OB

EDC: Naegels rule (-3 months, +7 days)

AOG: Count number of days from LMP divide by 7, any days left over is placed over 7 days

Pap smear

(Note: read on proper procedure, describe lesion, different instrument, Johnsons formula, fundic height, breast exam, etc)

Abdominal Examination of a pregnant woman:

1. Inspection
a. Shape and size of uterus
b. Asymmetry of abdomen
c. Fetal movt
d. Surgical scars
e. Cutaneous signs of pregnancy
i. Linea nigra
ii. Striae Gravidarum
iii. Striae Albicans
2. Palpation
a. Fundic Height
i. Bladder must be empty
b. Leopolds maneuver

Fundic height
20-35 weeks: measurement in cms has a direct correlation to fundic height
Landmarks: From the bony part of the superior border of symphysis pubis to the tip of fundus.
Approximates:
o 12 wks just above the symphysis
o 16 wks halfway between symphysis and umbilicus
o 20 wks umbilicus
o 32 wks midway between umbilicus and xiphoid
o 36 wks costal margin

Leopolds
I- fundic grip (head or breech)
II- umbilical grip (fetal back-firm, flat or linear or small parts- varying contour and movements)
III- pollex grip (presenting part (head or breech)
IV- (flexion of vertex and fetal occipital prominence) Position is at the patients head

Fetal Hearbeat:
Stethoscope = 17-19 weeks
Doppler = 10 weeks
US = 5 weeks

Fetal Movt:
20 weeks when examiner can feel it

Johnsons formula for estimating fetal weight

EFW=155 (x-n)
x= fundic height
n= 11 if not engaged 12 if engaged

G,P examples
Gravida has been pregnant whether FT, PT, ectopic, etc.
Para- reached age of viability at 20 weeks or more

Ex 1. Pregnant 3x, all aborted- G3P0 (0030)

Ex 2. 1st preg triplets, one died after 1 month (1 para even if triplet) delivered preterm 28 wks AOG
2nd preg- ectopic
3rd preg- FT delivery, intrauterine fetal death at 39 wks, delivered by NSD(2 para)
4th preg, aborted, complete curettage
5th preg- chorioCA, hysterectomy

G5P2 (1132)

1. Pap Smear
2. Internal Exam
3. Bi-Manual Exam
4. Rectovaginal Exam

Vaginal Exam
Williams pg. 413-414.

Pap Smear
Select speculum of appropriate size (Pedersen- small introitus and sexually active; Graves- parous with vaginal prolapse)
Lubricate with warm water
Enlarge vaginal introitus by applying downward pressure at its lower margin
After speculum has entered the vagina, remove fingers from introitus
Rotate to horizontal position, insert to its full length
Open carefully
Inspect cervix
o Color
o Position
o Surface characteristics
o Ulcerations
o Nodules
o Masses
o Bleeding, discharge
 Options for specimen collection
o Cervical scrape with Ayers spatula
o Endocervical brush (not used for pregnant women, instead cotton-tip applicator)
o Cervical broom
1. Endocervical
2. Cervical
3. Vaginal Pool (Transitional Zone)

NSS For STDs

KOH For Fungus

CHILDREN Vaginal Exam

Prone Knee-Chest
Frog Legs with mother

BREAST EXAM
1. Inspection
a. Hand over head Lateral
b. Hand on hip Medial
2. Palpation

Anesthesia
1. if pt is sedated and vomits, what will you do? Sellick maneuver
2. perform ambu bag, chin lift , jaw thrust
3. lateral decubitus position
4. if pt is sedated and has airway obstruction
a. laryngeal mask
b. endotracheal
c. oral airway *
d. oxygen cannula

(Note: read on anes procedures and scoring like ASA, mallampati, etc)

Sellick maneuver: pressure applied to anterior cricoid cartilage, using thumb and index finger, during ET intubation to protect against
regurgitation of gastric contents and to facilitate visualization of glottic opening during direct laryngoscopy and intubation

Class 1 faucial pillars, soft palate, uvula

Class 2 uvula masked by tongue base
Class 3 only soft palate
Class 4 only hard palate

ASA
Class 1 normal healthy pt
Class 2 mild to moderate systemic disease
Class 3 severe systemic disease that limits activity but not incapacitating
Class 4 constant threat to life, functionally incapacitating
Class 5 moribund pt not expected to survive 24 hrs with/without surgery
Class 6 brain dead pt whose organs are being harvested for transplant

Mask ventilation
prepare equipments
airway: head tilt, chin lift, jaw thrust
place the mask to surround nose and mouth; check if pressing on the eyes
deliver PPV

Endotracheal intubation
prepare equipment
select appropriate size tube, lubricate
patient in sniffing position
mouth opened with right hand; laryngoscope on left hand
advance laryngoscope to base of tongue
Macintosh (curved)- vallecula; Miller (straight)- epiglottis
Insert tube (up to around 23 cm)
Remove stylet
Inflate cuff
Check (auscultate, observe chest wall)

Review handout given

Psych- 1 station
Interview pt with major depression
(Note: read on outline of MSE, what to ask during history taking, criteria and treatment of choice for depression and bipolar, schiz, etc)

Questions to ask- pp. 230-232 Kaplan

Why are you going to see a psychiatrist?
What brought you to the hospital?
What seems to be the problem?
When did you first notice something happening to you?
Were you upset about anything when symptoms began?
Did they begin suddenly or gradually?
Have you been more active than usual?
How do you feel? Do you have thoughts that you want to harm yourself?
Do you have plans to take your own life?
Has there been a change in your sleeping habits?
Do you see things or hear voices?
Where do the voices come from?
Do they tell you to do things?
Do you feel people want to harm you?
 Do you have special powers?

Outline of MSE
appearance
speech
mood
thinking
perception
sensorium
o alertness
o orientation
o concentration
o memory
o calculations
o fund of knowledge
o abstract reasoning
insight
judgment

Schizophrenia
characteristic symptoms- 2 or more, 1 month
o delusions
o hallucinations
o disorganized speech
o disorganized behavior
o negative symptoms
social/occupational dysfunction
at least 6 months
schizoaffective and mood disorder exclusion
substance and general medical condition exclusion

Major depressive
5 or more, 2 weeks, at least 1 is depressed mood or loss of interest/pleasure
o Depressed mood
o Diminished interest/pleasure
o Significant weight loss or gain
o Insomnia/hypersomnia
o Psychomotor agitation/retardation
o Fatigue/loss of energy
o Feelings of worthlessness
o Diminished ability to think/concentrate
o Recurrent thoughts of death
Impairment in social/occupational etc.
r/o drugs, medical condition

Manic
elevated, expansive, irritable mood, 1 week
3 or more
o Inflated self esteem
o Decreased need for sleep
o More talkative
o Flight of ideas
o Distractibility
o Inc goal directed activity
o Excessive involvement in pleasurable activities

Radio (cardiopulmo, GI-GU, MSK, Neuro, ENT )

1. Id costophrenic recess
Condition which results in blunting pleural effusion

Id side affected right

Dx: pneumothorax

2. study done- barium enema

material used- barium

Id-psoas shadow
Id- pedicle

Id- common bile duct

ERCP

(Note : read normal amount and amount for blunting, causes for blunting, manifestations of effusion , pneumothorax and hemothorax,
barium enema and swallow, kidney shadow and other shadows, grading of pedicle rotation, Scotty dog sign, grading of
spondylolysthesis, portal triad, difference between ERCP and other procedures)
(read on common cases like sinusitis, TB , pneumonia, etc)

Review Powerpoint

Pedia

6 mo old girl
1. how do you assess brain growth? Head circumference
2. perform- glabella and occipital prominence
3. until when do you perform? Up to 3 years old
4. plot head circumferencebelow 50th percentile
5. interpret- microcephaly

(Note: read on anthropometrics, normal values and computations, read also on other well baby test, APGAR, milestones, newborn skin)
Anthropometrics
Waterlow Classification of Wasting
Actual weight/ideal weight for actual height x 100%
Normal: >/= 90%
Mild wasting : 80-90%
Moderate wasting: 70-80%
Severe wasting: <70%

Stunting
Actual height/ideal height for age x 100
Normal: >/=95%
Mild: 90 95%
Moderate: 80-90%
Severe: <80%

Assessment in Infancy
weight
o best index for growth and nutrition
o physiologic weight loss approx. 7-10 %
o ave: 3 kg
o < 6 mos age in mos x 600 + BW = wt in gms
o 6-12 mos age in mos x 500 + BW = wt in gms
o 2 yrs and above age in yrs x 2 + 8 = wt in kgs
o 4-5 mos BW x 2
o 1 yr BW x 3
o 2 yrs BW x 4
o 3 yrs BW x 5
o 5 yrs BW x 6
o 7 yrs BW x 7
o 10 yrs BW x 10

length or height
o reliable criterion of growth
o not affected by excess fat or fluid
o reflects growth failure/ chronic malnutrition
o average at birth: 50 cms
o at 1 yr: inc by 50%
o at 4 yrs: 2x
o at 13 yrs: 3x
o acceleration of growth: G 10-12 yrs B 12-14 yrs
o cessation of growth: G 17-19 yrs B >20 yrs
o gains in length
birth to 3 mos 9 cms
4-6 mos 8
7-9 mos 5
10-12 mos 3
total gain is 25 cms
o ht in cms = age in yrs x 5 + 80
o 1 yr: 1.5 x BL
o 2 yrs: mature height (boys)
o 3 yrs: 3 ft tall
o 4 yrs: 2 x BL
o 13 yrs: 3 x BL

Head circumference
o Taken up to 3 yrs
o Glabella/supraorbital ridge and most prominent part of occiput
o Related to intracranial volume and rate of brain growth
o HC at birth= 35 cms, HC>CC
o At 6 mos HC=CC
o At 12 mos HC<CC
o Range is relatively narrow
o Almost no variation based on racial, nutritional, geographical factors
o 1st yr = 4 inches (10 cms) rapid inc
o 1st 4 mos=1/2 inch per mo = 2 inches
o next 8 mos= inch per mo= 2 inches
o 2nd yr= 1 inch (2.54 cms)
o 3rd-5th yr= inch per yr= 1.5 inches
o 6-20th year- inch every 5 years= 1.5 inches

Chest circumference
o Taken at level of xiphoid or substernal notch
o Thoracic index = transverse diameter/AP diameter
o At birth= 1.0
o At 1 y/o =1.25
o At 6 y/o= 1.35

Abdominal measurements
o Most prominent during infancy and childhood
o CC=AC until age 2

Midarm circumference
o Good gauge of nutrition <6 y/o

Triceps/ skin fold thickness

o Rough estimate of body composition

Body proportion
o Upper segment crown to symphysis
 o Lower segment- symphysis to sole
o Detect endocrine problems
o At birth= 1.7
o 10 y/o=1

Posture
o At birth = thoracic and sacral curves
o 3 mos with head control= cervical curve
o walking (3 y/o)= lumbar curve

Tanner Staging (Sexual Maturity Staging)

FEMALES
Breast Changes Pubic Hair
I pre adolescent No hair
II breast budding Sparse, pigmented, long, straight, along labia
III Continued enlargement Darker, coarser, curlier
IV secondary mound by areola and papilla Resembles adult but dec. distribution
V mature breast Adult, hairs spread to medial thigh

MALES
Genital Changes Pubic hair
I pre adolescent No hair
II enlargement of penis with change in texture Sparse, pigmented, long. Straight, base of penis
III growth in length and circumference Darker, coarser, curlier
IV further development of glans penis Adult but dec distribution
V Adult Adult in quantity , spread to medial thigh

APGAR
0 1 2
Appearance blue blue limbs, pink body completely pink

Pulse absent <100/min >100/min

Tone limp some flexion active motion

Grimace absent grimace cough/sneeze

Respiratory absent slow,irregular good, crying

Neuro- 1 station (CVA, seizure, CNS infections, neuropathies, myopathies, myelopathies, movement disorders)

Increased ICP : papilledema (venous stasis, blurred disk margins, hyperemic, physio cup not visible, clear, many disk vessels),
headache, projectile vomiting.

Pt is paralyzed left side of face and left leg, 60 y/o with atrial fibrillation
1. is it upper or lower motor neuron? Upper
2. what are the characteristics of UMN? Give 4.
a. Hyperreflexia
b. Spasticity
c. (+) babinski
d. (-) atrophy
e. (+) ankle clonus
3. what is the etiology : embolic (vascular lesion)
4. localize? Left supratentorial

(Note : read on CVA and different types, localization, bells palsy and course of facial nerve, UMN vs LMN, temporal profile of each
etiology, diagram for localization, read also on MG and other common conditions)
(Note: read also on test for nystagmus, coordination test and Rombergs, different Babinski test, etc)

Cranial Nerves
I olfactory occlude 1 nostril and close eyes, let patient smell
II visual acuity, visual confrontation, pupil reaction to light, accommodation, fundoscopy
III, IV, VI eoms SO4, LR6, rest of the muscles CN III; Inwards (obliques: upward- inferior oblique; downward superior oblique);
outwards (rectus: upward: superior rectus; downward: inferior rectus); ptosis; marcus-gunn (efferent)
V masseter and temporalis (clench teeth) strength; sensation (ophthalmic, maxillary, mandibular); corneal reflex
VII- corneal reflex (indirect); close eyes, smile, frown, pursed lips, press cheeks
VIII rub fingers; rinne (normal: AC>BC; BC>AC on the affected ear conduction hearing loss; AC>BC on the affectedl ear:
sensorineural loss), weber (lateralization; lateralizes to normal ear: sensorineural; lateralizes to abnormal ear: conductive hearing loss)
IX, X: uvula, soft palate (X), gag reflex
XI: shoulder shrug (trapezius); head resistance (SCM)
XII: tongue deviation

Motor: 5- normal; 4-with resistance; 3-against gravity without resistance; 2-with gravity; 1- flicker; 0- no movement
Gait: walk, heel to toe, on heels, on toes, hop on 1 foot, sit and rise
DTRs: biceps (C5, C6); triceps (C6-C8), brachioradialis (C5, C6), patellar ( l2-l4), achilles (S1, S2)

Romberg sign
patient stands with the feet placed closely together
note the amount of body sway with the patients eyes open
compare when the patients eyes are closed
positive sign if abrnomal accentuation of sway or actual loss of balance
injury to lemniscal pathway

Babinski sign
stroke plantar surface of outer border of foot with blunt object
normal response: plantarflexion of great toe
 (+) sign- dorsiflexion of great toe and fanning of other toes
Chaddocks: lateral side of the foot
Schaeffer: squeeze Achilles tendon
Oppenheim: use knuckles to slide on the shin
Gordon: squeeze calf
Bing: multiple light pin pricks on the dorsolateral foot
Gonda, Stransky: 4th toe pull outward and downward
(+) signs: fanning of the big toe

Hoffmans reflex: flick distal phalanx of middle finger: (+) flex thumb and index hyperreflexia
Brudzinskis signs: nuchal rigidity px supine position, flex neck, + if with adduction and flexion of leg
Kernigs sign: knee flexed and then extended + when with nape pain
Lasseagues sign: straight leg raising resistance of movement
Cervical cord lesion: Lhermittes sign shock like sensation

Coordination tests
Ask patient to touch an index finger alternately to his nose and then to your finger, which you hold at full arms length away
from the patient
Ask the patient to run his heel from the opposite knee straight down to the shin to the foot , then elevate the leg in the air and
repeat the movement
Test rapidly alternating movements by having patient alternately pronate and supinate one hand , touching the palm of the
opposite hand

Medicine (CAD, HF, CAP, PTB, Asthma, COPD, PUD, UTI, Hep, ARF, CKD, Anemia, Gout, SLE, DM, Pancreatitis, HPN)
1. pt with petechiae, 3 days high grade fever, back pain and orbital pain
Dx: dengue hemorrhagic fever
Lab tests: CBC with platelet count and Hct
Abnormalities to look for: thrombocytopenia and hemoconcentration to plateau as sign of start of improvement

2. pt with chest pain radiating to arm

Dx: acute MI
ECG findings: ST elevation and large Q wave (identify in tracing)

3. dysuria, urinary frequency and hypogastric pain, no flank pain

WBC in urine
Dx: acute uncomplicated cystitis
Prescription writing: Co-trimoxazole 800 mg BID x 3 d (complete prescription according to guidelines)

(Note : read on criteria for DHF and difference with DF, grading of dengue, manifestations, diagnostics, AMI enzymes timetable, ECG
findings, guidelines for prescription for CAP and UTI of different age groups and population including the drug of choice for each and
dosage and preparation).

CRITERIA
Fever, or recent history of acute fever
( 2- 7 days )
Hemorrhagic manifestations
Low platelet count (100,000/mm3 or less)
Objective evidence of leaky capillaries:
elevated hematocrit (20% or more over baseline); any hematocrit > 40%; a drop in hct >20% following volume
replacement
low albumin
pleural or other effusions
GRADING
Grade 1
Fever and nonspecific constitutional symptoms
Positive tourniquet test is only hemorrhagic manifestation
Grade 2
Grade 1 manifestations + spontaneous bleeding
Grade 3
Signs of circulatory failure (rapid/weak pulse, narrow pulse pressure, hypotension, cold/clammy skin)
Grade 4
Profound shock (undetectable pulse and BP)

DANGER SIGNS Dengue Hemorrhagic Fever

Abdominal pain - intense and sustained

Persistent vomiting
Abrupt change from fever to hypothermia, with sweating and prostration
Restlessness or somnolence

CLINICAL
Fever lasting from 2 to 7 days, regardless of the character of the fever
Hemorrhagic manifestations
At least a positive tourniquet test except in the presence of shock*
In the presence of spontaneous petechiae, there is no need to perform the tourniquet test. WHO recommends using Wintrobes
method: the presence of more than 20 petechiae/inch2 is considered positive
Wrap sphygmomanometer cuff around arm, covering 2/3 of it
Inflate cuff at mean of systolic and diastolic pressures for 10 minutes (or shorter if numerous petechiae appear on forearm)
Count the number of petechiae in an area 1 inch2 an inch below the cubital area

HOW TO DO A TOURNIQUET TEST

From the Fundamental Diagnostic Hematology: The Bleeding and Clotting Disorders, 2nd ed. Centers for Disease Control, US
Department of Health and Human Services and WHO, 1992
Place patient in a reclining position
Inflate sphygmomanometer cuff to pulse pressure for 5 minutes
Deflate cuff for another 5 minutes; then read
In an area 2-3cm in diameter on the volar surface of the forearm count the number of petechiae
The presence of more than 10 petechiae in that area is abnormal
 Rumpel-Leede Test:
A pressure midway between systolic and diastolic is maintained by cuff wrapped around the upper arm for 5 to 10 minutes
Five minutes later, the skin distal to the cuff is examined for petechiae
Normally, not more than 15 petechiae appear in a circular area 2 inches in diameter on the flexor surface of the forearm

LABORATORY
A fall in the platelet count
A normal platelet count does not necessarily rule out dengue hemorrhagic fever
Prolonged bleeding time, using the Ivy method
Modified Ivy method
Apply a sphygmomanometer cuff on the arm and inflate to 40mmHg
A standardized cut with a Feather lancet is then made on the volar surface of the forearm, timer is started,
and at 30 seconds, the resulting drops of blood are blotted with filter paper (with care that the paper does not
directly touch the wound edge itself)
When blood no longer stains the filter paper, the timer is stopped.
The procedure is repeated twice
The results are then averaged.
Normal values: 2-5minutes. Value is definitely prolonged if its is more than 9 minutes.
Prolonged partial thromboplastin time
Prolonged prothrombin time
Steadily increasing hematocrit in spite of proper hydration or objective evidences of increased vascular permeability, e.g.
serosal effusion and edema due to hypoproteinemia

Hemoconcentration usually precedes the drop in blood pressures and changes in the pulses

CLASSIFICATION OF DENGUE FEVER ACCRDG TO SEVERITY

Grade I Fever accompanied by non-specific constitutional symptoms, the only hemorrhagic manifestation is a positive
tourniquet test.

Grade II The additional manifestation to those of Grade I is spontaneous bleeding to the skin and/ or other hemorrhages.

Grade III Circulatory failure manifested by rapid and weak pulse, narrowing of pulse pressure (20 mm hg or less) or
hypotension, with the presence of cold, clammy skin and restlessness

Grade IV Profound shock with undetectable blood pressure and pulse.

TESTS FOR ETIOLOGICAL AGENT

Virologic tests
Isolation of the virus
Molecular technology: Polymerase Chain Reaction (PCR)

SEROLOGIC TESTS
Hemagglutination inhibition (HI)
Complement fixation (CF)
Plaque reduction neutralization (NT)
IgM capture enzyme-linked immunosorbent assay (MAC ELISA)
Indirect IgG ELISA
Others: Immunoblot (Dengue blot)

GENERAL CONSIDERATION IN MANAGEMENT OF DENGUE

IVF should be isotonic, similar composition to plasma
Rate of plasma leakage is not consistent in the 24-48 hr period, periodic assessment needed
No need for increased fluid therapy after 48 hrs of onset of leakage
Reabsorption of extravasated plasma takes place 2-3 days thereafter ( convalescent)
Strong pulse and BP and diuresis are good signs during reabsorption phase
Recognize concealed bleeding: to know appropriate blood to transfuse
Platelet concentrates NOT routinely administered
When DIC is suspected, FFP or cryoprecipitate is given
Uncorrected acidosis may lead to DIC massive bleeding

MANAGEMENT PROTOCOL
DF and DHF Gr I without danger signs
Home management
Ask patient to come back daily until 72 hours afebrile, or to return immediately if with any of the criteria for admission
Give oresol 75 ml/kg body weight in 4 to 6 hours or 2 3 liters in adults
Paracetamol for fever; No aspirin
DF and DHF Gr I with any of the danger signs and DHF Gr II
Admit if with any of the criteria fopr admission
If without dehydration may give maintenance therapy
If with dehydration or hemoconcentration give IVF (D5LRS or D50.9 NaCl or Plain LRS ) at 5-7 ml/kg/bw/hr for 3 hours
If with dehydration or hemoconcentration
D5LRS or D50.9NaCl or Plain LRS
5-7 ml/kg/bw/hr for 3 hours

With improvement If NO improvement, increase

Reduce IVF at 3 ml/kg/hr (2-3 L/day IVF by 3-5 ml/KBW
In adults and maintain same rate 24- increments up to 15 ml/kg/BW
48 h Then adjusy accordingly
Using D5LRS alt with D5IMB
( <2 y/o)
Or D5 0.3 NaCl ( >2 y/o)

Surgery (GS 1,2, and 3, ortho, burns, TCVS, PS, GU)

1. anterior neck mass, moves with swallowing
 Dx test: FNAB (to know if malignant or benign)
Therapeutic: thyroidectomy (possible malignant degeneration of papillary Ca)

2. perform Rovsings sign

( colonic displacement of gas which causes pain in the appendix )

3. pt with obstruction, jaundice, dilated CBD, etc.

dx test after ultrasound: ERCP

choose from pts A and B(lab forms) for lab tests that will support dx
there should be inc in bilirubin (jaundice) and alkaline phosphatase (obstruction)
(Note : read on thyroid mass both benign and malignant with staging, manifestations, diagnostics including normal and
expected lab values and treatment, appendicitis test and rationale for each, biliary obstruction and cholecystitis manifestations
and diagnostics with normal lab values and expected lab results)

Tests for appendicitis

Rebound tenderness Blumberg sign ask patient to cough, palpate and quickly withdraw to elicit pain on the RLQ
Rovsings
o Press deeply and evenly in the LLQ
o Then quickly withdraw fingers
Psoas
o Place hand just above the pts right knee
o Ask pt to raise thigh against hand
o OR
o Ask pt to turn onto left side
o Extend the pts right leg at the hip
o (+) pain at the pelvis iliopsoas muscle
Obturator
o Flex the pts right thigh at the hip, with the knee bent and rotate the leg internally

Test for cholecystitis

Murphys
o Hook left thumb or finger of right hand under the costal margin (point where lateral border of rectus intersects with
costal margin)
o Ask pt to take a deep breath
o (+) if sudden stop in inspiratory effort