CHRONIC CHOLECYSTITIS (Biliary Colic)

Clinical Manifestations:
o Recurrent attacks of pain, episodic
o Pain is constant and increases in severity over the first half hour or so, typically lasts 1-5 hours. It is located in the
epigastrium or right upper quadrant and frequently radiates to the right upper back or between the scapula
o Pain is occurs typically during the night or after a fatty meal
o Often associated with nausea and vomiting
o On PE: RUQ tenderness during an episode of pain

Laboratory Findings:
o WBC count and liver function tests are usually normal in uncomplicated gallstones
o Ultrasound standard diagnostic test for gallstones
o CT scans show extrahepatic biliary tree status and adjacent structures
o Endoscopic retrograde cholangiography (ERCP) and Endoscopic ultrasound rarely needed for uncomplicated gallstones
but for the stones in the common bile duct, in particular when associated with obstructive jaundice,
cholangitis or gallstone pancreatitis.

Management:
o For symptomatic gallstones, elective laparoscopic cholecystectomy is the procedure of choice.
o Diabetic patients with symptomatic gallstones should undergo cholecystectomy promptly as they are prone to develop
acute cholecystitis
nd
o In pregnant women, elective laparoscopic cholecystectomy is allowed during the 2 trimester

CHOLEDOCHOLITHIASIS
SURGERY
Common bile duct stones
RUQ tenderness, nausea, vomiting
Symptoms such as pain and jaundice may be intermittent

Imaging Studies:
o Magnatic Resonance Cholangiography (MRC) provides excellent anatomic detail and has a sensitivity and specificity of 95
and 89%, respectively
o Ultrasonography
o Endoscopic cholangiography is the gold standard for diagnosing common bile duct stones

Management:
o Endoscopic cholangiogram
o Sphincterotomy and ductal clearance of stones followed by laparoscopic cholecystectomy

2014 Edition

ORAL REVALIDA REVIEWER

MYOCARDIAL INFARCTION (ST-SEGMENT ELEVATION)
MEDICINE
May precipitate various physical exercise, emotional stress or a medical or surgical illness
Chest pain deep and visceral, heavy, squeezing and crushing
Similar to discomfort of angina pectoris, occurs at rest but more severe, lasts longer
Accompanied by weakness, sweating, nausea and vomiting, anxiety and a sense of impending doom, pallor, substernal chest pain of
more >30 minutes
Pericardial friction rub is usually heard

Laboratory Findings:
o ECG ST elevation, Q wave

Transmural MI is present if the ECG demonstrates Q wave and loss of K waves

Nontransmural MI is considered if ECG shows only transient ST segment and T wave changes
o Serum Cardiac Biomarkers

Cardiac-specific troponin-T and troponin-I are biochemical markers which usually rise in patients with STEMI not
seen in healthy individuals.
o MB isoenzymes of CK more specific but not diagnostic of a myocardial rather than a skeletal muscle source of CKMB
o Non-specific reaction to myocardial injury is associated with PMN leukocytosis, WBC often reaches 12,00-15,00; ESR rises
more slowly than WBC
o 2D-Echo cardiac imaging provides abnormalities of wall motion
o High-resolution MRI contrast agent (gadolinium) is administered, and images are obtained after a 10-minute delay; a
bright contrast appears in areas of infarction

Differential Diagnosis:
o Acute Pericarditis

Chest discomfort radiating from trapezius is not seen in STEMI

o Pulmonary Embolism

STEMI may present with sudden onset of breathlessness that may progress to pulmonary edema and embolism

Initial Management:
o Pre-hospital Care

Patient may manifest arrhythmias or mechanical complications (pump failure)

May cause sudden ventricular fibrillation

o Management in Emergency Department

Aspirin in suspected STEMI causes inhibitin of cyclooxygenase I followed by reduction of thromboxane A2

If there is hypoxemia, O2 administration with nasal cannula or face mask at 2-4L/min

o Control of Chest Discomfort

Nitroglycerine (sublingual) up to 3 doses of 0.4mg at about 5mins interval should be administered, or IV

nitroglycerine if with ongoing ST segment ischemia shifts.

IV -blockers diminishes O2 demand

Hospital Phase Management:

o Activity ambulation should be encouraged if without complication
o Diet diet rich in potassium, magnesium and fiber but not sodium
o Bowel use of stool softener
o Sedation diazepam or lorazepam (adverse effect: delirium)

Pharmacotherapy:
o Antithrombotic Agents its role is to maintain patency of infarct related artery and reduce thrombosis that can lead to
embolization

Clopidogrel reduces risk of clinical events, reinfarction, stroke and death

Heparin + Aspirin may help about 6 liver per 1000 patients

o Beta-adrenergic blocker improves the myocardium O2 demand, reduces pain, reduces infarct site, reduces arrhythmias
o Inhibition of RAAS reduces mortality rate; reduction in ventricular remodeling with subsequent reduction in the risk of
CHF, indolent to ACE inhibitors

NORMAL SPONTANEOUS DELIVERY (NSD)

1. Secure consent for procedure
2. Transfer patient to OR
3. Wear cap and mask
4. Place patient in dorsal lithotomy position
5. Asepsis, antiseptic technique
6. Straight catheterization
7. IE (fully dilated cervix, fully effaced, cephalic, intact BOW, station?)
8. Apply sterile drapes
9. Infuse 5cc lidocaine at right mediolateral (RML) wall of vagina, aspirate before infusing

OB-GYN

2014 Edition

ORAL REVALIDA REVIEWER

10.
11.
12.
13.
14.
15.
16.
17.
18.
19.

Do RML episiotomy
Once babys head is out, rotate gently then pull upward and downward then slide head on fetal back and hold fetal legs
Clamp the cord, place one clamp 2cms above the umbilicus, another
Deliver placenta using Ritgens maneuver
Once placenta is out, inspect cotyledon
Give oxytocin, check BP first
Do episiorapphy
Do final IE
Final asepsis and antisepsis
Monitor VS q15 for 1 hour then q30 for the next hour, and then q4 thereafter

DENGUE HEMORRHAGIC FEVER

Clinical Manifestations:
o Fever of 2-7 days
o Headache, muscle and joint pain
o Nausea and vomiting
o Rashes (Hermans rash)

Laboratory Findings:
3
o Low platelet count (<100,000/mm )
o Elevated hematocrit (>20% from baseline)
o Low albumin
o Pleural or other effusions

Dengue Shock Syndrome

o 4 criteria for DHF, plus:

Evidence of circulatory failure

Rapid and/or weak pulse

Narrow pulse pressure

Cold clammy skin

o Shock

Differential Diagnosis:
o Typhoid fever, measles, rubella

Management:
o Rehydration management
o Palliative treatment, antipyretics
o Monitor vital signs, hematocrit, platelet count, level of consciousness

PEDIATRICS

PCAP PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA

PEDIATRICS

Clinical Manifestations:
o 3mos-5yrs fever, tachypnea and chest indrawing
o 5-12yrs fever, tachypnea, crackles
o 12yrs and above fever, tachypnea, tachycardia, at least one abnormal chest finding of diminished breath sounds,
rhonchi, crackles or wheezes

Classification:
Variables

PCAP-A
Minimal Risk

PCAP-B
Low Risk

PCAP-C
Moderate Risk

PCAP-D
High Risk

Comorbid illness
Compliant caregiver
Ability to follow-up
(+)Dehydration
Ability to feed
Age
Respiratory rate, age 2-12mos
Respiratory rate, age 1-5 yrs
Respiratory rate, age >5 yrs

None
Yes
Possible
None
Able
>11 mos
50/min
40/min
30/min

Present
Yes
Possible
Mild
Able
>11 mos
>50/min
>40/min
>30/min

Present
No
Not possible
Moderate
Unable
<11 mos
>60/min
50/min
35/min

Present
No
Not possible
Severe
Unable
<11 mos
>70/min
>50/min
>35/min

2014 Edition

ORAL REVALIDA REVIEWER

Signs of Respiratory Failure:

PCAP-A PCAP-B
PCAP-C
PCAP-D
Retraction
None
None
Intercostals/subcostal
Supraclavicular
Head bobbing
None
None
Present
Present
Cyanosis
None
None
Present
Present
Grunting
None
None
None
Present
Apnea
None
None
None
Present
Sensorium
Awake
Awake
Irritable
Lethargic/Stupurous/Comatose
Respiratory Complications
None
None
Present
Present
Action Plan
OPD
OPD
Admit to regular ward
Admit to PICU
Diagnostics:
o PCAP A & B Clinical
o PCAP C & D:

CXR PA-Lateral

WBC count

Pleural fluid C/S

Blood C/S for PCAP-D

Tracheal aspirate upon initial intubation

Blood gas and pulse oximetry

Sputum C/S for older children

Treatment:
o For PCAP A or B DOC: oral amoxicillin (40-50mg/kg/day in 3 divided doses)
o For PCAP C and D:

(+)HiB vaccine pen G (100,000u/kg/day in q4)

(-)Hib vaccine IV ampicillin (100mg/kg/day q4)

SEPSIS NEONATORUM
PEDIATRICS

Characteristics:
o temperature instability, hypotension, poor perfusion with pallor and mottling of skin, metabolic acidosis, tachycardia or
bradycardia, apnea, respiratory distress, grunting, cyanosis, irritability, lethargy, seizures, feeding intolerance, abdominal
distention, jaundice, petechiae, purpura, bleeding.

Initial S/S in Newborn Infants:

o General fever, temperature instability, poorly feeding, edema
o Gastrointestinal abdominal distention, vomiting, diarrhea, hepatomegaly
o Respiratory apnea, dyspnea, tachypnea, retractions, flaring, grunting, cyanosis
o Cardiovascular pallor, mottling, cold, clammy skin, tachycardia, hypotension, bradycardia
o Renal oliguria
o CNS irritability, lethargy, tremors, seizure, hyperreflexia, hypotonia, abnormal Moro reflex, irregular respirations, bulging
fontanels, high pitched cry
o Hematologic system jaundice, splenomegaly, pallor, petechiae, purpura, bleeding

Differential Diagnosis:
o Respiratory Distress Syndrome
o Aspiration Pneumonia amniotic fluid, meconium or gastric content

Laboratory Studies:
o Blood and CSF culture
o Antigen detection (urine, CSF)
o Autopsy

Evidence of Inflammation:
o Leukocytosis, immature/total neutrophil count ratio
o Acute-phase reactions; ESR, CRP
o Cytokines, interleukins
o Pleocytosis in CSF

Treatment:
o Initial treatment with ampicillin and aminoglycoside (gentamicin)
o Nosocomial infections methicillin or nafcillin for S.aureus (antistaphylococcal drugs, or) vancomycin for CONS or MRSA
o Pseudomonas infections piperacillin, ticarcillin, ceftazidine or an aminoglycoside
o Antifungal therapy in infants with very low birth weight
rd
o Most gram(-) enteric bacteria ampicillin and an aminoglycoside or 3 gen cephalosporin (Cefotaxime or Ceftazidine)
o Enterococci penicillin (ampicillin or piperacillin) + an aminoglycoside
o Anaerobic infections clindamycin or metronidazole
o GBS penicillin

2014 Edition

ORAL REVALIDA REVIEWER

TYPHOID FEVER
PEDIATRICS / FAMILY MEDICINE

Salmonella typhi (etiologic agent)

Acquired through contaminated foods and water or close contact with infected person

Clinical Manifestations:
o High grade fever (39-40C)
o Headache
o Rose spots on chest and abdomen
o Cough, epistaxis
o Abdominal pain, with either constipation or diarrhea
o Weakness and fatigue
o Severely ill patients may experience delirium, shock, and intestinal hemorrhage

Diagnosis:
o Culture blood, urine, stool
st

1 week blood (+) 40% in the first week

nd

2 week urine and stool, highly (+)

Bone marrow single most sensitive test, (+) in 85-90%, less sensitive if influenced by prior antimicrobial therapy
o Typhi Dot
IgM IgG
Interpretation
(+)
(-)
Acute infection
(+)
(+) Recent infection
(-)
(+)
Equivocal

Management:
o Susceptible strains 14 day-treatment

Chloramphanicol 50-60mg/kg/day in 4 divided doses, or

Cotrimoxazole 800/160 1 tab BID, or

Ampicillin or Amoxicillin 100mg/kg/day in 3-4 divided doses

o Resistant strains

Ceftriaxone, 7-10 days, 3gm TIV, or

Ciprofloxacin (507 days) 500mg tab BID

o Chronic Carrier

High dose IV ampicillin or oral amoxicillin with probenecid for 4-6 weeks

For adult carriers: Ciprofloxacin

MENINGITIS

Etiology:
o First 2 months groups B and D Streptococci, Gram (-) enteric bacilli, and Listeria monocytogenes
o 2 months to 12yrs S.pneumoniae, N.meningitidis, H.influenza type B

Epidemiology:
o Close contact (e.g. household, daycare centers, military barracks), crowding, poverty, male gender

Transmission:
o Person to person contact through respiratory tract secretions or droplets

Clinical Manifestations:
o Several days of fever
o Upper GI or respiratory symptoms
o Meningeal irritation nuchal rigidity, back pain, Kernig sign, Brudzinski sign
o Headache, vomiting, cranial nerve neuropathies (10-20%)
o Seizures due to cerebritis, infarction or electrolyte disturbances (20-30%)

Diagnosis:
o CSF analysis
o CBC, platelet count, blood C/S, ESR, ABG
o Na, K, BUN, Creatinine, RBS
o Urinalysis, Urine G/S, C/S
o Stool, throat, nasal C/S
o Viral cultures (Coxsakie, Echinococcus, Mumps, EBV, HSV, CMV, Arbovirus)
o CXR, ECG, CT scan, MRI, EEG

PEDIATRICS

2014 Edition

ORAL REVALIDA REVIEWER

Normal
Pressure (mmH2O)

Leukocytes (mm )

CHON (mg/dL)
Glucose (mg/dL)

Others

50-80

Cerebrospinal Fluid Analysis

Acute Bacterial
Viral
TB
Meningitis
Meningitis
Meningitis
Usually high
Normal or
Usually
(100-300)
slightly high
elevated

75, 75%
lymphocytes

100 to 10,000
or more;
usually 3002000 PMN

20-45

100-500

>50

<40
Usually seen on
gram stain
recovered by
culture

Rarely >1000
cells

30-100
Generally
normal
HSV,
encephalitis by
focal CT scan
findings

10-500, PMN
early, then
lymphocytes
predominates
in most cases
100-3000
<50 in most
cases
Acid fast almost
never seen in
smear; can be
detected by
PCR or CSF

Fungal
Meningitis
Usually
elevated
5-50, PMN
early but
mononuclear
cells
predominate in
most cases
25-500
<50

Budding yeasts
may be seen

Anaerobic
Meningitis
Elevated

1000-10,000 or
more, PMN
predominates
50-500
Normal or
slightly low
Mobile amoeba
can be seen

Management:
1. Diet regular, fluid restriction if with ICP
2. IVF D5W at KVO
A. Meningitis Empiric Therapy (15-50 y.o)
1. Pen G 4 million units IV or Ampicillin IV, plus
2. Ceftriaxone 2gm IV q12
Or Ceftazidine 2gm IV q8
Or Chloramphenicol IV (if allergic to PenG)
B. Empiric Therapy for Patients above 50 years, Alcoholic, taking Corticosteroids, or with Hematologic Malignancy, or other
debilitating conditions
1. Ampicillin IV or Pen G
2. Cefotaxime of Ceftriaxone or Ceftazidine or Aztreonam and TMP-SMX
C. Therapy based on Specific Etiologic Agent
1. S. pneumonia Pen G
2. S. aureus - Oxacillin IV or Vancomycin IV
3. N. meningitides Pen G IV, or Chloramphenicol IV
4. H. influenza Ampicillin IV or Cefuroxime IV
5. Gram (-) bacilli (not P.aeruginosa or Enterobacter) Cefotaxime IV or Ceftriaxone IV or Ceftazidine IV
6. P. aeruginosa Ceftazidine IV or Piperacillin-Tazobactam IV

DIABETES MELLITUS

HbA1c primary target for blood sugar control

Clinical Manifestations:
o 3 Ps: polyuria, polydypsia, polyphagia
o Weight loss
o Easy fatigability
o Body weakness
o Slow healing wounds or frequent infection

Risk Factors:
o Family history
o Weight
o Sedentary lifestyle
o Race
o Age
o Gestational diabetes

Diagnosis:
1. Fasting Blood Sugar (FBS)
At least 8hrs fasting is required
Normal FBS is <100mg/dL (5.6 mmol/L)
FBS of 100-125mg/dl (5.6-6.9 mmol/L) is considered impaired fasting glucose

MEDICINE & FAMILY MED

2014 Edition

ORAL REVALIDA REVIEWER

2.

75gram oral glucose tolerance test

Normal value: <140mg/dL (7.8 mmol/L)
2 hr plasma glucose of 140-100mg/dL (7.8-11.0 mmol/L) is impaired glucose tolerance
2 hr plasma glucose of 200mg/dL (11.1 mmol/L) is diabetes
Management:
A. Non-Pharmacologic (Step 1)
1. Diabetic diet ( low salt, low fat)
2. Lifestyle modification, exercise
3. Weight reduction
B. Pharmacologic (Step 2)
1. Sulfonylureas
For older patients: Glipizide (Minidiab)
For younger patients: Glibenclamide (Euglucon)
2. Biguanides
If still uncontrolled with sulfonylureas
Metformin (Glucophage) 500mg tab TID
3. Alpha-glucosidase inhibitors
If with post-prandial hyperglycemia
Acarbose (Glucobay) 50-100mg tab TID with first mouthful of food
4. Thiazolinediones
Rosiglitazone (Avandia) 4-8mg tab OD
C. Insulin Treatment (if still uncontrolled)
1. Short Acting lispro, insulin aspart to regular (Humulin R, Actrapid HM)
2. Intermediate Acting NPH (Humulin N, Insulatard), Lente
3. Long Acting Ultralente (Humulin U), Glargine
4. Combinations 70% NPH - 30% regular (Mixtard 30, Humulin 70/30), Novomix 30

PYELONEPHRITIS

Clinical Manifestations:
o Abdominal or flank pain
o Fever
o Malaise
o Nausea and vomiting
o Occasional diarrhea

Diagnostics:
o CBC, UA, Blood C/S
o Urine G/S, C/S
o RBS, BUN, Creatinine, Renal Ultrasound

Management:
o Regular diet
o IVF: D5NM 1L x 8hrs
o Symptomatic medications pain relievers
o For moderately ill, non-septic pyelonephritis:

Treat for 14 days

Cephalexin 500mg 1cap QID or 2gm 1 dose PO

or Ciprofloxacin, norfloxacin, ofloxacin, co-amoxiclav, co-trimoxazole

o For severely ill, septic pyelonephritis:

Gentamicin 1.5mg/kg q7 x 21 days or Tobramycin/Amikacin IV

Ampicilin IV 1 gram q6 x 21days

or Ceftriaxone IV, Ceftazidine IV, Ciprofloxacin IV, Co-amoxiclav IV, Ampicillin/Sulbactam IV

ECTOPIC PREGNANCY
"eccyesis; Implantation of fertilized ovum outside the endometrium

Pathology:
o Salpingitis
o IUD
o Previous ectopic pregnancy
o Failed bilateral tubal ligation
o Myomas, adnexal masses
o Idiopathic

MEDICINE

OB-GYN

2014 Edition

ORAL REVALIDA REVIEWER

Clinical Manifestations:
Symptoms (Classic Triad)
Signs
Abdominal pain, colicky
Wiggling tenderness (most common sign)
Amenorrhea
Uterus smaller than AOG
Vaginal bleeding
hemoperitoneum
Diagnosis:
o CBC hemoglobin, hematocrit, and leukocyte count
o Lower HCG and progesterone levels
o Ultrasound diagnostic criteria:
1. Detection of adnexal mass
2. Absence of gestational sac using transvaginal UTZ when HCG >2,500 mIU/mL at 5-6wks
3. Intrauterine gestational sac rules out an ectopic pregnancy except in a heterotropic pregnancy
Management:
o Unruptured Eccyesis
1. Medical management
a. Methotrexate
b. RU-486 competes for progesterone binding sites
2. Surgical management partial salpingectomy, salpingostomy, salpingotomy
o Ruptured Eccyesis (primarily surgical)
1. Radical
a. Hysterectomy
b. Total salpingectomy with our without oophorectomy
2. Conservative segmental resection

ABORTION
- termination of pregnancy prior to 20 weeks' gestation or with a fetus born weighing less than 500g

Clinical Manifestations:
o Vaginal bleeding
o Passage of meaty tissue
o Foul-smelling uterine discharge
o Fever
o Profuse sweating
o Moderate tachycardia
Types of
Abortion
Threatened
Imminent
Inevitable
Incomplete
Complete
Missed
Habitual

Uterine
contraction
+/++
+++
+/+/-

Bleeding
+/+
++
++
+/Spotting
+

Cervical
dilatation
Closed
Open
Open
Open
Closed
Closed
Open

Uterine size VS
gestation
Compatible
Compatible
Incompatible
Incompatible
Incompatible
Incompatible
Compatible

OB-GYN

BOW

Others

Intact
Intact
Ruptured
Not appreciated
Not appreciated
Not appreciated
+/-

(+) FHT
(+)FHT
(+)FHT
Meaty tissue
Absent of signs of preg.
(-) FHT
(+) FHT

Diagnostics:
o CBC, UA, Urine chemistry, Electrolytes, Uterine discharge G/S, C/S
o Blood culture, CXR, blood chem.
o Close monitoring of VS and UO
Management:
o Blood transfusion with 7 u PRBC
o Antimicrobial therapy ampicillin + gentamicin + clincamycin/metronidazole (TIV)
o Completion curettage prompt evacuation of products of conception as follows:
1. Patient placed in dorsal lithotomy position under spinal anesthesia
2. Asepsis/antisepsis
3. Sterile drapes applied
4. Straight catheterization and internal examination posterior vaginal retractor applied to visualize the cervix
5. Anterior lip of the cervix grasped using tenaculum forcep
6. Evacuation of products of conception using ovum forcep
7. Initial hysterometry
8. Curettage done using blunt followed by sharp curette until frothy, gritty and bright red blood obtained
9. Final hysterometry

2014 Edition

ORAL REVALIDA REVIEWER

BRONCHIAL ASTHMA
Pathophysiologic Hallmark: reduction in airway diameter
Hypoxia - universal finding during acute exacerbations

Classic Symptom Triad: (1) Wheezing, (2) Dyspnea, (3) Cough

Typical Acute Attack:

o Often occurs at night
o With occupational asthma, attacks may occur at work or after work
o Patients experience a sense of constriction in the chest, often with a nonproductive cough
o Respiration becomes audibly harsh
o Wheezing is first noted during expiration and then with inspiration as well
o Expiration becomes prolonged
o Mucus plugging and impending suffocation
o Accessory muscles become visibly active, and a paradoxical pulse often develops
o The end of an episode is frequently marked by a cough that produces thick, stringy mucus

4 Major Classification of Asthma Severity by Clinical Features

o Mild, intermittent
Symptoms occur 2 or fewer times per week.
Asymptomatic between attacks
Exacerbations are brief (hours to at most days) and of varying intensity.
Nocturnal symptoms are rare, less than twice a month.
The FEV1 is >80% predicted during episodes.
o Mild, persistent
Symptoms occur more than 2 times a week but less than once a day.
Exacerbations may affect normal activity.
Nocturnal symptoms occur more than twice a month.
FEV1 is >80% predicted during episodes.
o Moderate, persistent
Symptoms occur daily.
Exacerbations occur more than twice a week and may last days.
Exacerbations affect normal activity.
Nocturnal symptoms occur more than twice a month.
FEV1 is between 60% and 80% during episodes.
o Severe, persistent
Symptoms are continual.
Physical activity is limited.
Exacerbations are frequent.
Nocturnal symptoms are frequent.
FEV1 is always abnormal and < 60% predicted during episodes.

Differential Diagnosis:
1. Chronic Bronchitis
2. Foreign Body Aspiration
3. Chemical Pneumonias
4. Acute Left Ventricular Failure

Diagnosis:
o Reversibility 15% in FEV1 after 2 puffs of B-adrenergic agonist
o Positive wheal and flare reactions to skin tests
o Sputum and blood eosinophilia
o Chest radiograph

Management:
o Eliminate allergen first, avoid trigger factors
o Oxygen at 2-6 lpm via nasal cannula
o Nebulization
- Salbutamol neb/inhaler q3-6hours (1 neb/2-4 puffs), or
- Ipatropium bromide + Salbutamol (Combivent)
o Drug Therapy:
1. Quick-Relief Medications (Relievers)
a. Adrenergic Stimulants catecholamines, resorcinols, salegenins
b. Methylxanthines theophylline
c. Antigcholinergic ipatropium bromide

MEDICINE & PEDIATRICS

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2014 Edition

ORAL REVALIDA REVIEWER

2.

Long-Acting Medications (Controllers)

a. Glucocorticoids (inhaled)
- Methylprednisolone
- Prednisolone
- Prednisone
b. Combined medications
- Fluticasone/Salmeterol
c. Mast cell stabilizing agents
- Cromolyn
- Nedocromil
d. Leukotriene antagonists
- Montelukast
- Zafirlukast
- Zilueton

IMMUNIZATION

PEDIATRICS
Expanded Program of Immunization (EPI)

Vaccine
BCG
Hepa B
DPT
OPV
HiB
Rotavirus

Route
ID
IM
IM
IM/PO
IM
PO

Measles
MMR

SC
SC

Dosing
At birth to 1 week
At birth to 1 week 4 weeks 14 weeks
6 weeks 10 weeks 14 weeks
6 weeks 10 weeks 14 weeks
6 weeks 10 weeks 14 weeks
6 weeks
9 months
12 months

Recommended Vaccines:

Hepa A 12 months (IM)

PCV 6 weeks (IM)

Influenza 6 months (SC/IM)

Varicella 12 months (SC)

HPV 10 years (IM)

Contributors:
Badillo, Lawrence Albert (March 2012) | Mirasol, Dave John (Nov. 2012) | Monterola, Francis Pierre (Nov. 2012) | Comia, Ralph Joseph (Nov. 2013) | Fontanilla, Agatha (March 2014)

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