InternalMedicineReview

20142015

DISCLAIMER
Thispresentationdoesnotpretendtobeallinclusivebutto
brieflycoverfrequentlytestedtopicsinInternalMedicine.
ThispresentationdoesNOTcontainanymaterialsor
questionsfromtheNBMESubjectExamination,andsoany
resemblancebetweenthispresentationandtheexamispure
coincidence.

ExamDistributionbySystem
Generalprinciples

15%

Immunologicdisorders

510%

Diseasesofthebloodandbloodformingorgans

510%

Diseaseofthenervoussystemandspecialsenses

510%

Cardiovasculardisorders

1520%

Disordersoftherespiratorysystem

1520%

Nutritionalanddigestivedisorders

1015%

Gynecologicdisorders
Renal,urinary,andmalereproductivedisorders

15%
1015%

Disordersoftheskinandsubcutaneoustissue

510%

Diseasesofthemusculoskeletalsystemandconnectivetissue

510%

Endocrineandmetabolicdisorders

510%

ExamDistribution

Promotinghealthandhealthmaintenance

1015%

Understandingthemechanismofdisease

2025%

Establishingadiagnosis

4045%

Applyingprinciplesofmanagement

2025%

DoNOTRelyonStatisticalAdjustments!
YourrawscoreisadjustedaccordingtotheNational18th
percentile

DoNOTRelyonStatisticalAdjustments!

So,forexample,ifyourrawscoreis68

70/69=1.014
68x1.014=69.0

TipsfortheExam

Theexamconsistsof100110questions,usually96
multiplechoicequestions,and4matches
Youhaveatotalof2hours30minutestocompletethe
exam,thatisroughly1.5minutesperquestion
Vignettesarelooooooooong
SometimesanswersgofromAtoN
Littlephysicalexaminformationandscantlaboratory
results

TipsfortheExam

Readquestionandanswersfirst!!!
Sometimesyoudontneedtoreadthewholethingto
getthequestionright,soyousaveaminutehereand
there
Ruleoutanswersasyoureadthrough
Ifyoudontimmediatelyknowtheanswer,MARKyour
gutguessandkeepon.Ifyouhavetime,checklater
Dontgetstuckononequestion!Youmightendupmissing
thisoneandseveralothersifyourunoutoftime!

Cardiology

MustKnowECGs

Atrial fibrillation

Atrial flutter

MustKnowECGs

Torsades depointes

Ventriculartachycardia

MustKnowECGs

Ventricularfibrillation

MustKnowECGs

STelevationMI

MustKnowECGs

Acutepericarditis

MustKnowECGs

Pericardialeffusion

ArterialHypertension

DefinedbytwoseparateBPmeasurements> 140/90mmHg
Secondarycausesofhypertensionshouldbeconsidered,
particularlyifveryyoungorveryoldatonset
Pharmacologictherapyisstartedassoonasdiagnosisis
established,usuallywiththiazide diuretic(alwaysathiazide for
exams!)

Renovascular Hypertension
Fibromuscular Dysplasia

Usuallyaffectsthedistaltwothirds
andbranchesoftherenalarteries
inyoungwomen

AtheroscleroticDisease

Usuallyaffectstheproximalthirdof
therenalarteriesinoldermen

PrimaryHyperaldosteronism

Aldosterone increasesNa+reabsorption andK+excretion,

leadingtohypertensioninthesettingofresistanthypokalemia
alongwithmildhypernatremia
Test:renin :aldosterone ratio

Syncope
Mechanism
Vasovagal

Orthostatic
Subclavian steal
syndrome

Cardiogenic

Clue
Young females.Heraldedbydizziness,
diaphoresis,nausea.Situational.
Bradycardia withhypotension.
Older individuals.OrthostaticBPandHR
changes.Hypovolemia.
Syncopewhile combinghair.Occlusionof
thesubclavian arteryreversesflowin
vertebralartery. Stenosis canbedueto
cervicalrib,arteritis.
Valvular disease, cardiomyopathies,
arrhythmias

HeartMurmurs

Descriptionsareusuallyvague,somustrelyonothercluesfor
diagnosis
Unlikelytogetquestiononmaneuvers,butjustincase:
Allrightsidedmurmursincreaseduringinspiration,
EXCEPTpulmonarystenosis
AllmurmursdecreasewithValsalva andstandingfrom
squatting,EXCEPTmitralvalveprolapse andhypertrophic
cardiomyopathy

Pericardium

Thinkpericardiumwhenheartsoundsaremuffledordistant.
Thinkpericardialeffusionsandtamponade inthesettingof
acuteMI,renalfailure,malignancy,trauma
Hypotension
Enlargedcardiacsilhouette
Pulsus paradoxus (fallinBPduringinspiration)
LowQRSvoltages
Thinkconstrictivepericarditis whenthereislongstanding
historyofprogressiveheartfailuresymptoms

HeartFailure

Mostcommonetiologyofheartfailureisischemic
cardiomyopathy
Treatmentaccordingtostageofheartfailure
StageA Riskforheartfailurebutnostructuraldisease:
treathypertension,DM,considerACEinhibitors/BB
StageB Structuraldiseasebutnosymptoms:ACE
inhibitors/BB
StageC Symptoms:Digoxin,spironolactone,diuretics
StageD Refractorysymptoms:transplantation,
ventricularassistdevices,inotropes

ComplicationsofMI

Characteristic

VentricularSeptal
Rupture

VentricularFreeWall
Rupture

PapillaryMuscle
Dysfunction

Clinical
manifestations

Chestpain,shortnessof
breath,hypotension

Syncope,hypotension,
arrhythmia,sudden
death

Abruptonsetof
shortnessofbreath
andhypotension

Physicalfindings

Harshholosystolic
murmur,thrill,S3,
pulmonaryedema.

Pulsus paradoxus,
electromechanical
dissociation,shock

Asoftmurmurin
somecases,nothrill,
pulmonaryedema,

Rightheart
catheterization

Increaseinoxygen
saturationfromright
atriumtoright
ventricle,largev waves

Equalizationofdiastolic Largev wave,very

highpulmonary
pressuresamongthe
capillarywedge
cardiacchambers
pressures

Hypertesive Crisis
Hypertensiveemergencyisdefinedashypertension> 180/120
mmHgwithacutedysfunctionofoneormoreorgansystems
DecreaseMAPby25%withinthefirsttwohours,then
lowerBPslowlytoreachgoalBP.
UseIVmedications:betablockers,calciumchannel
blockersornitrates(betablockerspreferredovernitrates)
Hypertensiveurgencyisdefinedasseverehypertension
withoutevidenceofendorgandamage
Useoralantihypertensive

AorticDissection
Usuallypresentswithchestpainthatradiatestothe
interscapular areaanddelayedorabsentpulsesdistalto
dissection.
IfTypeA,maybeassociatedwithSTelevationsininferior
leadsduetoextensionintoRCA,acuteaorticregurgitation,and
pericardialeffusion(whichyoushouldnotdrainuntilyou
correctdissection!!!)
Ifsuspected,startIVbetablockerstoHR<60andSBP<120
andobtainimagingstudies.Avoidnitrates.
TypeAtreatedsurgically;typeBtreatedmedically.

ACLS

Wheneverapatientisunresponsive,thereisasystole,
pulseless electricalactivity,checkforthefollowing:
Hyperkalemia andhypokelamia
Hypothermia
Hypoglycemia
Hydrogen(acidosis)
Hypoxemia
Hypercapnea
Tamponade
Thrombosis(stroke,MI,PE)
Tensionpneumothorax

Endocarditis Prophylaxis

Bacterialendocarditis prophylaxisisrecommendedfor
patientswith:
Valvular replacement
Defectsrepairedusingprostheticmaterial
Priorhistoryofendocarditis
Unrepairedorincompletelyrepairedcyanoticcongenital
heartdefects
Hearttransplantwithanyvalvulopathy

Warfarin Overdose

INR

Management

INR<5.0;nosignificant
bleeding

Lowerdose

INR> 5.0but<9.0;no
significantbleeding

SkiponeortwodosesandmonitorINR
OR givevitaminK< 5mgPOifhighriskforbleeding

INR> 9.0;nosignificant
bleeding

Holdwarfarin therapyANDgivenvitaminK510mg
POandmonitorINR

Serious bleedingatany
INR

Holdwarfarin andgivefreshfrozenplasma
Mayalso supplementwithvitaminK10mg

OralvitaminKisthetreatmentofchoice,unlessthepatientcannottoleratePO
SubQvitaminKisslowerbutsaferthanIVvitaminK,whichmayinduceanaphylactic
reactionsandsuddendeathhasbeenreported

Pneumology

PulmonaryDiseasesoftheYoung
CysticFibrosis

Alpha1AntitrypsinDeficiency

Pathogenesis

Abnormalchloridetransport
Defectivegenefor enzyme,
leadingtothicksecretionsand leadingtoexcessive
bronchiectasis
destructionofelastin and
strutural proteins

Presentation

Apical emphysemaearlyinlife; Basalemphysemainthe30sto

shortlifeexpectancy.
40sofage.Autosomal
Autosomal recessive.
dominant.

Otherfindings

Exocrinepancreatic
insufficiency with
malabsorption
Chronicsinusitisandnasal
polyps
Staphylococcusand
Pseudomonasinfections

Liver cirrhosis

PulmonaryFunctionTests

Obstructive

Restrictive

FEV1

Verylow

Low

FVC

Normalorlow

Verylow

Very low

Normalorhigh

Increasedornormal

Decreased

FEV1/FVC
TLC
Examples

Emphysema
Chronicbronchitis
Bronchiectasis
Asthma

Pulmonaryfibrosis
Chest deformity
Neuromuscular
Morbidobesity

DecreasedDLCOareconsistentwithparenchymal disease;
IncreasedDLCOseeninalveolarhemorrhageandcongestiveheartfailure

BronchialAsthma
Usuallypresentswithshortnessofbreath,wheezing,non
productivecough
Precipitantsmayincludeexercise,upperrespiratorytract
infections,rhinitis,sinusitis,postnasaldrip,GERD,changesin
weather,andstress.
Associatedfindingsincludeallergicrhinitis,nasalpolyps,
asthatic shinersandatopicdermatitis.

BronchialAsthma

Characteristic

Controlled(allof
thefollowing)

Partlycontrolled
(anyoffollowing)

Uncontrolled

< 2times/week

>2times/week

Limitationof
activities

None

Any

Threeormore
featuredof
partlycontrolled
asthma

Nocturnal
symptoms

None

Any

Needfor
reliever/rescue
inhaler

< 2times/week

>2times/week

Lungfunction
(PEForFEV1)

Normal

<80%predicted

Daytime
symptoms

BronchialAsthma

CONTROLLED

STEP2
Addlowdoseinhaledcorticosteroid
STEP3
Addlongactingagonist
STEP4
Increasetomediumorhighdose
inhaledcorticosteroid
STEP5
Addoralcorticosteroid

UNCONTROLLED

STEP1
Rapidactingagonistasneeded

SolitaryPulmonaryNodules
Roundedopacitymeasuringlessthan3cm,notassociated
withinfiltrate,atelectasis oradenopathy
Evaluationshouldstrivetoidentifymalignantdiseasewithout
performinginvasiveproceduresinbenigndisease
Firstevaluateoldchestxraystoevaluategrowth
Inpatientsolderthan30andsmokers,thechancesoflung
cancerishigher,soconsidermorespecificimaging(eg,CTscan)
earlyon

Sarcoidosis
Usuallypresentsasasymptomaticbilateralhilar adenopathy
inanAfricanAmericanwomaninher40s
Somepatientsmaypresent:
Erythema nodosum
Hypercalcemia
Arthritis
Heartblock
Ventriculartachycardia
Constitutionalsymptoms

DeepVenousThrombosis
Wellscriteria:
Cancer
Paralysisorrecentcasting
Immobility>3days
Localveintenderness
Limbswelling
Unlitaral calfswelling>3cm
Pittingedema
Collateralsuperficialvein

DeepVenousThrombosis

PulmonaryEmbolism
Wellscriteria:
ClinicallysuspectedDVT 3points
AlternativediagnosisislesslikelythanPE 3.0points
Tachycardia>100bpm 1.5points
Immobilization> 3days 1.5points
Surgeryinprevious4weeks 1.5points
HistoryofDVTorPE 1.5points
Hemoptysis 1.0points
Malignancywithin6months 1.0points

PulmonaryEmbolism

LungCancer

CancerType
Squamous cell
carcinoma

Paraneoplastic Syndromes
Hypercalcemia (PTHrp) mostcommon
Hornerssyndrome(miosis,ptosis,
anhydrosis)duetoinvasionsympathetic
chain
Ulnar radiculopathy (Pancoast tumor)
Smallcellcarcinoma Cushingssyndrome
SIADH hyponatremia andconfusion
EatonLambert (Absagainstpresynaptic
Ca++channels) weaknessthatimproves
withexertion
Adenocarcinoma
Pulmonaryosteoarthropathy

CriticalCareMedicine

TypesofShock
TypeShock
Distributive

SVR

CO

PaOP

CVP

Cardiogenic

Obstructive

Hypovolemic

Examples
Septic
Anaphylactic
Adrenalcrisis
Neurogenic
AcuteMI
Heartfailure
Tamponade
PE
Pneumothorax
Hemorrhage
Burns

Nephrology

AcidBaseDisorders

Disorder
Metabolicacidosis
Metabolicalkalosis
Respiratoryacidosis
Respiratoryalkalosis

pH

pCO2

HCO3

AcidBaseDisorders
Startbyestablishingwhattheprimarydisorderis:
pH7.31
pCO2 34
CO2 16
Inthiscase,thisisametabolicacidosis.So,thesecondstepis
toverifyappropriatenessofrespiratorycompensation.
ExpectedpCO2iscentralCO2 +10.Inthiscase16+10=
26.AspCO2 ishigherthanexpected,thereisconcomitant
respiratoryacidosis.

AcidBaseDisorders
Thenextstepwhendealingwithmetabolicacidosisistocheck
aniongap:
Na+142
Cl 101
CO2 16
Aniongap=Na+ (Cl +CO2)=142 (101+16)=25
Sothisishighaniongap(>12)metabolicacidosis

MetabolicAcidosis
MetabolicAcidosis

Highaniongap

Normalaniongap

Ketones +

Ketones

DKA,alcoholic
ketoacidosis,
starvation

Lactic,uremia

Intoxication

Negativeurine
aniongap

Positiveurine
aniongap

Diarrhea,
dilutional

RTA

Osmolar gap

Noosmolar
gap

Methanol
Ethyleneglycol

Salicylates
Paraldehyde

AcuteRenalFailure

Incitingfactors
BUN/creatinine ratio
Urinarysodium
FENa+

PreRenal
Dehydration
Hypovolemia
Radiocontrast
NSAIDs
>20
<20mEq/L

Urineosmolality

<1%
>500mOsm/L

Urinesediment

Bland

Intrinsic
Toxins
Ischemia
Medications
<20
>20mEq/L
>1%
<350mOsm/L
Muddybrown
casts

AcuteRenalFailure
Theleastcommontypeofrenalfailureisobstructiveorpost
renal,butitisimportanttoidentifyasitisreversible
Recoveryfromacuterenalfailuremayleadtopolyuric phase,
inwhichfluidlossmustberepleted toavoidprerenal
azotemia.

Rhabdomyolysis
Cluetodiagnosisisurinarydipstickthatispositiveforbloodin
absenceofredbloodcellsinsediment.
Laboratoryanomaliesassociatedwithrhabdomyolysis
include:
Hyperkalemia
Hyperphosphatemia
Hypocalcemia

Nephrotic Syndrome
Nephrotic syndromeisdefinedas:
Proteinuria >3.5gm/24hours
Hypoalbuminemia
Edema
Hyperlipidemia
Systemiccausesinclude:diabetes,amyloidosis,multiple
myeloma
Causeslimitedtothekidneyinclude:minimalchangedisease,
focalsegmentalglomerulosclerosis,andmembranous
gromerulonephritis

Nephrotic Syndrome

Cause
Minimalchange
disease

Focal segmental
glomerulosclerosis
Membranous
glomerulopathy

PreRenal
Mostly inchildren,though10%inadults
MaybecausedbyNSAIDs
Goodprognosis
Tx:steroids
MostcommoninAfricanAmericans
Associatedwithheroinuse,HIV,andsickle
cellanemia
Associatedwithhepatitis B,syphilis,
endocarditis,SLE

NephriticSyndrome
Nephriticsyndromeisdefinedas:
Hematuria
Proteinuria
RBCcasts
Etiologiesinclude:
PostinfectiousGN
Membranoproliferative GN
Cryoglobulinemia
Goodpasteure
Vasculitis

Glomerulonephritis AfterURTI

Cause
Latentperiod

PostStreptococcal
Three weeksafter
infection
Usuallychildren

Findings

Lowcomplement
PositiveASLOtiter
Antibiotics

Treatment

IgA Nephropathy
Threedaysafter
infection
Mostcomon causeof
GN,especially inAsian
men
Normalcomplement
SerumIgA elevated
ACEinhibitors

Hyponatremia
Hyponatremia

Isoosmolar
(280295mOsm/kg)

Hypoosmolar
(<280mOsm/kg)

Nonosmolar substance
occupyinglargeportionof
plasma(hyperlipidemia,
hyperproteinemia)

Hyperosmolar
(>295mOsm/kg)
Osmolar ubstance
occupyinglargeportionof
plasma(hyperglycemia)

Hypovolemic

Euvolemic

Hypervolemic

Renalorextrarenal losses
(vomiting,diarrhea,
diuretics)

SIADH,psychogenic
polydypsia,
hypothyroidism

Congestiveheartfailure,
chronicliverdisease,
renalfailure

Gastroenterology

Dysphagia
EsophagealDysphagia
Intermittent
Solidsonly

Solidsandliquids

Progressive
Solidsonly

Solidsandliquids

Carcinoma
Esophagealrings

Diffuse
esophageal
spasms

NoHeartburn

Heartburn

Achalasia

Scleroderma

Malabsorption
Fatmalabsorption
(>7gm/day)
Dxylose test
Positive(serumlevel<25
gm/dL in1hour)

Negative(serumlevel>
25gm/dL in1hour)

Intestinalmalabsorption

Pancreaticinsufficiency

Trialantibioticsorglucose
breathtest

AbdominalxrayorCT
scan

Smallbowelbiopsy

ERCP

AcuteDiarrhea
Characteristics
Presentation

Causing agents

Inflammatory
Frequent,bloody,
smallvolume
Feverandcramps
Affectscolon
Fecalleukocytes+
Salmonella
C.jejuni
C.difficile
E.coliO157:H7
Shigella
Yersinia

Noninflammatory
Largevolume, watery
diarrhea
Nausea,vomiting
Affectssmallintestine
Fecalleukocytes
Bacilluscereus
Giardia lamblia
Enterotoxigenic E.coli
Staphylococcus
Vibrio cholerae
Norwalkvirus
Rotavirus

IrritableBowelSyndrome
Atleastthreemonthsof:
Abdominaldiscomfortrelievedbydefecation
Onsetofpainassociatedwithchangeinstoolfrequency
and/orconsistency
Usuallypresentswithassociatedsomaticsymptoms,suchas
musculoskeletalpain,headaches,fatigue,anxiety
Treatment:reassurance,education,andsupport;frequent
officevisits

IschemicColitis
Chronicischemiccolitispresentsaspostprandialpainand
bloatingleadingtoavoidanceoffood.Itresultsfrom
atheroscleroticdisease.
Acutebowelischemiapresentsasseverepainwithminimal
physicalexaminationfindings.Laboratoryanalysesmayshow
markedhighaniongapacidosis.Causesinclude:
Embolicocclusion(50%cases) lookforatrial fibrillation
Thrombosisofatheroscleroticvessel
Lowflowstateduetohemorrhageorshock

ColonCancerScreening

PatientHistory
No personalorfamily
history
Familyhistoryinarelative
olderthan60years
Familyhistoryinarelative
youngerthan60years
Personalhistoryofcolon
cancerfollowingresection

FrequencyofScreening
Colonoscopyatage50,then every10
yearsifnormal
Colonoscopyatage40,then every10
yearsifnormal
Colonoscopyat age40or10years
youngerthanrelativesageattimeof
diagnosis;thenevery5years
Colonoscopy every3years

HepatitisBSerology

Stage

HBsAg

Anti
HBsAb

Anti
HBcAb

HBeAg

Anti
HBeAb

AcuteHepatitis B
ChronicHepatitis B
Recoveryfrom
HepatitisB
Vaccination
againstHepatitisB
Falsepositiveor
pastinfection

+/
+

IgM
IgG

+/
+/

+/

IgG

+/

IgG

CluestoHepaticDisease
Etiology
Toxic hepatitis,
Acuteviralhepatitis,
Shockliver
Alcoholic hepatitis
Autoimmune
Nonalcoholic
steatohepatitis
Hemochromatosis

Clues
ASTandALT elevationscloseorabove
1,000IU/L
MaycauseincreaseinPT/INR
AST/ALTratio>2
ASTelevation<300IU/L
Usuallyinyoungwomen
Otherautoimmune conditionspresent
Obesefemale
AST/ALTratio <2
Skin discoloration
Diabetes,arthralgias

Jaundice

Pattern
Unconjugated
(indirect)

Mechanism
Increasedbilirubin
production
Impairedbilirubin uptake
Hepatocellular damage

Conjugated
(direct)

Obstruction toflow
Impaired secretionfrom
hepatocytes

Examples
Hemolysis
Gilberts
CriglerNajar
Toxichepatitis
Choledocholithiasis
Pancreaticcancer
Rotor
DubinJohnson

Ascitic Fluid
SerumAlbuminGradient

> 1.1g/dL
Transudate

<1.1g/dL
Exudate

Portalhypertension

Malignancy,tuberculosis,
pancreatitis

Ascitic fluidtotalprotein

<2.5g/dL
Livercirrhosis

>2.5g/dL
Congestiveheartfailure

Pancreatitis
Ranson Criteriadictateseverity:
Uponadmission:
Age>55years
WBC>16,000/mm3
Glucose>200mg/dL
AST>250IU/L
LDH>350IU/L
At48hours:
Calcium<8mg/dL
Hematocrit fall
PO2<60mmHg
BUNincreaseby>5mg/dL
Sequestrationoffluid

Rheumatology

Arthritis
Arthritis
Osteoarthritis

Pathogenesis
Findings
Degenerationof
Narrowingofjoint
cartilagedueto tear space
andwear
Knee obese
Hands hereditary
Rheumatoidarthritis Lymphocytic
Symmetricarthritis
infiltrationofjoint
Atleast3joints,
includinghands
Morningstiffness
Goutyarthritis
Depositionofurate
Monoarticular: toe,
monosodium
knees
Tophi
Pseudogout
DepositionofCa++ Chondrocalcinosis
pyrophosphate
Usuallyfollowing
dihydrate
surgery

Osteoarthritis

Bouchardsnodes

Hebedens nodes

Gout

Inpresenceoftophi,giveallopurinol
Foracuteattacks:NSAIDs

Goutvs.Pseudogout

Characteristic
Setting

Gout
Males,afteralcohol
consumption
Hyperuricemia

Crystals

Needlelikewith
negativebirefringens

Pseudogout
Olderthan60
Usually2448hours
aftermajorsurgery
Associatedwith
hemochromatosis
Rhomboidshaped
weaklypositive
birefringens

MuscularWeaknessSyndromes

Dermatomyositis

Polymyalgia
rheumatica

Polyarteritis
nodosa

Presentation

Proximalweakness
Heliotroperash
Grottons papules

Proximalmuscle
inflammationand
pain
Weakness
secondarytopain

Vasculitis with
sparingoflung
Footdrop
Renalfailure
Seizures

Findings

HighCPKandESR
AbnormalEMG

HighESR
NormalCPKand
EMG

HighESR andWBC
Anemia

Associations

Ovariancancer

Temporalarteritis

HepatitisBandC

Treatment

Highdose steroids

Lowdosesteroids,
unlesstemporal
arteritis present

Highdosesteroids,
cyclophosphamide

AutoimmuneDisordersInvolvingLungs

Wegeners
Granulomatosis

Goodpasteures
Syndrome

ChurgStrauss
Vasculitis

Presentation

Rhinosinusitiswith
nasalseptal
perforationand
saddlenose
Cough,hemoptysis
Glomerulonephritis

Nonasal
involvement
Glomerulonephritis
Alveolar
hemorrhage

Asthma
Eosinophilia
Fleeting infiltrates
Sinusitis
Neuropathy
Renalinvolvement

Antibody

CANCA

AntiGBM

PANCA

AutoAntibodies

Antibody
AntidsDNA
Antihistone
AntiSmith
Anticentromere
AntiSSA(Ro)
AntiSSB (La)
AntiCCP

Condition
SLE goodfordiagnosisandprognosis;
absentindruginducedlupus
Druginducedlupus
VeryspecificforSLE
Limited scleroderma
Scleroderma,Sjgrens
Sjgrens
Rheumatoidarthritis

MusculoskeletalComplaints
Bicipetal
Tendinitis
Presentation Anterior
shoulder pain,
worsebylifting
armoverhead
Worsewhen
lyingover
affectedside
Signs
Tendernessto
palpationlateral
toacromion
Difficultyto
abductshoulder

Lateral
Epicondylitis

Medial
Epicondylitis

Tenderness
causedbyuse
ofextensor
musclesof the
elbow

Tenderness
causedbyuseof
flexormusclesof
theelbow

Painby
resistedwrist
extension

Painby
resistedwrist
flexion

HematologyOncology

Anemia

Type
Normocytic
normochromic
Microcytic
hypochromic

Etiology
Anemiaof chronic
disease
Irondeficiency
Betathalassemia

Findings
Highferritin
Low ferritin andiron
RDW>15%
Normalferritin andiron
RDW<15%

HemolyticAnemias
Etiology

Mechanism
Membranedefects

Intrinsic

Oxydation
Hemoglobinopathies
Defective metabolism
Immunemediated

Extrinsic

Microangiopathic
Infection

Examples
Hereditary spherocytosis
Paroxysmalnocturnal
hemoglobinuria
G6PDdeficiency
Sicklecellanemia
Pyruvate kinase deficiency
Autoimmuneanemia
Drugtoxicity
TTP
DIC
Malaria

Aplastic Anemia

Fattyinfiltrationofbonemarrow,resultingindecreasecounts
inallcelllines.
Noabnormalcells,hepatosplenomegaly,lymphoadenopathy,
orbonetenderness.Retic countisdecreased.

Thrombocytopenia

Mechanism
Decreased production

Increaseddestruction

Sequestration
Pseudothrombocytopenia

Examples
VitaminB12defficiency
Leukemias
Aplastic anemia
ITP
TTP
DIC
Chronicliverdisease
Hypersplenism
False positiveduetoclumping

MultipleMyeloma

Plasmacellexpansion,
characterizedby:
Anemia
Proteinuria
Backpain
Recurrentinfections
Heartfailuresymptoms
Lytic bonelesions
hypercalcemia
Roleaux formationonblood
smear

Lymphoma

Hodgkin
NonHodgkin
Painlesslymphoadenopathy,
Retroperitoneal,pelvic,or
mostcommonlyofneckarea
abdominallymphoadenopathy
Usuallyinmales
Prognosisispoor
Contiguousspreadintothorax
andmediastinum
Prognosisisgood

BreastMasses PremenopausalWomen
Breastmass

Clinically
benign*
Mammogram

Cystic

Aspirate

Nonbloody&
resolves
Excisionif
recurrent

Clinically
malignant*
Mammogram

Solidbutbenign
looking

Possibly
malignant

Biopsy

Biopsyvs.
reexaminationin
14months
Biopsyif
persistent

*Clinicallymalignant:asymmetric
breasts,edema,erythema,bloody
discharge,nippleretraction,skin
retraction,poorlydemarcatedborders

BreastCancer

Breastconservingsurgerywithradiationisthepreferred
formoftreatment
Endocrinetherapy(eg,tamoxifen)isgivenforhormone
receptorpositivecases
Chemotherapyimprovessurvival,particularlyinnode
positive,hormonereceptornegative,and/orHER2/neu
positivecases
Trastuzumab maybeusedforHER2/neupositivecases

Endocrinology

DiabetesMellitus

Diabetesisdiagnosedbyanyofthefollowing:
Fastingglucose> 126mg/dL ontwooccasions
Plasmaglucose> 200mg/dL 2hoursafter75gmoral
glucoseloadingafterovernightfasting
Randomglucse > 200mg/dL withsymptoms
HgbA1c> 6.5%(screening,notdiagnostic)

Cushings
Usuallypresentwith:
Hypertension
Centralobseity
Easybruising
Amenorrhea
Diabetes
Striae

Cushings
Cushings
Low

SerumACTH

ACTHindependent

NormalorHigh

Highdosesuppression
test(8mg)

AbdominalCT
(adrenaltumor)

Suppresses=Pituitary

Doesnotsuppress=
ectopic

PituitaryMRI

Chest/abdominalCT,
somatostatin scan
Negative

InferiorPetrosal Sinus
Sampling

DiabetesInsipidus

Urine
osmolality

Normal

Central DI

Nephrogenic
DI

Psychogenic
polydypsia

Noincrease
(noADH)

Noincrease
(noresponse
toADH)

Partialincrease

After
dehydration

Increased

After
vasopressin

<5%increase >50%increase
(already
maximally
concentrated)

Lithiumcausesnephrogenic DI

Noincrease
Minimal
(noresponse increase(<9%)
tovasopressin) kidneys
concentration
abilityis
impaired

ThyroidDisorders

Characteristic

Hashimotos

Subacute
thyroiditis

Gravesdisease

Presentation

Painlessgoiter
withinitial
hyperthyroidism
followedby
hypothyroidism

Painfulgoiterwith
hyperthyroidism
followedby
hypothyroidism

Mostcommon cause
ofhyperthyroidism
withexophthalmos +
goiter

Etiology

Autoimmune
destructionof
thyroidgland

Viral

Antibodiesagainst
TSHreceptor

HormoneReplacement
TheindicationforHRTissymptomaticrelief.Forpreventionof
osteoporosis,tamoxifen maybeusedinstead.
Unopposedestrogentherapyincreasesriskofendometrial
cancer,soavoidinwomenwithintactuterus.
Progesteroneincreasesriskofbreastcancermoresothan
estrogen

FamilialHypercholesterolemia

LDLcholesterollevelsextremelyhighinthesettingoffamily
historyofprematurecoronaryarterydisease
Xanthomas common
DuetodecreasedconcentrationofordefectiveLDLreceptors

Allergy/Immunology

HypersensitivityReactions

TypeIreactionsareIgEmediated
degranulation ofmastcells(examples:
anaphylaxis,asthma,allergicrhinitis)

IgE

IgG

TypeIIreactionsconsistofcomplement
ativation duetoIgG adheringtocell
membraneantigens(examples:drug
reactions)

HypersensitivityReactions
IgG

TypeIIIreactionsareduetosoluble
antigensthatcreatecomplexeswithIgG
andactivatecomplementandphagocytes
(example:serumsickness)

TypeIVreactionsareduetoactivationof
Thelpercellsbymacrophagesupon
detectionofsolubleantigen(examples:
contactdermatitis)
TH1

InfectiousDiseases

Gonorrhea
Urethritis usuallysymptomaticinmale;symptomsinfemales
usuallywhenPIDhasdeveloped.
Gramnegativediplococci andWBCs
Concomittant Chlamydiainfection,sotreataswell
Pharyngealinfection
Disseminatedinfectionpresentswithpustular rash,
asymmetricarthritis

Syphilis

Primarysyphilispresentsaspainlesschancre
Secondarysyphilistypicallypresentspruritic rashoftheplms
andsoles
Tertiarysyphilismaycauseaortitis,damagetoCNS,
dementia,etc.

HIV/AIDS

ScreenallpatientsforHIV!
AIDSisdefinedby:
CD4+Tlymphocytecount<200cells/mm3
CD4+Tlymphocyte<14%oflymphocytes
AIDSdefiningconditions:esophagealcandidiasis,cervical
cancer,Kaposisarcoma,lymphoma,TB,Pneumocystis
jirovecii pneumonia,Toxoplasmosis,etc.

HIV/AIDS P.jirovecii

Usuallypresentsfever,cough,dyspnea,highLDH,lowpO2,
anddiffuseinterstitialinfiltrates.
SteroidsaddedtotherapyifSO2<90%,pO2<70%and/orA
agradient>35mmHg

Endocarditis
Majorcriteria:
Newregurgitant murmur
Bloodculturespositivefortypicalorganism
Typicalechocardiographic findings
Minorcriteria:
Riskfactors(ie,poordentition,IVdruguse)
Fever>38C
Embolicevents(ie,Janeway lesions,pulmonaryemboli)
Rheumatologicevents(ie,Rothspots,Oslernodes,ANA+,
glomerulonephritis)
Nontypicalechocardiographic findings
Nontypicalorganisminbloodculture

Endocarditis
RothsSpot
Whitecentered
retinal
hemorrhage

OslerNodes
Tender,red,
raisedlesions
onthefingers
andtoes
Janeway Lesions
Bacterialembolitoskinvessels

JarischHerxheimer Reaction
Sepsislikesyndromecausedbyantibiotictreatmentof
spirochetal diseasesduetoreleaseofbacterialendotoxins.
Seeninrelapsingfever,leptospirosis,syphilis,Lymedisease
Presentsusuallywithintwohoursofantibiotictherapywith
fever,chills,hypotension,tachycardia
Treatment:antiinflammatory drugs

LymeDisease
Tickbitefromendemicareas,lastingatleast24hours
Stage1consistsoferythema chronicum migrans atthesiteof
bite
Stage2maypresentwitharthralgias andheartblock
Stage3presentsneuropathy

LymeDisease
Tickbitefromendemicareas,lastingatleast24hours
(usually36hours).Iflessthanthistime,noneedfor
prophylactictreatment
Stage1consistsoferythema chronicum migrans atthesiteof
bite
Stage2maypresentwitharthralgias andheartblock
Stage3presentsneuropathy

MostCommon

Condition
Pneumonia
Sinusitis

MostCommonOrganism
Streptococcuspneumoniae
Haemophilus influenzae usedtobemore
commonbeforevaccine;
NowStreptococcuspneumoniae and
Moraxella catarrhalis

UTI
Catheterrelated
infections
Meningitis

Escherichiacoli
Staphylococcusepidermidis
Neisseria meningitidis

VaccinationsforAdults

PrecautionswithVaccines
Livevaccines,suchasVaricella,Zoster,andMMRare
contraindicatedinpatientswith:
HIVandCD4+Tlymphocytecount<200cells/mm3
Pregnancy
Immunocompromised state

Neurology

StrokeTerritories
Artery
Middlecerebral
artery
Posteriorcerebral
artery
Anteriorcerebral
artery
Vertebral artery

Findings
Aphasia (Wernicke orBroca)
Spatialneglect
Contralateral facialandarmparalysis
Verticalgazepalsy(3rd nerve)
Sensorydeficit
Agitation
Hyperactivity
Lefthandapraxia
Contralateral lossofposition and
vibratorysense
Contralateral hemiparesis

Dementia
Type
Alzheimers

Presentation
Mostcommon causeofdementia
Usuallyolderagebutyoungerpossible
withfamilyhistory
Multiinfarct
Second mostcommon
Riskfactorsforatheroscleroticdisease
Stepwiseprogression
Hungtintons disease Usuallybetween35and45yearsofage
Changedinpersonality
Jerky, randommovements
Lewy body
OverlapswithAlzheimersand
Parkinsons
Visualhallucinations

SerotoninSyndrome
Excessserotonergic activityasresultfromSSRIuse,overdose
orinteractionswithotherdrugs,aswellasuseofcertain
recrational drugs.
Symptoms:
Cognitive:Hypomania,confusion,hallucinations,agitation
Autonomic:Shivering,sweating,hypertension,
tachycardia,nausea,diarrhea,hypertheremia
Somatic:Myoclonus,hyperreflexia,tremor

Neuroleptic MalignantSyndrome
Adversereactiontoneuroleptic orantipsychoticdrugsaswell
aswithdrawalfromanticholinergic drugs(ie,Parkinsons)
Symptomsinclude:
Musclerigidity
Fever
Autonomicinstability
Delirium
HighCPK
Treatment:dantrolene,bromocriptine,benzodiazepines,
antipyretics

MyastheniaGravis
Autoantibodies bindtoacetylcholinereceptors,causing
weaknessandfatiguethatincreaseswithmuscleuseand
improveswithrest(oppositetoLambertEatonsyndrome)
Usuallyassociatedwiththymoma
Anticholinesterase drugsmaybehelpful(ie,Neostigmine,
pyridostigmine)
Crisismaybetreatedwithplasmapheresis orintravenous
immunoglobulin

Headaches
Type
Migraine

Cluster

Tension

Presentation
Lateralized,dullorthrobbing
Associatednausea, anorexia,
photophobia,phonophobia
Familyhistory
Treatment:sumatriptan,NSAIDs,
ergotamine
Prevention:propanolol,SSRIs
Behind andaroundtheeyewith
lacrimation,flushing,nasalcongestion
Usuallyseveraldaysinarow
Treatment:oxygen
Bandlike aroundhead
Treatment:NSAIDs,amitryptiline

PeripheralNeuropathies

Type
Ulnar nerve
Radialnerve
Mediannerve

Presentation
Clawhand
Commonincyclists
Wristdrop
Saturdaynightpalsy
Carpaltunnelsyndrome
Mostcommoncauseispregnancy

Dermatology

RashestoKnow

Erythema multiforme isassociatedwithherpessimplexvirus,

Mycoplasma pneumoniae,andcertaindrugs,mostly
antibiotics.
StevensJohnsonsyndromeisseveremanifestation.Treated
withIVIg

RashestoKnow

Rosacea presentsaserythema andtelangectasia ofthe

cheeksandnose,usuallyprecipitatedbyalcohol,emotions,
andheat
Treatment:topicalmetronidazole ororaltetracycline

RashestoKnow

Pytiriasis rosea presentsasoval,fawncoloredplaquesthat

followcleavagelinesonthetrunkcreatingaChristmastree
pattern
Heraldpatchusuallyprecedeseruptionby12weeks.
Treatment:UVlight

RashestoKnow

Psoriasisisanautoimmunemanifestationcausingsilvery
whitescalesorplaques
Maybeassociatedwithpsoriaticarthritis
Treatment:topicalcorticosteroids,phototherapy

RashestoKnow

Acanthosis nigricans presentsasvelvety,patchydiscoloration

offlexuralareas
Associatedwithinsulinresistance,PCOS,acromegaly,and
malignancy

SkinCancers
Type

Appearance

FactstoKnow

Melanoma

The mostimportantfactorfor
prognosisisdepthofthelesion
Sunexposureishighestrisk
factor
Highriskformetastasis

Squamous cell
carcinoma

Hardraisededgednecrotic
ulcers
Actinickeratosis predisposes
Sun exposureandsmokingare
riskfactors

Basalcell
carcinoma

Sun exposureisriskfactor
Presentsclearlydefinedmargins
withtelangiectasia
Metastaticpotentialislow

KaposisSarcoma

AIDSdefiningneoplasmcausedbyHerpesvirus 8
Reddishbrownnodulesorblotches,usuallypapular,typically
foundonsunexposedskin

Blisters

Cause
Pemphigus vulgaris

FactstoKnow
Painfulbullae
PositiveNikolskys sign
Treatment:coticosteroids,IVIg

Bullous pemphigoid

Noacantholysis NegativeNikolskys sign

Treatment:topicalsteroids

Epidemiology

NumberNeededtoTreat
Simplycalculateabsoluteriskreductionin%:
ARR=8% 5%=3%

Thendivide100byabsoluteriskreduction:
NNT=100/ARR=100/3=33

Question
Healthy

Diseased

Aboveisshowndistributionoftestresultsforscreeningofprostate
cancer.Thearrowindicatesthecutoffpointatwhichthetestis
consideredpositive.
Whichofthefollowingistrue?
a.
b.
c.
d.

Specificityishigh;sensitivityislow
Specificityislow;sensitivityishigh
Bothspecificityandsensitivityarelow
Bothspecificityandsensitivityarehigh

Sensitivity

Sensitivityistheabilityofatesttoidentifyindividualsafflictedby
adisease
Sensitivity= Individualswithdiseaseandpositivetest
Allindividualswithdisease
=

Truepositive
Truepositive+Falsenegative

Specificity

Specificityistheabilityofatesttoidentifyhealthyindividuals
Specificity= Healthyindividualswithnegativetest
Allhealthyindividuals
=

Truenegativetests
Truenegative+Falsepositive

PositivePredictiveValue

PPVistheprobabilityofapositiveresultpredictingtruedisease
PPV=

Truepositiveresults
Allpositiveresults

Truepositive
Truepositive+Falsepositive

NegativePredictiveValue

NPVistheprobabilityofanormalresultpredictingabsenceof
disease
NPV=

Truenegativeresults
Allnegativeresults

Truenegative
Truenegative+Falsenegative

GoodLuckontheExam!