Ishi Kokka Shiken cheat sheet

Action potential: resting membrane potential ≈ -70 mV; threshold ≈ -55 mV; depolarization from Na+ influx; repolarization from K+ efflux; refractory periods prevent backward conduction.

Cardiac output = heart rate × stroke volume; Fick principle: CO = VO2 / (CaO2 - CvO2).

Enzyme kinetics: Michaelis-Menten v = Vmax[S]/(Km+[S]); competitive inhibitors increase Km, noncompetitive decrease Vmax.

DNA replication is semiconservative; leading strand synthesized continuously, lagging strand as Okazaki fragments; RNA primers removed by RNase H and replaced by DNA polymerase.

Inflammation cardinal signs: redness (rubor), heat (calor), swelling (tumor), pain (dolor), loss of function (functio laesa); mediated by histamine, prostaglandins, bradykinin.

Antibody classes: IgG (most abundant, crosses placenta), IgM (primary response, pentamer), IgA (mucosal, dimer), IgE (allergy, parasites), IgD (B-cell receptor).

Pharmacokinetics: first-pass effect reduces oral bioavailability; volume of distribution Vd = dose / plasma concentration; clearance = rate of elimination / plasma concentration.

Cell cycle checkpoints: G1/S (restriction point, p53), G2/M (DNA damage), spindle assembly checkpoint (M).

Acute myocardial infarction: ST elevation in contiguous leads indicates STEMI; troponin rises 3-6 h after onset, peaks 12-24 h, remains elevated 7-10 days.

Heart failure: BNP <100 pg/mL makes acute HF unlikely; >400 pg/mL supports diagnosis; treat with diuretics, ACEi/ARB, beta-blockers, mineralocorticoid antagonists.

COPD: post-bronchodilator FEV1/FVC <0.70 confirms persistent airflow limitation; GOLD stages based on FEV1 % predicted.

Diabetes: HbA1c ≥6.5% or fasting glucose ≥126 mg/dL or 2-h OGTT ≥200 mg/dL or random ≥200 mg/dL with symptoms diagnose diabetes.

Acute kidney injury: KDIGO criteria - increase in serum creatinine ≥0.3 mg/dL within 48 h or ≥1.5× baseline within 7 days, or urine output <0.5 mL/kg/h for 6 h.

Cirrhosis complications: ascites (SAAG ≥1.1 g/dL indicates portal hypertension), variceal bleeding (non-selective beta-blockers for prophylaxis), hepatic encephalopathy (lactulose, rifaximin).

Geriatric syndromes: falls, incontinence, delirium, frailty; Beers criteria list potentially inappropriate medications in older adults (e.g., benzodiazepines, anticholinergics).

Thyroid: primary hypothyroidism shows high TSH, low free T4; Graves disease shows low TSH, high free T4, positive TSH receptor antibodies.

Acute appendicitis: migration of pain to right lower quadrant, McBurney point tenderness, leukocytosis; Alvarado score ≥7 supports operative management.

Bowel obstruction: air-fluid levels on upright abdominal X-ray; initial management with IV fluids, nasogastric decompression, and serial abdominal exams.

Shock: hemorrhagic shock classes based on estimated blood loss (Class I <15%, II 15-30%, III 30-40%, IV >40%); hypotensive in class III-IV.

Surgical site infection prevention: preoperative chlorhexidine skin prep, appropriate antibiotic prophylaxis within 60 min before incision, normothermia, glycemic control.

Trauma: primary survey ABCDE (Airway, Breathing, Circulation, Disability, Exposure); FAST exam for hemoperitoneum; permissive hypotension in penetrating trauma without TBI.

Hernia: indirect inguinal hernia passes through deep inguinal ring lateral to inferior epigastric vessels; direct hernia through Hesselbach's triangle medial to vessels.

Postoperative fever: within 48 h consider atelectasis; days 3-5 consider urinary tract infection or pneumonia; days 5-7 consider surgical site infection or anastomotic leak.

Breast cancer: sentinel lymph node biopsy for clinically node-negative early breast cancer; triple assessment includes clinical exam, imaging (mammography/ultrasound), and core biopsy.

APGAR score: Appearance, Pulse, Grimace, Activity, Respiration; each 0-2, total 0-10; score 7-10 normal, 4-6 moderately depressed, 0-3 severely depressed.

Pediatric dehydration: mild <5% weight loss, moderate 5-10%, severe >10%; use ORS for mild-moderate; IV isotonic fluids for severe or unable to drink.

Kawasaki disease: fever ≥5 days plus 4 of 5 criteria (conjunctivitis, oral changes, rash, extremity changes, cervical lymphadenopathy); treat with IVIG and aspirin to prevent coronary aneurysms.

Preeclampsia: new hypertension after 20 weeks gestation with proteinuria or end-organ dysfunction; severe features include BP ≥160/110, platelets <100,000, elevated liver enzymes, pulmonary edema, visual symptoms.

Gestational diabetes screening: 50-g glucose challenge at 24-28 weeks; if abnormal, 100-g 3-h OGTT; diagnose with ≥2 elevated values.

Postpartum hemorrhage: uterine atony most common cause; manage with uterine massage, oxytocin, then other uterotonics (carboprost, misoprostol), tranexamic acid, and surgical measures.

Neonatal jaundice: physiologic peaks at days 3-5; pathologic if appears <24 h, bilirubin rises >5 mg/dL/day, or direct bilirubin elevated; treat with phototherapy.

Cervical cancer screening: start at age 21 with cytology every 3 years, or age 30-65 with cytology plus HPV co-testing every 5 years; stop after age 65 if adequate prior negative screening.

Stroke: sudden focal neurologic deficit; noncontrast CT excludes hemorrhage; IV alteplase within 4.5 h of ischemic stroke onset in eligible patients; thrombectomy up to 24 h in selected large vessel occlusion.

Depression: DSM-5 requires ≥5 symptoms for ≥2 weeks, including depressed mood or anhedonia; first-line treatment SSRIs, psychotherapy, or combination.

Schizophrenia: positive symptoms (hallucinations, delusions), negative symptoms (flat affect, avolition), cognitive symptoms; antipsychotics are mainstay; monitor for metabolic side effects.

Status epilepticus: continuous seizure ≥5 min or recurrent seizures without recovery; first-line benzodiazepines (lorazepam), then second-line (fosphenytoin, levetiracetam, valproate).

Delirium: acute onset, fluctuating course, inattention; common in hospitalized elderly; identify and treat underlying cause; avoid antipsychotics unless severe agitation.

Multiple sclerosis: demyelinating lesions disseminated in time and space; MRI shows periventricular, juxtacortical, infratentorial, spinal cord lesions; CSF oligoclonal bands.

Parkinson disease: resting tremor, bradykinesia, rigidity, postural instability; treat with levodopa/carbidopa; dopamine agonists in younger patients.

Serotonin syndrome: triad of altered mental status, autonomic hyperactivity, neuromuscular abnormalities (clonus, hyperreflexia); triggered by serotonergic drugs; treat with cyproheptadine in severe cases.

ACLS: ventricular fibrillation/pulseless VT - defibrillate immediately, CPR, epinephrine 1 mg every 3-5 min, amiodarone after 2-3 shocks; reversible causes (Hs and Ts).

Anaphylaxis: IM epinephrine 0.3-0.5 mg (1:1000) in anterolateral thigh; adjuncts: antihistamines, corticosteroids, fluids; observe for biphasic reaction.

Sepsis: qSOFA (respiratory rate ≥22, altered mentation, systolic BP ≤100) for screening; Sepsis-3 defines sepsis as life-threatening organ dysfunction from dysregulated host response to infection; initial resuscitation with 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L.

Acute respiratory distress syndrome (ARDS): Berlin criteria - onset within 1 week, bilateral opacities, PaO2/FiO2 ≤300 mmHg with PEEP ≥5 cmH2O; lung-protective ventilation with tidal volume 6 mL/kg predicted body weight.

Anesthesia: MAC (minimum alveolar concentration) is the alveolar concentration at which 50% of patients do not move in response to surgical stimulus; lower MAC with age, hypothermia, pregnancy, and opioids.

Malignant hyperthermia: triggered by volatile anesthetics and succinylcholine; signs include hyperthermia, muscle rigidity, hypercarbia; treat with dantrolene 2.5 mg/kg IV.

Rapid sequence intubation: preoxygenation, pretreatment (optional), paralysis with induction agent and neuromuscular blocker (e.g., rocuronium or succinylcholine), intubation, post-intubation care.

Poisoning: activated charcoal within 1 h for ingestions of toxins adsorbed by charcoal (not metals, alcohols, hydrocarbons); antidotes: naloxone for opioids, flumazenil for benzodiazepines (caution), N-acetylcysteine for acetaminophen.

Sensitivity = TP/(TP+FN); specificity = TN/(TN+FP); positive predictive value depends on prevalence; likelihood ratio positive = sensitivity/(1-specificity).

Study designs: cohort studies calculate incidence and relative risk; case-control studies calculate odds ratio; randomized controlled trials provide strongest evidence for causality.

Informed consent requires capacity, disclosure of material risks and alternatives, understanding, and voluntariness; exceptions: emergency, therapeutic privilege, waiver.

Confidentiality: may be breached with patient consent or when required by law (e.g., notifiable diseases, gunshot wounds, child abuse); disclose only minimum necessary information.

Brain death: irreversible loss of all brain function including brainstem; confirmed by clinical criteria (coma, absent brainstem reflexes, apnea) and exclusion of confounders.

Screening principles (Wilson-Jungner): condition important, accepted treatment, facilities for diagnosis and treatment, recognizable latent stage, suitable test, test acceptable, natural history understood, cost-effective.

Public health: herd immunity threshold depends on basic reproduction number R0; for measles R0 12-18, threshold ~92-95%.

Medical error disclosure: duty to disclose harmful errors to patients; apologize and explain; report through incident reporting systems; root cause analysis for system improvement.

Medical interview structure: greet and establish rapport, open-ended question, listen without interruption, explore symptoms with OLDCARTS (Onset, Location, Duration, Character, Aggravating/Associated, Relieving, Timing, Severity), summarize, and plan.

Vital signs: normal adult resting heart rate 60-100 bpm, respiratory rate 12-20/min, blood pressure <120/80 mmHg, temperature 36.5-37.5°C, oxygen saturation ≥95% on room air.

Cardiac auscultation: aortic area (right 2nd intercostal space), pulmonic (left 2nd), tricuspid (left 4th), mitral (left 5th midclavicular); S1 closure of mitral and tricuspid valves; S2 closure of aortic and pulmonic valves.

Abdominal examination: inspection, auscultation (bowel sounds before palpation), percussion, palpation; liver span 6-12 cm in midclavicular line; spleen palpable only when enlarged.

Neurologic exam: mental status, cranial nerves, motor (tone, strength, bulk), sensory, reflexes, coordination, gait; deep tendon reflexes graded 0-4+.

Communication: use teach-back method to confirm understanding; avoid medical jargon; use interpreter for limited English proficiency; SBAR (Situation, Background, Assessment, Recommendation) for handoffs.

Breaking bad news: SPIKES protocol - Setting, Perception, Invitation, Knowledge, Emotions, Strategy/Summary.

Shared decision-making: discuss options, benefits, risks, and patient values; document the conversation; use decision aids when available.

Diagnostic reasoning: generate differential diagnosis based on problem representation; use likelihood ratios to update pretest probability; avoid premature closure and anchoring bias.

Chest pain: assess for life-threatening causes (ACS, aortic dissection, pulmonary embolism, tension pneumothorax, esophageal rupture); ECG within 10 min; troponin, CXR, and focused history.

Dyspnea: differentiate cardiac, pulmonary, metabolic, and psychogenic causes; use BNP, D-dimer, chest imaging, and ABG as indicated; consider PE with Wells score.

Syncope: distinguish cardiac (arrhythmia, structural) from reflex and orthostatic; red flags: exertional, no prodrome, family history of sudden death, abnormal ECG; admit high-risk patients.

Fever of unknown origin: define as fever ≥38.3°C on multiple occasions for ≥3 weeks without immunocompromise; workup includes cultures, imaging, and biopsy of suspicious lesions.

Acid-base disorders: calculate anion gap (Na - [Cl + HCO3]) normal 8-12; delta gap = (anion gap - 12) / (24 - HCO3); if delta gap <1, mixed disorder; if >2, additional metabolic alkalosis.

Hyponatremia: assess volume status and urine osmolality; hypovolemic hyponatremia treat with isotonic saline; SIADH (euvolemic, urine osmolality >100) treat with fluid restriction; correct sodium slowly (≤8-10 mEq/L/day) to avoid osmotic demyelination.

Antibiotic stewardship: obtain cultures before starting antibiotics when possible; narrow spectrum based on results; duration based on evidence; de-escalate when culture results allow.