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USMLE WORLD: MEDICINE

y Primary Adrenal Insufficiency: hypotension, pigmentation, hyponatremia, hyperkalemia, eosinophilia, elevated ACTH, low cortisol. MCC in developed countries is autoimmune adrentalitis with Ab against steroidogenic enzymes. History of other AI diseases (especially endocrine). Endocarditis: fever, generalized weakness, new right sided heart murmur (increase with inspiration). History if IVDA and cellulitis. Staph if IVDA, strep and entero if not. Vancomycin is most commonly used as empiric therapy in IVDA due to MRSA coverage. Folic Acid Deficiency: present with megaloblastic anemia. MCC is poor diet and alcoholism. Phenytoin, primidone, phenobarbital inhibit folate absorption. TMP and methotrexate inhibit DHFR causing folate deficiency. Huntingtons Disease: autosomal dominant that presents 30-50 years. Mood disturbances (depression, apathy), dementia, choreiform movements, positive family history. Symptoms are progressive -> severe disability. UTI: lower abdominal discomfort, burning, increased frequency, suprapubic tenderness, significant bacteriuria. Predisposing factors: antibiotics, genital infections, contraceptives (diaphragm, spermicide), poor hygiene. Occur via ascending route. Systemic Sclerosis: affects all organ systems. Cutaneous findings are that of scleroderma. Thickening of the skin, edema -> obliteration of hair follicles and sweat glands and flexion contractures. Mask like appearance to face. Myofibroblast proliferation -> increased collagen and ground substance production. Kidney involvement -> hypertension. Pulmonary hypertension -> right heart failure. Esophageal and gastric dysmotility -> GERD. Find ANA and anti-topoisomerase I antibodies. Clostritidum difficile Diarrhea: antibiotic treatment predisposes. Diffuse watery, non bloody, diarrhea with abdominal cramps and fever. Nausea, vomiting, elevated WBC. Toxin to intestinal epithelial cells. Detect toxin in the stool. Treat with IV/oral metronidazole. Oral vancomycin can also be used. Acute Limb Ischemia: sudden decrease in perfusion that threatens limb vitality and presents 2 weeks of symptom onset. Pain, pulselessness, pallor, parasthesias, paralysis. Due to embolism (MCC), thrombosis, trauma. Atrial fibrillation -> embolism. Prevent with warfarin. Essential Tremor: action/intention tremor in the absence of other neurological signs. Difficulty holding newspaper, writing legibly, drinking coffee, feeding themselves. Treat with beta blocker (propranolol). Primidone or topiramate also work. BZDs can be helpful but run risk of addiction. Creutzfeldt Jakob Disease: rapidly progressive dementia, myoclonus, sharp periodic bi/triphasic synchronous discharges on EEG. Caused by a prion -> spongiform encephalopathy. CSF is usually normal. Most patients die within 1 year. Rotator Cuff Tendonitis: shoulder pain with reaching or lifting arm overhead. Due to repetitive activity at shoulder height (painters), MC in middle aged/older. Confirmed on PE by Neer test with pain and guarding. Confirmed with lidocaine injection -> improvement. MRI for definitive diagnosis. HIV Infection: increased risk of viral, bacterial, fungal, protozoan infections. Need vaccinations at diagnosis, especially influenza, hepatitis, Strep pneumo. MMR is necessary

(measles can be fatal in HIV). Can give with CD4 > 200, and no history of AIDS defining illness. y Lung Adenocarcinoma: least association with smoking. MC type of lung cancer, even in non smokers. Located peripherally. Columnar cells growing along septa. Presents as solitary nodule. Bronchoalveolar type is most important. Related to pulmonary scars as in fibrosis. Metastisizes early to adrenals, bone, CNS. HIV: presents with nonspecific symptoms such as weight loss, malaise, neurological changes, anorexia, weight loss. Usually present early, can present late with PJP or Candida esophagitis. HIV Dementia: waxing and waning, difficulty with complex tasks, poor memory, apathy. Mixed Cryoglobulinemia:palpable purpura, proteinuria, hematuria, non-specific systemic symptoms, arthralgias, hepatosplenomegaly, hypocomplementemia, peripheral neuropathy. Demonatrate circulating cryoglobulins to confirm. Usually have underlying HCV infection. Acute Cord Compression: back pain with associated tenderness at the site of metastasis (usually prostate). Progressive or sudden compression with neurological deficit can ensue. Medical emergency that needs prompt treatment. First do neurological exam for signs of myelopathy (if so, give steroids). Then do MRI or CT myelogram if no MRI. Radiotherapy to treat. Respiratory Acidosis: decreased pH, primary increase in PCO2. Along with low PO2 levels, suggest alveolar hypoventilation (MCC). Causes: pulmonary/thoracic (COPD, OSA, CF, obesity, scoliosis, ankylosis), neuromuscular (MG, LE, poliomyelitis, muscular dystrophy, GBS, ALS), drug induced (anesthesia, narcotics, sedatives), primary CNS (brainstem lesion, infection, stroke). Bronchodilator Response Test: used to demonstrate reversibility if airway obstruction. Differentiates COPD from asthma, but subset of COPD will have airway reactivity (diseases are on a continuum). Measure FEV1 before and after bronchodilator (beta agonist). Increase of 15% needed for reversibility. Low DLCO and CT findings support COPD. Iron Deficiency Anemia: hypochromic/microcytic anemia, low iron/ferritin. MCC is chronic blood loss. Can be caused by dietary deficiency or malabsorption. Adult male or post menopausal female -> test for occult blood in stool. PUD, angiodysplasia, diverticulosis are other causes. Niacin: used to treat lipid abnormalities. Frequently produces flushing and pruritis due to vasodilation. Caused by drug induced release of histamine and PG. Low dose ASA can help alleviate if taken 30 minutes prior. Usually improve after 2-4 weeks of therapy. TCA Overdose: CNS depression, hypotension, hyperthermia, anticholinergic effects (dilated pupils, blocks SLUD). Decreases myocardial conduction velocity -> wide QRS (best indication of extent of OD) -> ventricular arrhythmia. Treat with NaHCO3 (narrows QRS). Renovascular Hypertension: headache, elevated BP, renal bruit due to RAS (fibromuscular dysplasia in young women, atherosclerotic in older). Interventional therapy is better than medical alone. Attempt angioplasty and stent. If patient is older, not good candidate or refuses surgery, can use medications alone (ACE and diuretics). Generalized Resistance to Thyroid Hormones: hypothyroid can be caused by thyroid (primary), pituitary (secondary), hypothalamus (tertiary), or GRTH. Results from receptor defects on peripheral tissues. Present early with growth and mental retardation. Elevated thyroid hormones and normal/elevated TSH. Features of hypothyroid with elevated T3/T4.

Lambert Eaton Syndrome: caused by Ab against voltage gated calcium channels in presynaptic motor nerve -> decreased Ach release -> proximal muscle weakness and loss of DTR. History of features of SCC of the lung. Muscle response increases with repetitive simulation. Treat with plasmapheresis and immunosuppressants. Myasthenia Gravis: caused by Ab to postsynaptic receptors -> reduction of Ach receptors -> muscle weakness and preservedor brisk DTRs. History of features of SCC of the lung. Muscle response decreases with repetitive stimulation. Microangiopathic Hemolytic Anemia: elevated serum LDH and schistocytes. Have decreased haptoglobin, reticulocytosis, elevated indirect BRN. One cause are artificial valves. Pulseless Electrical Activity: presence of rhythm with no palpable pulses. Any patient with arrest with nonshockable rhythm (anything other than VF/VT) -> give CPR, establish airway, give 100% O2. Atrial fibrillation is not a shockable rhythm during arrest with no pulses. IV access for epinephrine, vasopressin, atropine. Caused by 6Hs (hypovolemia, hypoxia, hydrogen/acidosis, hypoglycemia, hyper/hypokalemia) or 6Ts (tamponade, tension pneumothorax, thrombosis/MI/PE, trauma/hypovolemia, tablets/drugs, toxins). Vitamin B12 Deficiency: common after total or partial gastrectomy (gastric derived IF binds B12 and facilitates absorption in the stomach). Necessary cofactor for demethylation of methyl-THF -> THF needed for purine synthesis. Other causes: pernicious anemia, gastritis, intestinal disorders, old age. Presents as megaloblastic anemia with glossitis and neurologic changes. Aortic Dissection: three clinical findings: abrupt onset tearing pain in chest or back, variation in pulse/BP between arms, wide mediastinum on CXR. Tear in intima -> subintimal hematoma. HTN, smoking, family history of CAD. May extend into pericardium, CA, carotids > tamponade, MI, stroke. Nephritic Syndrome: dependent edema, hypertension, hematuria with or without dysmorphic RBC or RBC casts. Decreased GFR -> fluid overload -> weight gain, hypertension, exertional dyspnea. Rash, low grade fever possibly due to systemic disease. UA -> RBC with or without casts. May have proteinuria. Biopsy to determine exact type of GN. Testicular Cancer: AFP, beta-HCG, placental ALP are useful for diagnosis, staging, monitoring patients. Seminoma: PLAP, embryonal carcinoma: AFP + beta-HCG (50%), choriocarcinoma: beta-HCG. LDH and CEA have some use but are non-specific. Pneumocystis Jiroveci Pneunonia: an important cause of progressive dyspnea and hypoxia in HIV/AIDS patients. Hypoxia in pneumonia results from alveolar and interstitial inflammation -> V/Q mismatch -> increased A-a oxygen gradient. Polymyositis: inflammatory muscle disease. Slowly progressive proximal muscle weakness > difficulty standing or climbing stairs, difficulty combing hair or working overhead. Muscles of mastication and facial expression are spared. May develop dysphagia due to involvement of upper pharyngeal muscles. Weakness is primary, may have mild tenderness. Muscle biopsy is diagnostic. Shows mononuclear infiltrate surrounding necrotic/regenerating fibers or overt fibrosis. COPD: recurrent pulmonary infections, chronic cough, smoking history, increased AP diameter, wheezing. Chronic hypoxemia -> constriction of pulmonary arterial system -> pulmonary hypertension -> RVH -> RVF -> elevated JVP, hepatosplenomegaly, hepatojugular reflex, lower extremity edema. NO PULMONARY EDEMA.

Lactic Acidosis: if results from poor O2 delivery to tissues is called type A. Shock and CO poisoning are causes. CO binds with high affinity to Hgb -> displaces O2 -> decreases O2 content and causes left shift of Hgb O2 dissociation curve -> decreased unloading of O2 -> increased anaerobic metabolism -> lactic and anion gap metabolic acidosis. Acute Pancreatitis: pain radiating to the back, leukocytosis, elevated serum amylase and lipase. Causes acute abdomen. Managed conservatively with analgesics (meperidine or fentanyl), IVF, NPO. Can use NG if necessary to decrease gastrin release. Dipyridamole: is a coronary vasodilator along with adenosine. With CAD, diseased arteries are maximally dilated and cannot increase blood flow and is redistributed to non-diseased segments. Used during myocardial perfusion scanning to reveal areas of restricted perfusion. Redistribution of coronary blood flow to non-diseased segments is called coronary steal. Hypertensive Hemorrhage: focal neurological signs that gradually worsen over minutes to hours. Onset is not abrupt like SAH or embolism. Can develop HA, vomiting, altered mental status. MC site is the putamen (35%). Internal capsule is adjacent -> hemiparesis. Can have hemi-sensory loss, homonomous hemianopia, stupor, coma. Eyes deviate away from paralytic side. Amiodarone: causes pulmonary toxicity. Avoid in patients with pre-existing lung disease. Can cause chronic interstitial pneumonitis, organizing pneumonia, acute respiratory distress syndrome. Side effects are dose dependent. Rheumatoid Arthritis: symmetric polyarthritis, ulnar deviation, swan neck, boutonniere, morning stiffness > 1 hour. Fever, weight loss, malaise. Lab tests show rheumatoid factor and anti-cyclic citrullinated peptide. Radiographs show joint erosions, juxta-articular osteoporosis, narrowing of joint spaces. PIP and MCP joints are affected. DMARDs are used early to promote remission. First line is methotrexate. Can also use hydroxychloroquine, sulfasalazine, leflunomide, etanercept, infliximab, azathioprine. Postoperative Cholestasis:hypotension, extensive blood loss into tissues, massive blood replacement. Jaundice due to increased pigment (transfusions), decreased liver function (hypotension), decreased BRN excretion (tubular necrosis). Breaking Bad News: o Quiet, private, comfortable environment o Ask patient how much they know or what they think o Ask patient how much they want to know o Give warning shot saying you have bad news o Break the news if they want you to o Give prognosis, keep aware of options available o Explain everything as clearly and simple as possible Tamoxifen: mixed agonist and antagonist on estrogen. Reduces risk of recurrence and new cancer in the other breast. Increases endometrial cancer and uterine sarcoma. Also have increased risk of venous thrombosis. Celiac Disease: intermittent abdominal distension, flatulence, greasy stool. Iron deficiency is one of the most common presentations (iron absorbed in duodenum). Dermatitis herpetiformis is also associated (chronic intensely burning pruritic papulovesicular rash) with granular IgA deposits in upper dermis. Atypical Mycobacterium: HIV infected, unexplained fever, cough, CD4 < 50, no history of or exposure to tuberculosis. If CD4 < 50, give azithromycin as prophylaxis.

Migraine: suspected with unilateral headache with a pulsatile quality, especially if accompanied by vomiting and photophobia. Sometimes have an aura of neurological symptoms. No concerning features are present. Give IV antiemetics (chlorpromazine, prochlorperazine, metoclopramide) acutely solo or with NSAIDS. Triptans can also be effective if used early in course of migraines. Diarrhea in HIV: Salmonella, Shigella, Campylobacter, C diff, Giardia, Cryptosporidium, Mycobacterium avium complex, CMV. Evaluate with stool culture, O&P, and test for C diff toxin. Complicated GERD: dysphagia, odynophagia, weight loss, overt or occult bleeding, iron deficiency anemia in addition to typical symptoms. Endoscopy is indicated and possible biopsy. Endoscopy is also indicated if medications fail. pH monitor if (-) endoscopy. Inflammatory Monoarthritis: septic, trauma, crystal induced. Septic should be considered until proven otherwise. History of RA predisposes to septic arthritis, especially with Staph aureus. Do fluid analysis, gram stain, culture. Treat with antibiotics and joint drainage. Staph Aureus Pneumonia: most often affects hospitalized patients, nursing home residents, injection drug users, patients with CF, people with recent influenza. Serious complication of influenza. G(+) clusters on gram stain. Treat with antibiotics. Necrotizing Fasciitis: infection involving fascia of deep muscles. Occurs after trauma or foreign bodies. GAS or Staph aureus are usual cause. Sudden onset pain and swelling. Purple discoloration and gangrene. Systemic signs of toxicity can be present. Surgical debridement is necessary and antibiotics (ampicillin+sulbactam and clindamyacin). History of DM. Vanishing Bile Duct Syndrome: progressive destruction of intrahepatic bile ducts with ductopenia on biopsy. PBC is MCC of ductopenia in adults. Toxic Adenoma: clinical features and lab findings of hyperthyroid with iodine scan showing uptake in one area and suppression of rest of gland. Do not have infiltrative ophthalmopathy. Emphysema: permanent airway destruction without obvious fibrosis. Smoking cessation and home O2 therapy are the only two things shown to decrease mortality. Myasthenia Gravis: decreasing muscular strength with continued contraction. A disease of the NMJ. Fluctuating weakness in voluntary muscles -> diplopia, ptosis, extremity weakness. Extraocular symptoms are the most common. Medial Medullary Syndrome: contralateral spastic hemiplegia, contralateral vibration and proprioception loss, tongue deviation towards injured side. Occlusion of vertebral artery or one of branches. Acute Pain: all patients should receive same standard pain management regardless of drug history. Use IV morphine. Never undertreat pain even with risk of abuse. Frequently reassess, outpatient follow up, referral to pain specialist if abuse is suspected. Chronic Wounds: until proven otherwise, suspect SCC in a chronic wound -> non-healing, painless, bleeding ulcer. SCC is cancerous changes in the mid epidermis -> extension into dermis. Skin and mucous membranes can be affected. Sun-exposed or burn areas are involved. Rough scaly nodules -> ulcerate -> metastasize. Tar derivatives, carcinogens, radiation predispose. Immunosuppression increases risk. Punch biopsy confirms.

Pellagra: dietary deficiency of niacin, common in people on corn based diets. Also in alcoholics, carcinoid syndrome, Hartnups disease. Triad of Ds: diarrhea, dermatitis in sun exposed areas, dementia. Untreated -> death. Cardiac Arrest: leading cause for witnessed, outside hospital events is ventricular arrhythmia. Immediate defibrillaion in the first 4-5 mins improves survival. For unwitnessed or when defibrillator is not available, 2 mins CPR prior to shock improves survival. Myasthenia Crisis: weakness of respiratory/pharyngeal muscles that is life threatening. Treat with intubation and withdrawl of anti-AChE for several days. MCC is intercurrent infection, also use antibiotics. Monitor PFTs bedside when suspected. Thyrotoxicosis: weight loss, irritability, tachycardia, tremors, lid retraction. Systolic HTN and increased PP. Hyperdynamic state -> HTN. Due to increased myocardial SR Ca-dependent ATPase, or decrease in Ca-inhibiting protein and phospholamban. Increased sensitivity to catecholamines by increasing adrenergic receptors. Can cause high output failure. PCP: bilateral interstitial opacification, no hilar LA, cavitation, pleural effusion, cardiomegaly. Mycoplasma or Chlamydia also suspected. DOC is TMP-SMX or pentamidine. Also give azithromycin until PCP confirmed and evaluate for HIV infection. Nephrotic Syndrome: proteinuria (>3-3.5 g/day), hypoalbuminemia, edema, hyperlipidemia, lipiduria. Altered permeability of GBM due to MCD, membranous, MPGN, FSGN, mesangial proliferative. Complicated by hypercoagulation due to loss of antithrombin 3. Renal vein thrombosis, arterial thrombosis, PE can occur. Can cause protein malnutrition, iron resistant microcytic hypochromic anemia due to transferrin loss, vit D deficiency due to loss of cholecalciferol binding protein, decreased thyroxine levels due to loss of thyroxine binding globulin, increased susceptibility to infection. Absence Seizures: sudden cessation of ongoing mental activity, < 30 seconds. Return is also abrupt. No post ictal state or confusion. Diagnosed by EEG with activation procedures. Atrial Fibrillation: causes LV diliation and decreased EF due to tachycardia, no atrial kick, AV dissociation. Control rate and/or rhythm to improve LV function. AAA: surgery if > 5 cm, rapid rate of growth, symptoms present. If smaller, do periodic imaging. Atherosclerosis is precipitant. Smoking is major RF for formation, enlargement, rupture. Cessation is best intervention to slow progression. Confounding: bias that results in exposure-disease relationship with effect of extraneous factors. Influence both exposure and outcome. Match case and control based on confounding factor or stratify based on confounding factor. Pulsus Paradoxus: usual drop in systolic pressure during inspiration is < 10 mm Hg due to increased venous return to right -> impeding LV filling. PP when drop in systolic > 12 mm Hg with inspiration. Caused by tamponade, tension pneumothorax, severe asthma (elevated intrathoracic pressures -> impedence of LV pumping). HNPCC: Amsterdam Criteria I: at least 3 relatives with CoCa with one being first degree of other 2, > 2 generations, one before 50 y/o, FAP excluded. Lynch I is hereditary site specific CoCa. Lynch II is cancer family syndrome and high rate of extracolonic tumors. MC is endometrial cancer (43% of affected females). Isoniazid: causes hepatits picture via idiosyncratic liver injury with histological features similar to viral hepatitis.

Drug Induced Liver Injury:rash, fever, arthralgias, leukocytosis, eosinophilia. Occurs via direct cytotoxic effects or idiosyncratic reaction. Direct is dose dependent with short latent periods (tetrachloride, Tylenol, tetracycline). Idiosyncratic is not dose dependent with variable latent periods (INH, chlorpromazine, halothane, antiretrovirals). Catagorized by morphology: 1) Cholestatic, 2) Fatty liver, 3) Hepatitis, 4) Toxic/fulminant liver failure, 5) Granulomatous. Acute Bronchitis: common cause of blood tinged sputum due to virus. Lack of history or physical indicating more severe disease. Have malaise, throat pain, wheezing. No fever (rules out pneumonia). Weight loss or more blood suggest TB or malignancy. Observe and follow. Howell Jolly Bodies: nuclear remnants in RBCs usually removed by spleen. Single, round, blue inclusions on Wright stain. Usually due to physical or functional asplenia due to infarction, infiltration, congestion. Fibromuscular Dysplasia: MCC secondary HTN in children. Also seen in premenopausal women. Have hum or bruit at CVA due to collateral circulation. Right more affected than left. Angiography shows string of beads pattern. Anemia of Chronic Disease: usually normocytic. Decreased iron, TIBC, transferrin. Ferritin can be normal or high. Involves iron trapping by macrophages. Associated with chronic inflammatory conditions, heart disease, DM, acute inflammation. Treat underlying cause. Saline Responsive Metabolic Alkalosis: urine chloride < 20 mEq/L and due to GI proton loss (ex vomiting in bulimia), volume depletion, diuretic abuse. Treat with isotonic saline infusion. Antihistamines: first generation anti-H1 (diphenhydramine, chlorpheniramine, doxepin, hydroxizine) have anti-Ach effects -> dry eyes, mouth, respiratory tract, urinary retention due to failure of contration of detrussor (worse in patients with BPH), and dysuria. Hypertrophic Cardiomyopathy: crescendo-decrescendo systolic murmur along LSB without carotid radiation. Location and no radiation differ from AS. Symptoms of syncope (due to outflow obstruction, arrhythmia, ischemia, baroreceptor -> vasodilation), dyspnea, chest pain. Left ventricular hypertrophy is present. Diabetic Nephropathy: starts with hyperfiltration (increased GFR) and microalbuminuria. Progresses to macroproteinuria (> 300 mg/d) and decreased GFR. Intensive BP control reduces decline in GFR, < 130/80. ACE and ARB are preferred and decrease decline GFR in patients with significant azotemia and proteinuria > 1 g/d. Hyperkalemia can ensue. Confidence Interval: mean + standard score (z) * Standard Error of Mean (SD/root n). As SD increases, SE and CI increase. As n increases, SE decreases. Larger CI indicates wider range of effects. Boerhaave Syndrome: spontaneous esophageal rupture. Acute, severe chest pain or epigastric pain after retching. Fever and dyspnea common. No hematemesis. See tachycardia, tachypnea, subcutaneous ephysema, widened mediastinum, contrast extravasation from swallowing. Pleural fluid has high amylase, low pH, can contain food. False Negatives: patients with negative test who have the disease. When cutoff levels are raised, FN increase. Neurofibromatosis: neurocutaneous syndrome. Autosomal dominant, chromosome 22. Type I has caf-au-lait spots, axillary freckles, Lisch nodules of iris, neurofibromas, bony lesions.

Type II has brain tumors especially BL acoustic neuromas (diagnostic). Develop CNS, PNS, skin, visceral tumors. y Sturge Weber: neurocutaneous syndrome. Port wine stains in V1 distribution, angiomatous malformations of the brain, seizures, hemiparesis. Tuberous Sclerosis: neurocutaneous syndrome. Ash leaf hypopigmentation, cardiac rhabdomyomas, kidney angiomyolipomas, mental retardation, seizures. Hypercalcemia: malignancy is a common cause via cytokines, PTHrP, calcitriol, ectopic PTH. Metastases to bone cause osteolysis due to IL-1 and TNF (usually lung and breast). With non metastatic solid tumors produce PTHrP -> low PTH levels. Ovarian, lung, neuroectodermal tumors can ectopically produce PTH. Hodgkins disease has increased calcitriol. Hypertension and Hypokalemia: caused by primary hyperaldosteronism, renovascular disease (2 most common), renin secreting tumor, syndrome of apparent mineralocorticoid excess, some forms of CAH, glucocorticoid suppressible hyperaldosteronism. Primary HA has low plasma renin activity, renovascular disease has high plasma renin activity. Obstructive Uropathy: flank pain (capsular distension), poor urine output (obstruction), intermittent high volume (obstruction overcome). UA shows RBC and WBC but no casts. Mutations: nonsense and frame shift mutations are typically more severe than missense or splice site mutations. Silent (same sense) mutations do not affect the protein structure. Renal Cell Carcinoma: usually asymptomatic. Classic triad: flank pain, hematuria, palpable abdominal renal mass, only seen in 10%, suggests advanced/metastatic disease. Hematuria is frequent (40%). Varicoceles (usually left) fail to empty when patient lies down. Increased erythropoietin -> polycythemia, thrombocytosis. Abdominal CT to diagnose. Bacterial Pharyngitis: MCC is GAS. Fever, painful cervical LA, exudative pharyngitis. Viral pharyngitis: conjunctivitis, rhinorrhea, exanthum. Lots of overlap -> confirm with rapid strep test. Penicillin V to treat. (+) rapid strep do not need culture confirmation, (-) do. OSA: recurrent transient obstruction of upper airway due to pharyngeal collapse. Patients are overweight, have excessive daytime sleepiness, snoring, morning headaches, impotence, HTN. Hypoxia -> erythropoietin -> polycythemia. Treatment improves polychythemia. Scatter Plots: useful for crude analysis. Can demonstrate association (linear or non-linear) if one is present. If linear, correlation coefficient can be calculated. Hemi Neglect: patient neglects one side and only senses the other. May only shave, comb, ignore people on one side. Ask patients to fill in clock, will only fill in one side. Caused by lesion in right (non-dominant) parietal lobe, responsible for spatial organization. Hemoptysis: can be blood streaked sputum to massive with respiratory failure. Airway disease (bronchitis, bronchiectasis, trauma, tumors) are MCC. Parenchymal disease (infections, diffuse alveolar hemorrhage), and vascular (AV malformations, PE). With significant smoking -> think chronic bronchitis. Do CXR to check for cancer. Anemia in ESRD: normocytic, normochromic due to erythropoietin deficiency. Attempt iron first, then erythropoietin injections (Hgb < 10, Hct < 30 if iron deficiency is ruled out). 30% have worsening HTN (10 mm Hg in SQ route, remove fluid by dialysis and give beta blockers or vasodilators). 15% have headaches. 5% have flu like symptoms (in IV route, use antiinflammatories). Rare red cell aplasia.

Incidence: frequency of new cases over a period of time. To determine, subjects without disease must be followed for a period of time to see if they develop it. Cohort study is best option. A prospective observational study where group is chosen based on presence or absence of certain factors. Then are observed for development of disease. Brain Metastases: most common type of intracranial brain tumor. Usually at gray-white junction, single or multiple, seen frequently in NSCLC. Median survival is 1 month without treatment. If single with stable extracranial disease, surgery is done first to relieve mass effect, diagnose, improve local control. Then do whole brain radiotherapy to destroy residual. Steroids are symptom control, do not increase survival. If multiple, just do whole brain radiation. Syphilis: chronic systemic infection. Primary -> chancre. Secondary -> systemic infection with malaise, headaches, anorexia, generalized MP rash, moist skin or mucous membrane papules. Involves trunk, extremities, palms, soles. Develop condyloma lata: broad exophytic formations in anogenital region or upper thighs that ulcerate. Serology is positive. Lipid Screening: start at age 35 in men, 45 in women. Risk factors are (+) FH, smoking, HTN, low HDL, age. With 0-1, goal LDL < 160. With 2, goal LDL < 130. With known CAD or CAD equivalent (diabetes, AAA, symptomatic CVD, 10 year risk > 20%), goal LDL < 100. Colon Cancer Screening: regular screening at 50 years old. Can do FOBT, flexible sigmoidoscopy, colonoscopy, double contrast barium enema. Interval to repeat depends on test. Pseudotumor Cerebri: benign intracranial HTN. Young, obsese female with headache suggestive of brain tumor, with normal imaging, elevated CSF pressure. Can have papilledema, visual field defects, VI nerve palsy. Can have history of steroid use or vitamin A. OCP also associated. There is impaired CSF absorption. Treat with weight reduction. Acetazolamide if no weight reduction. If fail or visual field deficits progress -> shunt or optic nerve sheath fenestration to prevent blindness, most significant complication. Cushings Syndrome: high cortisol -> vasoconstriction -> secondary HTN. Also enhance insulin resistance (hyperglycemia) and mineralocorticoid activity (hypokalemia). Proximal weakness, central obesity, thin skin, psych problems. Result from adrenal cortical hyperplasia, ACTH adenoma (Cushings disease), ectopic ACTH, steroid administration. Simple Renal Cyst: most commonly seen in patients > 50. Benign and incidentally discovered. Usually asymptomatic. Sometimes can become infected. Simply observe and no follow up needed. Make sure its not multiloculated, does not have thick or irregular walls, thickened septae, or contrast enhancement. Anticholinergic Toxicity: red as beet, dry as bone, hot as hare, blind as bat, mad as hatter, full as flask. Can have dizziness, headache, tachycardia. Can precipitate acute glaucoma due to mydriasis. Trihexylphenidyl and benztropine are used for Parkinsons and EPSEs. Squamous Cell Carcinoma: ulcer that is solitary, not healed for a long time, located in keratinized epithelium of the vermillion zone of lower lip. May also be chronic infectious, chronic autoimmune. Will have invasive cords of squamous cells with keratin pearls. Will have history of occupational sun exposure. Major of lip cancers are well differentiated SCC. Decubitus Ulcer: common in patients with diseases that impair normal sensation or movement. Develop rapidly when preventative measures not taken. May develop during hospitilization for acute issue. Occur over bony prominences (sacrum, heels, elbows, ears). Constant unrelieved pressure -> necrosis of overlying skin and muscle, when pressure > 32 mm Hg (normal arteriolar pressure). Change position every 2 hours.

Radioiodine: most popular treatment of hyperthyroid. Taken up by thyroid -> destruction via beta emission. May develop permanent hypothyroidism, greatest in patients with Graves disease, since whole gland is hyperfunctional -> general uptake -> complete ablation. Constrictive Pericarditis: thickened or scarred -> impaired diastolic filling -> decreased CO -> JVP, ascites, hepatic congestion, dyspnea, weakness. Kussmauls sign (decrease of JVP on inspiration) can be present but not specific. MCC are cardiac surgery, viral pericarditis, radiation. CXR -> calcified pericardium. CT/MRI -> thickened pericardium. Increased pressures on cardiac cath. Treat with diuretics or pericardiectomy. TCA Overdose: hyperthermia, anticholinergic effects (dilated pupils, ileus). Decreases myocardial conduction velocity -> QRS widening -> risk of ventricular arrhythmia. Majority of mortality due to hypotension. Secure ABCs. With hypotension, QRS prolongation, arrhythmia, give sodium bicarbonate. Acyclovir: can cause nephrotoxicity. Causes crystalluria and renal tubular obstruction -> renal failure. Occurs with large parenteral doses, especially with inadequate hydration. Disseminated Gonorrhea: gonococcal bacteremia due to untreated mucosal gonorrhea infections. Usually during menstrual periods. High fevers, tenosynovitis, migratory polyarthralgias. Skin lesions on extremities from 5-40, purpuric or pustular with hemorrhagic necrosis. May cause supperative arthritis (different from early arthralgias). Blood cultures often negative. Acute Back Pain: with positive straight leg raise -> herniated disk. With neurological defecit and perianal anesthesia -> cauda equina syndrome. Manage conservatively. Return to activities ASAP. Use NSAIDs and muscle relaxants. If longer 4-6 weeks, do imaging MRI or CT with or without contrast. Exercise and PT are not shown to be effective. Epidemiological Studies: goals are to be descriptive and analytical. Descriptive deals with rates, ratios, distribution. Analytical tests hypothesis created by descriptive and consists of observational and experimental studies. Case Control Study: retrospective study. Movement from effect to cause. Look at population with outcome and subjects are either cases or controls. Looks for presence of risk factors. Prospective Cohort Study: or longitudinal. Divides group into exposed and not exposed. Followed prospectively until onset of disease. Stronger than case control or cross sectional. In cohort studies, subjects are free of outcome at onset of study. Retrospective Cohort Study: starts between exposure and outcome. Reviews past records, classifies into exposed or not exposed, and follows until outcome. In cohort studies, subjects are free of outcome at onset of study. Cross Sectional Study: exposure and outcome are studied at one cross section of time. Not possible to determine temporal association between exposure and outcome. Randomized Control Trial: gold standard for studying efficacy of treatment or procedure. Randomly assigned to treatment or control group. Has least bias and shows strong causal relationship. Idiopathic Pulmonary Fibrosis: restrictive lung disease. Chronic inflammation of alveolar walls -> widespread fibrosis -> destruction of architecture. Dyspnea, non productive cough, digital clubbing. Dry, end-inspiratory crackles. Decreased lung volumes, normal FEV1/FVC. Diffusion capacity is reduced due to V/Q mismatch -> A-a gradient. CXR -> decreased lung volume, honeycomb pattern, vascular congestion at hilum.

Amaurosis Fugax: painless loss of vision from emboli. Cholesterol particles (Hollenhorst bodies) may be seen. Warning of impending stroke due to emboli -> mostly occur from carotid bifurcation -> do US of neck. Viral Arthritis: acute onset polyarticular symmetric arthritis that resolves in 2 months. MCC is Parvovirus, usually with those that work with children. Usually involve MCP, PIP, wrist. RA has chronic onset, elevated ESR/CRP, no resolution in 2 months. Chemicals in the Eye: first priority is immediate flushing under running water for at least 15 minutes. Call ER, 911, doctor after washing. Acid exposure has likely full recovery. Alkaline will more likely have permanent corneal damage. For foreign bodies or cuts/scratches, obtain medical care first. Rotator Cuff Tear: present with shoulder pain and weakness. Occur as end result of rotator cuff tendonitis or trauma (FOOSH). Aggravated by pushing, pulling, lifting overhead, lying on affected shoulder. Limited arc abduction and external rotation. Remains after lidocaine injection. Tendonitis resolves with lidocaine injection. MRI is diagnostic. HIV Pneumonia: acute onset, high grade fever, pleural effusion. Pneumococcous is the MCC. Impaired humoral immunity -> susceptibility to encapsulated organisms. Febrile Transfusion Reaction: fever and chills that respond to NSAIDS and acetaminophen. No hemodynamic abnormalities or renal dysfunction indicating hemolytic reaction or bacterial contamination. Caused by patient Ab to donor WBCs, usually HLA specific. Leukocyte depletion can reduce possibility. Cell washing, using frozen deglycerolized cells, or leukocyte depletion RBC filters. Ventricular Remodeling: after MI, ventricle slowly dilates and walls thin -> CHF which occurs over months to weeks. ACEs inhibit ventricular remodeling and should be started within 24 hours of MI if no contraindication. Radioiodine Therapy: treatment of hyperthyroid in non-pregnancy. Become euthyroid in 2-6 months. MC SE is hypothyroid (especially in Graves disease) due to follicle destruction, but is easily treated with synthroid. Eye disease may worsen at beginning of therapy. Complications of MI: mitral regurgitation due to papillary muscle rupture, LV free wall rupture, IV septum rupture. Present as hemodynamic compromise at 3-7 days when infracted myocardium is softest. Pansystolic murmur, loudest at the apex, with radiation to the axilla, soft S1, pulmonary edema & LVF -> SOB & crackles = acute mitral regurgitation. DI: presents as polyuria & polydipsia due to ADH deficiency or resistance. Excrete dilute urine, increased plasma osmolarity. Water deprivation -> fluid loss dehydration, increased plasma osmolarity -> CNS dysfunction. Lithium accumulates in kidneys -> tubular damage. Amiloride prevents Li accumulation. Give NS with CNS dysfunction and dehydration. When intravascular volume improves, then use hypotonic solutions. Chalazion: painful swelling -> nodular rubbery lesion. Meibomian gland obstruction -> chronic graulomatous inflammation. If persistent, can also be due to meibomian gland carcinoma. Basal cell carcinoma presents similarly. Do histopathology to rule out cancer. Tinea Corporis: ring shaped scaly patches with central clearing, distinct borders. Trichophyton rubrum is MCC, other dermatophytes can also cause. MC symptom is itching. KOH preparation shows hyphae. Treat with topical terbinafine if local. If extensive, give systemic griseofulvin and investigate for immunosuppresion (DM, HIV).

Aspergillosis: fungal infection with coarse fragmented septae, hyphae usually seen. CXR may show cresecent radiolucency next to rounded mass. Destruction of parenchyma -> cavitation -> debris and hyphae coalesce into ball. Mobile mass with intermittent hemoptysis. PML: opportunistic infection in immunocompromised patients. Caused by JC virus Involves white matter of cortex. No mass effect. Gradual onset of hemiparesis, disturbances in vision/gait/speech. MRI shows multiple demyelinating non-enhancing lesions. Limb Embolus:normal neurological exam with paresthesias, change in temperature, non detectable pulse. Immediate anticoagulation with heparin and embolectomy are needed. Tissue death and amputation if not treated within hours. BPH: increased frequency, urgency, weak stream, nocturia, sense of incomplete voiding. Starts in the center of the prostate (cancer in peripheral). If acute renal failure (one of MCC), place FC. If large volume is obtained, BPH is likely. If progresses for 2 weeks, can have permanent kidney damage. US can show hydronephrosis. Vitamin B12 Deficiency: causes are strict vegetarian diet (more than 3-4 years), and pernicious anemia, autoimmune disease resulting in parietal cell destruction -> measure intrinsic factor Ab and B12 levels. ACE Inhibitors: shown to prolong life in asymptomatic to severe heart failure. Started on low dose and titrated up (mortality improvement is dose dependent). Reduce preload and afterload. Beta blockers, spironolactone, and ARBs also improve mortality. PSC: inflammation, fibrosis, structuring of intra and extrahepatic biliary tree. Onion skin fibrosis -> ESLD & portal HTN, biliary stricture, cholangitis, cholelithiasis, cholangiocarcinoma, colon cancer. 25-90% have underlying IBD (usually UC). It is a multifactorial disorder. Present with fatigue or pruritis. Cholestatic pattern on labs -> elevated alk phos and BRN. IBD causes hypoalbuminemia. Can see positive p-ANCA. Cholangiography -> beading pattern. Treat with UDCA, dilatation & stenting, transplant. DM: RF are AA race, positive FH in first degree relatives. Present with polyuria, polydipsia, obesity. Measure fasting blood glucose (recommended screening test). > 126 on 2 occasions is diagnostic. Between 100 and 125 is insulin resistance or pre-diabetes. Pleural Effusion: use Lights criteria: exudate will have fluid to serum protein ratio > 0.5, fluid to serum LDH ratio > 0.6, or fluid [LDH] > 2/3 the upper limit for serum LDH. Complicated will have positive gram stain & culture, pH < 7.2, glucose < 60 and needs chest tube. Empyema is frank pus. Hospital Infection: common source of confusion. Check blood and urine cultures with new fever or WBC elevation. With recent abx, diarrhea, tender abdomen -> C diff colitis. Stool toxin assay and empiric metronidazole. Multiple stool samples are necessary. Hyperkalemia:> 5 mEq/L. Present with weakness, paralysis, respiratory insufficiency, cardiac toxicity -> sine wave or ventricular fibrillation. Use binding resin. MCC is medications, so review them. ACEs, ARBs, spironolactone block aldosterone. TMP and pentamidine also cause. Beta Thalassemia: microcytic anemia not responsive to iron, especially with Mediterranean origin. Point mutation in one of beta globin genes -> reduced synthesis. Minor is due to 1 defective gene with Hct between 28-40 and MCV 55-75. Major is due to 2 defective -> severe.

Zollinger Ellison: also called gastrinoma. Prominent gastric folds, ulcer located beyond duodenal bulb on endoscopy. Measure serum gastrin levels. > 1000 is diagnostic. If not, do secretin stimulation test. Hypocalcemia: hypoalbuminemia -> decreased serum, normal ionized calcium, no symptoms. Excess alcohol -> chronic pancreatitis -> vitamin D deficiency -> hypocalcemia and hypophospatemia due to malabsorption. Acute pancreatitis can also be a cause. Histoplasmosis: dimorphic fungus found as mold in soil. Present in bat and bird droppings in Mississippi and Ohio river areas. History of bat or bird exposure. Disseminates in IC patients. Nonspecific symptoms. Targets histiocytes and RE system -> LA, pancytopenia, hepatosplenomegaly. Palatal ulcers. CXR -> hilar LA, interstitial pneumonitis. Cocaine Intoxication: present with venous track marks, EKG changes of myocardial ischemia/infarction due to sympathetic effects -> tachycardia and hypertension. Treat with BZD (decreases anxiety & sympathetic effects), ASA (for clots), nitrates (for constriction). Alcohol Withdrawl: first 6-24 hours -> anxiety, insomnia, tremors, sweating. First 48 hours > seizures, hallucinations. Delerium tremens -> after 48-96 hours -> HTN, agitation, tachycardia, hallucinations, fevers. Treat with BZD like chlordiazepoxide (Librium). Nephropathy:preceded by protein excretion in urine. Starts with microalbuminuria -> 30300 mg/d. Spot urine and timed urine collection for microalbumin to Cr ratio are good screening methods. 24 hour urine is more inconvenient, but preferred. Lung Exam: inspection, palpation, percussion, auscultation. Normal will be resonant with vesicular sounds (quiet inspiratory, inaudible expiratory). Consolidation will have dullness, louder expiratory component if airways are open. If blocked, will decrease. Will also hear egophany and crackles. OCP: common cause of secondary hypertension. 5% of patients. Caused by estrogen mediated increase in synthesis of angiotensinogen. Discontinuation can correct the problem. HIT: combination of AV thrombosis and thrombocytopenia in patients receiving heparin. May manifest as acute ischemic stroke. Ab to heparin-platelet-factor 4. Antibodies activate platelets -> premature removal and thrombotic complications. Status Epilepticus: ongoing seizures activity for > 5-10 minutes or lack of interictal return to baseline. Resistant to medications. First step is appropriate oxygenation and blood pressure, with endotracheal intubation. Use BZD or phenytoin as second line. Warfarin: inhibits vit K dependent clotting factors II, VII, IX, X, protein C, S. Protein C has half life of 9 hours -> early signs of protein C deficiency -> hypercoagulabilty -> thrombus formation -> skin necrosis. Common in patients with congenital protein C deficiency. Chronic Alcoholism: multiple electrolyte abnormalities (low Mg, low K, low PO4). Hypomagnesemia causes refractory hypokalemia. Mg is an important cofactor for K uptake and maintenance if IC K levels. Check Mg to correct low K. Diuretics also causes low Mg. Diabetic Mononeuropathy: can be cranial or somatic. CNIII is affected most often of CN. Ischemia of somatic fibers and sparing of PS fibers -> ptosis and down-and-out gaze. Pupil response and accommodation are intact. If compression causes it, both fibers will be affected.

Acute Pyelonephritis: acute febrile illness, CVA tenderness, pyuria, bacteriuria. Treat initially with antibiotics. With no response in 72 hours, do renal CT or US to look for other pathologies (obstruction) or complications (abscess). Pulmonary Hypertension:> 25 mm Hg at rest, > 30 mm Hg with exercise. Caused by respiratory disorders, venous/cardiac, chronic thromboemboli, arterial (primary/ idiopathic), vascular malformations. Dyspnea, fatigue, weakness, chest pain, hemoptysis, syncope, hoarseness. Causes RVH and failure. CXR -> pulmonary artery enlargement, tapering of distal vessels, RVH. Can cause cor pulmonale. Pagets Disease:persistent dermatitis. Typically red, oozing, crusted, unresponsive to steroids or antibiotics. Biopsy -> proliferation of malignant epithelial cells scattered as well as cells with lots of pale staining cytoplasm surrounding hyperchromatic nuclei with prominent nucleoli. Usually underlying breast cancer. Could be DCIS or infiltrating ductal. Test Cut Off Points: lowering cut-off point increases sensitivity. Increase true positives and false positives. PPV = TP/TP+FP. PPV will decrease and false negatives will also decrease. Bisphosphanates: drugs of choice for mild to moderate hypercalcemia. Non toxic and more potent than IV saline. May reduce bone pain and fractures. May improve survival in patients with multiple myeloma or breast cancer. Zoledronic acid recommended in all women with metastatic breast cancer and radiographic lytic bone disease, receiving hormone or chemotherapy. CAD: risk factors -> men > 45, women > 55, HTN, smoking, HDL < 40, family history of early CAD (men < 55, women < 65). HDL > 60 negates one risk factor. Risk equivalents impart equal risk for MI as having a previous MI. They are DM, symptomatic CVD, AAA, PVD, 10 year risk > 20%. LDL Goal < 100 < 130 < 160 When lifestyle changes start > 100 > 130 > 160 When starts > 130 > 160 > 190 drug therapy

Risk Category CAD or Equivalent 2+ RF 0-1 RF

Diverticulitis: history of constipation with little fiber. LLQ pain and fever. Give IV antibiotics until symptoms resolve. If fail to response, do CT to evaluate for perforation, abscess, fistula. Febrile Neutropenia: ANC < 1500. Susceptibility increases < 1000. Ability to control own flora decreases < 500. Fever in these patients classified as one temperature > 100.9, or > 100.4 for over an hour. Bacteria from skin and flora are MC, mostly G(+). Start antibiotics that are broad spectrum and cover Pseudomonas. Ceftazidime, cefepine, imipenem, meropenem, or combination of aminoglycoside and anti-pseudomonal beta-lactam. Acute Monocytic Leukemia: M5. Dramatic onset, headaches, fever, weight loss, gum or nose bleeding. Gingival hyperplasia and skin lesions. Leukocytosis with blasts. Positive alphanaphthyl esterase test. Acute Myeloblastic Leukemia: M2. Predominance of myeloblasts. Acute Promyelocytic Leukemia: M3. Predominance of hypergranular promyelocytes with Auer rods. High incidence of DIC. Acute Lymphoblastic Leukemia: predominance of lymphoblasts that are PAS+.

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Acute Erythroleukemia: M6. Predominance of erythroblasts which have irregular outline and high N/C ratio. Gastric Cancer:early detection is critical since surgery and excision of affected tissues is mainstay therapy. Most are diagnosed at stage III-IV. Do CT scan to assess extent of disease after diagnosis is made. Also detects metastases, especially liver metastases. HCV: chronic hepatitis C with persistently normal LFTs on multiple occasions have minimal histological abnormalities and do not need to be treated with interferon or antivirals. Septic Arthritis: acute onset painful swollen joint, limited ROM, fever > 104, fluid WBC 50150k. Crystal induced presents similarly but WBCs between 10-50k and lower fever. Prosthetic joint increases risk. Knee is most commonly affected by hematogenous distribution. Staph aureus is MCC in prosthetic joint septic arthritis. HIV Immunizations: polyvalent pneumococcal vaccine recommended for all HIV patients whose CD4 count > 200. Annual influenza vaccination is also recommended. Contrast Nephropathy: caused by renal vasoconstriction and tubular injury. History of diabetes and chronic renal insufficiency are increased risk. Spike of Cr within 24 hours. Adequate hydration is most important. IV bicarbonate or NS. Mucomist also helps. SLE Nephropathy: classic presentation of young woman with joint pain, fatigue, ankle edema, facial rash. Mechanism is immune complex mediated kidney damage -> circulate and deposit in renal glomeruli -> complement activation and C3 level decrease. AI Hemolytic Anemia: acquired disorder that causes extravascular hemolysis. Pallor, jaundice, splenomegaly, elevated indirect BRN, reticulocyte count and LDH. Spherocytes with central pallor, (+) fragility test, (+) Coombs (not required). Can do micro-Coombs. Hereditary spherocytosis has spherocytes with no central pallor, (+) AD family history. Graves Disease: insomnia, fatigablilty, weight loss, lid lag, tremor. Atrial fibillation is common due to increased sensitivity of beta receptors. Best choice for stable patients is a beta blocker. Controls atrial fibrillation and other symptoms of hyperthyroidism. Vitamin D Overdose: seen in patients trying to lose weight. Can cause hypercalcemia -> constipation, abdominal pain, polyuria, polydipsia. Individuals trying to lose weight should be counciled about weight loss as vitamin and mineral toxicities are common. Asthma:intermittent -> daytime symptoms < 2x/wk, nighttime awakenings < 2x/mo, use of beta agonists < 2x/wk, baseline FEV1/FVR ratio is normal, no limitations of daily activities. Treat with short acting bronchodilator as needed. Mild persistent -> symptoms > 2x/wk but < daily, nighttime awakenings 3-4x/mo, minor limitation, normal PFTs. Add low-dose inhaled steroid as a controller. Moderate persistent -> daily symptoms, weekly nighttime awakenings, FEV1 < 60-80% predicted. Add long-acting inhaled beta 2 agonist. Severe persisent -> symptoms throughout the day, frequently nighttime awakenings, extremely limited activity, FEV1 < 60% predicted. Treat with as needed albuterol inhaler, long acting inhaled beta 2 agonist, high dose inhaled corticosteroids. Possible oral steroids. Radioactive Iodine:preferred treatment for Graves disease. Takes about 6-8 weeks for improvement. Contraindicated in pregnancy and very severe ophthalmopathy. No higher incidence of cancer. Diabetic Glomerulosclerosis: renal insufficiency, moderate levels of proteinuria. 50% of diabetics. Evident after 12-22 years of diabetes, progresses to CRF and ESRD in 4-5 years. Microalbuminuria can be detected within 4-5 years of onset. Secondary to microangiopathy.

Human Bite: clenched fist injury. Amoxicillin-clavulanate (beta lactamase inhibitor) is antibiotic of choice. Usually polymicrobial wounds and G(+), G(-), anaerobic coverage needed. Also drug of choice for dog bites. Sideroblastic Anemia: defective heme synthesis, MC due to pyridoxine-dependent impairment in early steps of protoporphyrin synthesis. Present with microcytic hypochromic anemia but can see normochromic cells (dimorphic population). Will have high iron and low TIBC. Isoniazid and alcoholism can be a cause. Give B6 to treat. Bone marrow biopsy will show ringed sideroblasts. Normal Distribution: 68% within 1 SD of mean, 95% within 2 SD of mean, 99.7% within 3 SD of mean. Lyme Arthritis: caused by untreated Lyme infection by Borrelia burgdorferi. Arthritis happens in late disease, commonly involves knee. Warmth, swelling, restriction of movements differ from arthralgias in early disease. History of intermittent inflammatory arthritis. First episode within 6 months of erythema migrans and travel to endemic area. Fronto-temporal Dementia:characteristic are personality changes (euphoria, disinhibition, apathy), compulsive behaviors (peculiar eating habits, hyperorality), impaired memory. Visuospatial functions intact. Possible family history. Pseudogout: hyperparathyroidism -> elevated calcium & low phosphorus -> constipation, fatigue, polyuria, abdominal pain, stones, mental status changes, osteoporosis. Couples with acute painful monoarthritis due to CPP crystals -> rhomboid, (+) birefringent. ADPKD: hypertension, palpable abdominal masses, microhematuria. Hepatic cysts are MC extrarenal manifestation. Also berry aneurysm (5-10%, bad when coupled with HTN, screening not recommended), MVP or AR, diverticulosis, abdominal wall & inguinal hernias. Schistocytes: also called helmet cells, are fragmented RBCs. Due to mechanical destruction: MAHA (DIC, HUS, TTP), or prosthetic valves. Mechanical are more traumatic than porcine. Labs show decreased haptoglobin, increased LDH & BRN. Drug Hypersensitivity: if mild (urticaria and pruritis without systemic symptoms), treat with antihistamines and discontinuation. Ampicillin and amoxicillin associated with urticaria, morbilliform rash, late maculopapular rash. PCP Intoxication: causes hallucinations, dissociative feelings, agitation, confusion, papillary dilatation, tachycardia, nystagmus (only drug that causes vertical, can be horizontal or rotary). Causes violent behavior. Cause severe HTN, seizures, hyperthermia. Give BZD for severe psychomotor agitation. Hyperkalemia: in fall with weakness, long time on floor -> due to rhabdomyolysis. Tall T waves on EKG indicates cardiotoxicity -> treat with IV calcium gluconate -> cardiac myocyte membrane stabilization. Cervical Spondylosis: chronic neck pain. Limited neck rotation and bending due to osteoarthritis and muscle spasm. Osteophytes -> radiculopathy -> sensory abnormalities. X ray -> bony spurs, sclerotic facet joints, narrowed disc spaces, hypertrophic vertebral bodies. These findings are of low specificity. MEN I: non-beta cell pancreatic tumor like gastrinoma -> abdominal pain, diarrhea. Endoscopy -> multiple ulcerations, prominent gastric folds. Also have primary hyperparathyroidism, pituitary tumors, other neuroendocrine pancreatic tumors.

Lewy Body Dementia: fluctuating cognitive impairment, hallucinations, parkinsonism resistant to therapy. Progressive decline that impedes functioning. Memory impairment in the long term. Deficits in attention, visuospatial ability, executive functions. Falls, syncope, transient loss of consciousness, neuroleptic sensitivity, systematized delusions. ARDS: inflammatory mediators due to tissue injury -> leaky alveolar capillaries -> pulmonary edema. Caused by sepsis, bleeding, infection, toxins, burns. Present with dyspnea, tachypnea, hypoxemia, infiltrates on CXR. Ventilation with low TV and PEEP (increases FRC, decreases work of breathing). PEEP may go upto 15 in ARDS, can improve oxygenation. SAH: rupture of saccular aneurysms is the MCC (2/3 of cases) of nontraumatic SAH. Saccular aneurysms occur in 3-4% of population, rupture is rare, high risk when > 7 mm. Common in anterior circle of Willis. Diagnose with cerebral angiography and treat surgically. Viral Arthritis: symmetric small joint inflammatory arthritis of acute onset and short duration. Joint swelling and low grade fever suggest inflammation. Symptoms resolve in 2 months. Caused by parvovirus, hepatitis, HIV, mumps, rubella. Can see positive RF and weakly positive ANA. Use NSAIDS. Antivirals are unnecessary. HEV: RNA virus. Histology -> focal necrosis, ballooned hepatocytes, acidophilic hepatic degradation. Transmitted through fecally contaminated water. Commonly found in India, Africa, Asia, Central America. Diagnosed by detection of HEV RNA by PCR in serum or feces or IgM Ab. Self limited, no chronic carrier state. Fulminant hepatitis can occur, more common in pregnant women, especially in 3rd TM, can be transmitted vertically. TMJ Dysfunction: history of teeth grinding, interpret as ear pain. Pain is worse with chewing. May have crepitus or clicks in the TMJ with movement. Exclude all other ear conditions. Initial treatment is conservative, like nighttime mouth guard. Surgery sometimes needed. Cushings Syndrome: excessive systemic cortisol levels. Can result from exogenous steroids or own overproduction. Present with fatigue, weight gain, easy bruising, central adiposity, proximal muscle weakness, hyperglycemia, osteopenia, osteoporosis, HTN, acne, cataracts, susceptibility to infections. Hypokalemia is most common electrolyte abnormality due to some mineralocorticoid activity. Can see hypernatremia. Treat with spironolactone. Multiple Myeloma: malignant plasma cell disease -> monoclonal protein and increased plasma volume. Normocytic anemia, hypercalcemia, renal failure, elevated protein, normal albumin, increased ESR, Bence Jones proteins. Presents in old age with back pain, recurrent infections. 1/3 of patients have leukopenia. Serum immunoelectrophoresis shows M spike. Pinworms: enterobiasis caused by Enterobius vermicularis. Adult lives in cecum and appendix. Female crawls out at night and deposits skin -> nocturnal anal pruritis. Diagnosed by scotch tape test which demonstrates eggs. Albendazole or mebendazole is first line, but not in pregnant patients. Pyrantel pamoate is an alternative. Lumbar Spinal Stenosis: degenerative condition where spinal canal is narrowed -> compression of one or more spinal roots. Due to enlarging osteophytes at facet joints and hypertrophy of ligamentum flavum. > 60 y/o, back pain that radiates into buttocks and thighs, worse with walking and extension, better with flexion. MRI confirms diagnosis. Hyperthyroid: plasma TSH is best initial test -> usually low unless TSH secreting adenoma. Free T4 is usually elevated. Do EKG to rule out arrhythmia. Do 24 hour radioiodine uptake to differentiate Graves from other disease. Use propranolol for symptomatic relief.

Myeloproliferative Disorder: polycythemia vera -> splenomegaly and pruritis with hot baths due to histamine release from increased basophils. 40% develop gout due to overproduction of uric acid because of increased catabolism and turnover of purines. Vitreous Hemorrhage: sudden loss of vision and onset of floaters. MCC is diabetic retinopathy. Fundus is hard to visualize or details obscured. Needs immediate ophthalmology consult. Conservative treatment (sleeping upright) is recommended. Familial Hypocalciuric Hypercalcemia: benign AD condition. Increased serum calcium and increased/normal PTH levels. Also seen in primary hyperPTH. Obtain 24 hour urine calcium and creatinine. FHH have decreased urine calcium. Hyper PTH have high urine calcium. Infective Endocarditis: major criteria ->> 2 blood cultures positive, endocardial involvement on echo, presence of new murmur. Minor criteria -> predisposing condition, fever > 38, vascular phenomenon (septic emboli), immunologic phenomenon (glomerulonephritis). Diagnosed with 2 major, 1 major & 3 minor, 5 minor. Mycotic aneurysms, abdominal abscesses, septic PE, renal abscesses, conjunctival hemorrhages, Janeway lesions all related to septic emboli. Oslers nodes (painful fingertip nodules) and GN due to immunologic phenomenon. Arthritis can be due to immune complex deposition. Enthesitis: inflammation and pain at sites where tendons and ligaments attach to bones. MC seen with recurrent tendon or ligament stress and HLA-B27 associated arthropathies like AS, psoriatic arthritis, reactive arthritis. Prominent in AS. Manifests with heel pain where Achilles inserts. Tibial tuberosities and iliac crests also involved. Pyelonephritis: if uncomplicated, can be switched to oral antibiotic after 48-72 hours of IV therapy. Switch based on sensitivities. Average duration of therapy is 2 weeks. Oral is more convenient and less expensive. Heat Stroke: core temperature > 40 and altered mental status. Can be exertional (factory workers, military, athletes) or non-exertional (at extremes of age, cannot get fluids or move from heat). Ambient heat and humidity prevent sweat production. Present as confusion, hyperthermia, tachycardia, epistaxis. Complications are rhabdomyolysis, renal failure, ARDS, coagulopathy. Cut Off Point: raising -> increased specificity, decreased sensitivity. Herniated Disk: unilateral radicular pain in dermatomal distribution. Back tenderness due to spasm of paraspinous muscles. Symptoms worse during straight leg raise. Cauda equina -> saddle anesthesia, no sphincter tone, urinary retention. Severe pain with mild obstruction (like BPH) inhibits ability to valsalva -> urinary retention. Severe Asthma Attack: normal or increased PCO2, speech difficulty, diaphoresis, altered sensorium, cyanosis, silent lungs. Tachypnea, increased work of breathing, low PO2. PCO2 should be decreased due to hyperventilation. Severe obstruction -> increased PCO2. Lung inflation and tachycardia are also normal. Endotracheal Intubation: to provide a secure airway. Should sit at the carina for safety and efficacy. Right bronchus intubation is a common complication due to acute angle -> overinflation of the right and underinflation of the left. Asymmetric breath sounds. CXR confirms. Pull back on ET tube slightly. Pseudotumor Cerebri: benign/idiopathic intracranial hypertension. Headache, blurry vision, papilledema, vision loss, CN palsies (especially CNVI). LP shows increased pressure. Can be due to isotretinoin in acne treatment. Derived from vitamin A -> similar to vitamin A OD.

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ACE Cough: non productive cough occurs in 5-20%. Kinins are degraded by ACE. Accumulation of kinins and some activation of the arachadonic acid pathway are the cause. Discontinue drug. If cough persists, do CXR, PFT, barium swallow, bronchoscopy. Paroxysmal Nocturnal Hemoglobinuria: intravascular hemolytic anemia, hypercoagulable state, bone marrow aplasia. Hemolysis is complement mediated. Elevated LDH and low haptoglobin. Pancytopenia -> reticulocytosis. Loss of urinary iron -> iron deficiency anemia. High incidence of thrombosis in hepatic, portal veins, Budd Chiari. Diagnose with flow cytometry for CD55 and CD59. TPN: GI tract is bypassed stimulus for GI hormone release is gone. CCK is stimulated by proteins and FA in duodenum. No CCK -> no GB contraction -> stasis -> bile sludge and gallstones -> cholecystitis. Humoral Immunodeficiency: history of recurrent bacterial infections. If selective, IgA or IgG can be deficient. Food allergies and autoimmune diseases may be present. IgA deficiency and CVID (suppressed cellular immunity and increased risk of malignancy). Diagnose with quantitative immunoglobulin levels. Compression Fracture: acute onset of back pain without trauma. Common complication of osteoporosis. Age and steroid use are RF. Localized tenderness. Absent ankle reflex is common in elderly people, otherwise neurological exam is normal. Hyperemesis Gravidarum: causes metabolic alkalosis with respiratory compensation via hypercapnea. ABG shows pH > 7.45, primary increase in HCO3, secondary increase in PCO2. Vomiting -> decreased HCl -> metabolic alkalosis (generation phase). Volume loss -> contraction metabolic alkalosis due to RAAS activation (maintenance phase). Prevention of Back Injury: usually present with lumbar strain (relation to heavy lifting, no radicular signs, good response to conservative therapy). Strengthen supporting muscles (abdominals), avoid sleeping on stomach, learning proper bending and lifting. No twisting and bending exercises. Bend at knees, not at waist. Keep back straight. Do warm ups. Lyme Disease: doxycycline is first line for early lyme. Also treats coexistant ehrlichiosis. In pregnant/lactating women and children, treatment choice is amoxicillin. Penicillin G is alternate for early localized during pregnancy or disseminated. IV ceftriaxone or cefotaxine (3rd generation) are used for early disseminated or late. Chest Pain: methods for diagnosing CAD are only helpful for those at intermediate risk. A (-) non invasive test in a high risk patient is likely false (-). A (+) test in a low risk patient is likely false (+). In young women, anxiety and psychosocial issues are a common cause. Infectious Mononucleosis: splenic rupture is a potential complication and patients with splenomegaly should avoid excessive physical activity and contact sports until spleen is not palpable (usually 1-3 months). HCV: major cause of chronic hepatitis (~80%) and MC acquired via infected blood. Recommended to get vaccinated against HAV and HBV (safe during pregnancy). Low evidence of sexual transmission. Allergic Conjunctivitis: environmental exposure -> acute hypersensitivity. Itching, hyperemia, tearing, edema. Possible photophobia and burning. Family history of asthma, allergies, atopic dermatitis are common. Reduce exposure, dont rub eyes, topical antihistamines, artificial tears, cool compresses to treat.

Colon Ulcer: on scope, questionable ulcer needs biopsy to rule out cancer and distinguish UC from Crohns since treatment is different for both. Solitary Pulmonary Nodule:< 3 cm circular lesion in middle or lateral 1/3 of lung surrounded by normal tissue. Mostly benign. Calcification favors benign. Popcorn calcification is hamartoma. Bulls eye calcification is granuloma. Look at old x-ray in low risk patients. If no change in 12 months -> benign. Follow by CXR every 3 months for 1 year, if no change -> benign. High risk patients need CT, FNA, possible excisional biopsy. Anabolic Steroids: SE are suppressed testicular function, gynecomastia, erythrocytosis, hepatotoxicity, psychological disturbance, cardiac disease, low HDL/high LDL, increased coagulation, premature epiphyseal closure. Virilization in females. Eyelid Lesion: squamous papilloma is frond like or lobular and MC benign tumor. Basal cell is MC malignant tumor and most common malignancy in humans. Fair skinned, long sun exposure are risks. Pearly lesions with rolled border, telangiectasias that can bleed or ulcerate and cause loss of eyelashes. Locally invasive, can -> enucleation. Resect to treat. Percarditis: non radiating, retrosternal pain relieved by sitting forward. ST elevation that is concave up and PR depression in aVR and friction rub. MCC is viral infection. Caused by bacterial infections, lupus, uremia (which is an indication for dialysis). Indication for Dialysis: refractory hyperkalemia, volume overload/pulmonary edema not responsive to diuretics, refractory metabolic acidosis (< 7.2), uremic pericarditis, uremic encephalopathy/neuropathy, coagulopathy due to renal failure. Gallstones: cholesterol, pigment (calcium bilirubinate), or mixed. Cholesterol and mixed > 80%. With GB hypomotility or excess cholesterol compared to bile salts -> precipitaiton. RF for cholesterol stones: Caucasian, obesity, rapid weight loss, female hormones/OCP, glucose intolerance, GB hypomotility (pregnancy, age, fasting, high TG, TPN), ileal disease -> bile salt malabsorption, clofibrate, octreotide, ceftriaxone. RF for pigment stones: chronic hemolysis, biliary tract infections and parasite infections, old age. Low carbs, exercise, coffee ingestion, aspirin/NSAIDS are protective. US for diagnosis. Surgery or UDCA for treatment. Lacunar Stroke: due to occlusion of single deep artery in brain due to microatheroma or hyalinosis. Better prognosis. HTN and DM are risks. Not usually seen on CT. MC site is posterior internal capsule -> pure motor stroke. Can have ataxia, pure sensory, or mixed. Elevated BUN/Cr Ratio: prerenal azotemia (elevated BUN with mild elevated Cr), steroid administration, or GI bleed (bacterial breakdown of hemoglobin with urea reabsorption). ACE I:reduces urinary albumin excretion and decline in Cr clearance. Slows the progression of diabetic nephropathy (reduces intraglomerular pressure). Used in patients with microalbuminuria, even with normal BP. Recurrent Thrombosis: thrombophlebitis with multiple DVTs, elevated PT/PTT and fibrin split products indicate activation of systemic cascade. Due to genetic defect in young or malignancy in elderly (gastric, pancreatic, ovarian). Do CT chest, abdomen, pelvis in old. Cirrhosis: gynecomastia and spider angiomata due to decreased estrogen metabolism, abdominal distension due to ascites, pedal edema due to decreased oncotic pressure due to decreased albumin. Palmar erythema, nail changes, caput medusa, hair loss, parotid swelling. MC cause is alcohol or viral hepatitis. Diagnose with biopsies and vial serology. B12 Deficiency: megaloblastic macrocytic anemia. Usually due to decreased IF -> malabsorption -> peripheral neurophaty, posterior column defects due to defective myelin

synthesis. B12 and folate convert homocysteine to methionine. Folate can improve B12 deficiency but worsen neurological defects. y Megaloblastic Anemia: due to folate or B12 deficiency. Smear shows large RBC and hypersegmented neutrophils. Have elevated homocysteine (cant convert to methionine). B12 converts methylmalonyl CoA to succinyl CoA. B12 deficiency -> elevated MMA. D Dimer: a fibrin degradation product elevated with blood clots and other inflammatory conditions. (+) test has a poor PPV and is not definitive. (-) test is good for ruling out a DVT or PE. Pleural Effusion: diagnosed by Lights Criteria: fluid is exudative if fluid/serum protein > 0.5, fluid/serum LDH > 0.6, fluid LDH > 2/3 ULN. Exudates are caused by increased capillary permeability, transudates caused by high hydrostatic/low oncotic pressure. Exudates caused by infection, autoimmune, neoplasm. Elevated lymphocytes in fluid: TB, sarcoid, lymphoma, RA. Herpes Zoster: reactivation of varicella zoster virus. Virus is latent in DRG after primary infection. Stress, age, HIV, lymphoma -> impaired cellular immunity -> reactivation along sensory nerve, usually T3-L3. Pain prior to rash. Valacyclovir or acyclovir to treat. Post herpetic neuralgia prevented with TCA with anti virals. Hypertension: has the strongest association with strokes. Increases the risk of all types of strokes. Have 4x higher risk of strokes than non-hypertensives. Smoking and DM are also risk factors. Hypercholesterolemia more associated with CAD. Vitamin K Deficiency: antibiotics and cystic fibrosis. Important cofactor in gamma-glutamyl carboxylase -> factor II, VII, IX, X, protein C & S deficiency. Carboxyl groups increase affinity for phospholipids on platelet surface. ALL: disease of children. Present with infections, lymphadenopathy, splenomegaly. Have lymphoblasts, with anemia/neutropenia/thrombocytopenia. Lymphoblasts have no peroxidase (+) granules, have PAS(+) material. Are also TdT(+) (only in pre B and pre T). HTN Management: pharmacologic and non-pharmacologic. Lifestyle modification is necessary: smoking cessation, weight loss, sensible alcohol, reduce salt in diet. With multiple readings of > 140/90, and not improved with lifestyle, JNC guidelines are to put on medication. Best first line is a thiazide. Asthma is a contraindication for beta blockers. D Parkinsonism: mask like immobile face, bradykinesia, tremors, rigidity, and hypokinetic gait. Stooped over, series of short accelerating steps, feet that shuffle and scrape the floor. Arms do not swing while walking. Degeneration of neurons in substantia nigra -> decreased DA and increased Ach activities. Treat with dopaminergic or anticholinergic drugs. Ischemic Colitis: suspect with evidence of atherosclerotic disease, abdominal pain, bloody diarrhea, minimal exam findings. Most commonly involves splenic flexure, or rectosigmoid junction, both watershed areas supplied by terminal SMA/IMA. Exacerbated by hypotension. Increased lactic acid, x ray can show thumb printing. Diabetic Nephropathy: diabetes is leading cause of ESRD in US. Most common histologic finding is diffuse glomerulosclerosis. Nodular glomerulosclerosis (Kimmelsteil Wilson lesion) is pathognomonic. Slow by strict glycemic control, treatment of HTN, ACE I. Stevens Johnson Syndrome: also called erythema multiforme major. Due to immune complex mediated hypersensitivity due to sulfonamides, NSAIDs, phenytoin. Sudden onset

mucutaneous lesions over two sites, characteristic target appearance, systemic signs of toxicity. Treat with supportive management, assessment of hemodynamic stability, fluids. y COPD Exacerbation: if refractory to steroids and bronchodilators, but patient is not crashing -> use NIPPV before intubation. Has decreased incidence of complications such as infection. Recommended with pH<7.35 or PaCO2>45 or RR>25. Better ventilation and less exhaustion of respiratory muscles. CI in patients that are septic, hypotensive, dysrhythmic patients. Hypovolemic Shock: blood loss -> loss of intravascular volume -> decreased CO, decreased PCWP (indirect measure of LAP) -> activation of SANS -> vasoconstriction, increased HR. Gastric Outlet Obstruction: rare complication of PUD. Prepyloric inflammation -> edema, fibrosis, scarring of the pylorus -> early satiety and intractable vomiting -> dehydration and hypokalemic hypochloremic metabolic alkalosis due to hyperaldosteronism from volume contration and renal potassium wasting to retain hydrogen. NG suction, hydration of NaCl, IV potassium initially, then treatment of the ulcer with possible surgery. Vertebral Fracture: patients suffering from ankylosing spondylitis for > 20 years are at risk due to decreased bone density and can result from minimal trauma and clinical suspicion should be high especially with history and onset of severe back pain. Pulmonary Embolus: anticoagulation with heparin should be initiated immediately in any patient with high likelihood PE and respiratory distress before diagnosis. RF: surgery in last 3 months, immobilization, malignancy, history of DVT. Present with dyspnea, cough, pleuritic chest pain, DVT symptoms, tachycardia, tachypnea, loud S2, hypoxemia by ABG. Symptomatic Hypercalcemia: vigorous hydration with IV normal saline is first step in management. Nephrolithiasis: 1) Imaging: CT scan without contrast. 2) Narcotics and NSAIDs: relieve pain of renal colic, NSAIDs do not exacerbate nausea and vomiting. 3) Size: < 5mm typically pass with fluid intake > 2L (dilutes urine). 4) Urology referral: if anuric, septic, ARF. Metabolic evaluation not necessary with first stone. Multiple Myeloma: proliferation of single transformed plasma cell producing IgG with lytic bone lesions, marrow plasmacytosis, urine and serum monoclonal proteins. Usually in elderly, have back pain, recurrent infections, renal failure, hypercalcemia, hyperviscosity. Achalasia: decreased esophageal body peristalsis and poor relaxation of the LES is typical. Presents with progressive dysphagia, chest pain, food regurgitation, and aspiration. Barium swallow shows dilated esophagus and birds beak deformity. Chronic Hepatitis: evaluation of liver damage is based on liver biopsy, acute hepatitis is evaluated by LFTs and viral serology. Chronic hepatitis persists for 6 months. HBsAg confirms HBV as cause. Acute Glaucoma: emergency. Treat with mannitol, acetazolamide, pilocarpine, timolol. Avoid mydriatic agents such as atropine (dilates the pupil and worsens the problem, or can be the cause). Use narcotics to control pain. Rubella: erythematous and maculopapular rash that starts of face and progresses to trunk and extremities. Prodrome of fever, occipital/posterior LA, malaise, arthritis, mild coryza, conjunctivitis. Tinea Corporis: also called ringworm is a superficial fungal infection with erythematous, scaly, pruritic rash with central clearing. Seen in hot/humid clients. Exposure to infected

animals, people, public places are RF. Diagnosed with skin scraping and KOH. Topic antifungals to treat. y Malaria: protozoan disease caused by plasmodium, RBC parasite transmitted by Anopheles mosquito. Endemic to Africa, Asia. Can be falciparum, vivax, ovale, malariae. Falciparum causes most deaths, vivax and ovale cause relapses. Cyclic fever is hallmark that coincides with RBC lysis. Vivax and ovale has fever every 48 hours, malariae every 72 hours, not seen with falciparum. See anemia and splenomegaly, hypotension and tachycardia. GBS: ascending paralysis, areflexia, sensory changes 3-4 weeks after a URI or GE. CSF albumino-cytologic dissociation is specific. Facial nerve paralysis and autonomic dysfunction can occur. Treat with IVIG and plasmapheresis. Myocarditis: otherwise healthy young people with acute onset CHF and lack of CAD risk factors. Usually viral due to coxsackie B virus. May have preceding viral type symptoms. SAH: causes cerebral salt wasting syndrome due to inappropriate secretion of vasopressin -> water retention, increased ANP/BNP -> salt excretion. Causes hyponatremia. Can see SIADH which causes hyponatremia and is treated with water restriction. Central/Tertiary Adrenal Insufficiency: low CRH due to chronic supratherapeutic doses of steroids -> low ACTH and cortisol, normal aldosterone levels (not under CRH control). MCC of adrenal insufficiency. Sinus Bradycardia: HR < 60, regular rhythm, constant PR interval. Caused by physical training, excess vagal tone, sick sinus syndrome, hypoglycemia, medications (CCB, BB, digoxin). May get lightheaded and dizzy, syncope. Give IV atropine -> decreases vagal tone. Dihydropyridine CCB: cause peripheral edema along with CHF, renal disease, venous insufficiency. Cause peripheral vasodilation. If significant, discontinue. Labs will be normal. Not an allergy! Bacillary Angiomatosis: bright red, firm, friable, exophytic nodules in HIV patient. Caused by Bartonella, a G(-) rod. Treat with oral erythromycin. Crohns Disease: involves entire GI tract and has skip areas. Can have apthous ulcers in the mouth (non specific) and can see granulomas. Associating abdominal pain with extraintestinal manifestations can help diagnose. Can have weight loss and anemia. Decubitus Ulcers: elderly, critically ill, immobile, poor nutrition, sensory impairment are all risks. Due to uninterrupted pressure on tissue over bony prominences like elbows, coccyx, hips, heels. Repositioning patients every 2 hours (point at which pressure begins to induce tissue damange) and pressure reducing devices prevent. Also maximize nutrition. Frostbite: best initial treatment is rapid rewarming with warm water (40-44). Results in less tissue damage than slow rewarming at room temperature. Immerse in room water that is continuously circulated. Do not attempt to debride initially. Dry heat is not effective. Vitiligo: autoimmune disease with areas of depigmentation due to lack of melanocytes. Associated with other AI: pernicious anemia, AI thyroid disease, type 1 DM, primary adrenal insufficiency, hypopituitarism, alopecia areata. RAS: systolic-diastolic abdominal bruit in patient with HTN, atherosclerosis. Causes secondary HTN and CKD. Bruit is due to turbulent blood flow and found in 85% of RAS vs. 25% of patients with HTN.

Hereditary Spherocytosis: AD and MC cause of hereditary hemolytic anemia in caucasians. Congenital RBC membrane defect. Have increased reticulocytes, increased BRN, (-) Coombs, spherocytes. Can be severely anemic with jaundice and splenomegaly on presentation. MCV is normal or high, MCHC > 36%. Osmotic fragility test is next best test. Pulmonary Tuberculosis: productive cough, hemoptysis, recurrent fevers, possible weight loss. Imaging shows upper lobe cavitary lesions with surrounding alveolar infiltration. Suspect in patients from endemic areas with subacute/chronic pulmonary complaints. S4: low frequency heart sound at the end of diastole just before S1. Associated with LVH from long standing HTN, or restrictive cardiomyopathy. Sounds like Tennessee. Results from atrial kick hitting stiff LV. HBV Vaccination: decreases incidence of HCC especially areas with high HBV like Africa and Asia (chronic HBV secondary to vertical transmission major cause of HCC). In US, MC contracted due to contaminated blood. 7th& 9th MCC cancer death in men and women. ASA Sensitivity Syndrome: pseudoallergic reaction due to ASA induced PG/LT misbalance in susceptible individuals. Have persistent nasal blockage, episodes of bronchoconstriction. ASA blocks COX -> increased lipoxygenase -> accumulation of LT. Treat with leukotriene inhibitors, topical steroids, ASA desensitization therapy. Cardiac Disease: detailed history and physical is most effective way to screen for cardiac disease and underlying hypertrophic cardiomyopathy. All school and collegiate athletes should be offered pre-participation by skilled healthcare workers. Metabolic & Respiratory Acidosis: low pH (<7.35) = acidosis, decreased HCO3 = metabolic acidosis, inappropriately normal PaCO2 = primary respiratory acidosis. Use Winters formula to calculate what PaCO2 should be: PaCO2 = 1.5(HCO3)+8+2. Megaloblastic Anemia: elevated MCV, elevated MCH, normal MCHC. Large RBC, hypersegmented neutrophils, anisocytosis, poikilocytosis, basophilic stippling. Caused by B12 deficiency, folic acid deficiency, other (hypothyroid, liver disease, anti-metabolites). Brain Lesion in HIV: MCC is toxoplasmosis. TMP-SMX for prophylaxis, sulfadiazine & pyrimethamine for treatment. If dont respond, then do brain biopsy. Brain irradiation is for CNS lymphoma (afebrile and weakly enhancing). Acyclovir: causes acute elevation of Cr. Is excreted by glomerular filtration and tubular secretion. When concentrations -> crystallization, crystalluria, renal tubular damage. Can be prevented with adequate hydration and slowing rate of infusion. Morning Hyperglycemia: due to Somogyi effect (high NPH dosing with peaks 4-10 hours after injection -> overnight hypoglycemia -> epi, NE, glucagon release -> glycogenolysis and gluconeogenesis -> morning hyperglycemia) or Dawn phenomenon (decreased insulin sensitivity between 3 and 8 AM -> hyperglycemia at 3 AM and 7 AM due to spikes of GH release which occurs shortly after falling asleep) or waning circulating insulin (usually coexists with Dawn phenomenon, 3 AM glucose is usually normal). Cholesteatoma: congenital or acquired secondary to chronic middle ear disease. New-onset hearing loss or chronic ear drainage despite antibiotics. Granulation tissue and skin debris with retration pockets of TM. Also causes CN palsies, vertigo, brain abscesses, meningitis. Need otologic exam, and CT or surgical visualization. Cut Off Point: lowering cut off point will increase sensitivity.

Zinc Deficiency: result from chronic TPN (lacks zinc) or malabsorption due to SB resection due to IBD. Causes alopecia, bullous/pustulous lesions around orifices or extremities, abnormal taste, impaired wound healing. Normally digested in the jejunum. Survival in CHF:ACE I, ARBs, beta blockers, spironolactone all confer survival benefit. Digoxin and furosemide can reduce symptoms and hospitilzations, but do not help survival. Isoniazid: can cause B6 deficiency -> peripheral neuropathy -> tingling in extremities, numbness, ataxia. Start on 10 mg/day prophylaxis, 100 mg/day for treatment. Hepatitis is another known side effect. Essential Tremor: AD, heads and UE are often affected, worse when arms outstretched at the very end of goal directed activities (intention tremor). Treat with propranolol. COPD: often have CO2 retention -> respiratory acidosis. Use diuretics to treat cor pulmonale but caution is needed because they have a reduction in CO with subsequent development of renal failure. Hydroxychloroquine: good for treatment of SLE with isolated skin and joint involvement. Most serious SE is retinopathy & corneal damage. Need eye exams every 6 months. Urinary Retention: abdominal pain and suprapubic fullness after taking TCAs (anticholinergic -> reduces detrussor contraction and sphincter relaxation). Catheterize -> document PVRV > 50 mL (diagnostic for urinary retention) and provides symptomatic relief. Metastatic Disease of the Vertebrae: metastases are the MC malignancy of bone. Lung, breast, prostate, thyroid, kidney can all metastasize. Pain is usually constant and worse at night with rest vs. degenerative which is worse with exercise and better with rest. History of malignancy makes diagnosis likely. Primary Polydipsia: problem of excessive water ingestion. Kidneys work property excreting dilute urine. Confirm by withholding water -> increases urine osmolality and specific gravity. Common in patients with schizophrenia, and phenothiazines given to them cause dry mouth increasing thirst. Hyponatremia -> seizures. Influenza: acute onset fever, chills, cough, malaise, myalgias. Occurs in winter. Febrile with wheezes, crackles, course breath sounds. CXR may be normal or have interstitial pattern. Nasal swabs confirm. Start antivirals within 48 hours. Neuraminidase inhibitors (oseltamivir and zanamivir) are used, rimantadine and amantadine are only effective against influenza A. ARDS: non cardiogenic pulmonary edema due to inflammation of alveoli. Sepsis, severe bleeding, trauma, toxic injury, burns can be causes. Diagnosed via: acute dyspnea, inciting condition, bilateral infiltrates, PCWP < 18 (> 18 indicates impaired LV function), PaO2/FiO2 < 200. Nephrotic Syndrome: edema, hypoalbuminemia, elevated urine protein (3g/day). Diabetes and amyloidosis are common causes. Minimal change disease is the MCC in children. FSGS and membranous are most common in adults. Active HBV infection causes membranous GN > nephrosis. Common association with HBeAg (+) due to deposition of Ag or Ab. HBV associated membranous GN more common in children than adults. Thyroid Function Tests: hyperlipidemia, unexplained hyponatremia, elevated serum muscle enzymes are indications for TFTs. Most commonly see hypercholesterolemia (increased LDL) or combined with high TG. Due to decreased LDL receptors. May be difficult to control cholesterol even with thyroid control. Caution: increased risk of myopathy with statin use.

Empyema: intrapleural collection of pus. Due to bacterial seeding of a parapneumonic effusion or inoculation of bacteria during surgery. MCC strep pneumo, staph aureus, klebsiella. Have fever, cough, SOB, pleuritic chest pain. CXR shows free flowing (early) or loculated (late) effusion. Opacity typically has abnormal contour. Treat via drainage and antibiotics. NF Type I: intensive axillary freckling, caf-au-lait spots, optic gliomas in ~ 15% of patients, usually those < 6. Slow progressive unilateral vision loss and dyschromatopsia. Can see exophthalmos, with swollen, atrophic, or normal optic disk. Lead Time Bias: always consider in evaluation of a screening test. Incorrect assumption of prolonged survival time and better prognosis. Actually, detected earlier so patients seem to live longer. Think of this with new screening test for poor prognosis diseases. SBE and IV Drugs: increased risk in both right and left heart. If tricuspid or pulmonic valves are involved -> septic emboli to the lung -> cough, chest pain, hemoptysis, round alveolar infiltrates. Proteinuria due to septic emboli or immune complex in the kidney. Tricuspid regurgitation is common -> systolic murmur that increase on inspiration. PPD: detect patients with latent TB infection. Degree of induration required for (+) test depends on pre-test probability. >15 mm is (+) for healthy patients with no known TB risk factors. >10 mm is (+) in immigrants from endemic area, IVDA, residents/employees of highrisk settings, patients with diabetes/CKD/hematologic malignancies/fibrotic lung disease, children < 4 or teens exposed to high risk adults. >5 mm is (+) in HIV, recent contact with TB, signs of TB on CXR, organ transplant, patients on immunosuppression. Pancreatic Cancer:5th MCC of cancer related mortality. RF: male sex, >50 years, black race, smoking (most consistent reversible RF), chronic pancreatitis, long standing diabetes, obesity, familial pancreatitis, and pancreatic cancer in close relative. Alcohol, gallstones, coffee intake are not RF. Type 4 RTA: hyperkalemia, renal insufficiency, non-anion gap metabolic acidosis (decreased bicarbonate and normal AG). Caused by aldosterone deficiency or tubular insensitivity to aldosterone. Failure to secrete acid as NH4+ and potassium retention. May occur due to diabetic nephropathy and can be worsened by ACEs and ARBs that inhibit aldosterone. Blastomycosis: broad based budding yeast endemic to north central and south central US. Affects lungs, skin, bones, joints, prostate. Primary pulmonary infection is asymptomatic or presents with flu-like symptoms. Can have verrucous (crusted, heaped up, warty, violaceous hue, sharp borders, surrounded by micro abscesses) or ulcerative skin disease. Wet mount shows organism. Kidney Stones: colicky flank pain with radiation to the groin. MC are calcium oxalate that are envelope shaped. RF are small bowel disease, surgical resection, chronic diarrhea -> bile salt and FA malabsorption -> calcium chelation -> reabsorption of oxalate. Allergic Contact Dermatitis: MC sensitizer is plant urushiol (poison ivy/oak/sumac, ginko, mango skin) in NA. Nickel, formaldehyde, fragrances, preservatives, rubber are also common. Type IV hypersensitivity: initial sensiztization -> 10-14 d -> re exposure -> reaction in 12-48 hours. Avoid contact. Can use calamine lotion, topical antihistamines, steroids. LFTs: PT is the most important test of functionality. Elevated transaminases = cellular injury. Decrease in transaminases = recovery or few functional hepatocytes (look at other tests). Rise in PT with decreased transaminases = low functionality = fulminant hepatic failure.

DVT: presents with calf pain, swelling, discoloration (other DDx is Bakers cyst, muscle strain, venous insufficiency, cellulitis). Decision to anticoagulate based on history, physical, and non-invasive testing: compression ultrasound. If low risk, do D-dimer. If negative, no anticoagulation. If positive, do ultrasound. Osteomyelitis: if coupled with chronic foot ulcer in a diabetic (due to neuropathy and arterial insufficiency) or other causes of arterial insufficiency, caused by contiguous spread. Aspiration Pneumonia: fever, cough with foul smelling sputum after endoscopy or other instrumentation. Poor dentition also RF. Add antibiotic with anaerobic coverage like clindamycin. Thoracic Aortic Aneurysm: MC site is ascending due to cystic medial necrosis. 2nd MC is descending distal to L SCA, fusiform, due to atherosclerosis. May also have AAA. Usually have comorbid CAD or pulmonary disease. Atrial Myxoma:MC primary intracardiac tumor, usually in LA. Can cause fever, weight loss, neurologic symptoms due to embolization, and mass on echo. Usually in elderly patients. Horners Syndrome: suspect lung cancer in a smoker. Cancer can cause cough, chest pain, weight loss, decreased appetite, weakness, swallowing difficulty, hoarseness, shoulder pain due to direct extension. Do simple CXR to start. Histoplasmosis: common and asymptomatic infection in Mississippi and Ohio River Valley and Central America. Commonly found in bird and bat droppings -> inhalation. Not common to get symptomatic disease. Will have fever, chills, non productive cough, with patchy infiltrates. Cavitary lesions can form in older adults with COPD which can be fatal. Can disseminate in immunocompromised and children. Can present as solitary nodule. Chronic Liver Disease: all patients should be vaccinated against HAV and HBV unless already immune (look at Ab levels), due to high risk for acute hepatic failure or cirrhosis. Post Splenectomy Sepsis: normally pathogens are phagocytosed by dendritic cells in white pulp -> MHC II presentation to TH2 cells -> marginal zone -> B bells in primary follicles -> secondary follicles and plasma cells -> Ab formation -> binding Ag -> phagocytosis by opsonization. No spleen -> impaired Ab mediated opsonization for phagocytosis -> risk for sepsis due to Strep pneumo, N meningitidis, H flu. NPH: abnormal gait (slow broad based shuffle), incontinence (urinary, fecal in late disease), dementia due to increased ventricular size without increased pressure. Treat with large volume LP and, if successful, VP shunt. Caustic Ingestion: no alteration of consciousness, dysphagia, pain, heavy salivation, mouth burns. Causes necrosis of GI tissue and can cause perforation of stomach or esophagus -> peritonitis and mediastinitis. Central Line Thrombosis: prolonged placement -> thrombosis -> swelling (arm if SCV). Remove catheter and duplex to document thrombus and need for anticoagulation. Common with TPN lines which should be in RA. Hyperosmolar fluid -> irritation of vein. Have swollen arm with present pulses. Swelling may extend into head and neck with distended veins. Pheochromocytoma: do not give beta blockers without alpha blockers. Beta block -> unopposed alpha activity. Give alpha first and then beta to treat tachycardia, otherwise can cause dangerous increase in BP. Labetalol has alpha and beta activity and can be given.

Hereditary Spherocytosis: AD disorder of spectrin -> increased RBC fragility. Not deformable and gets trapped in red pulp fenestrations. (+) family history, splenectomy, spherocytosis, can cause cholecystitis due to pigmented stones -> treat with folate and splenectomy. Whipples Disease: multi system infection caused by Tropheryma whippelli. Presents with arthralgias, weight loss, fever, diarrhea, abdominal pain. Can have chronic cough and myocardial/valvular involvement -> CHF or regurgitation. Have PAS(+) material in lamina propria on biopsy. Can have hyperpigmentation, LA, supranuclear ophthalmoplegia, myoclonus. Chronic Hepatitis C: waxing and waning of transaminase levels with few symptoms. May have arthralgias/myalgias. Can have cryoglobulins, porphyria cutanea tarda, GN. 20% develop cirrhosis. Hepatic function worsens in times of stress. Dehydration: altered MS, dry mucosa, high electrolytes/Hct, BUN/Cr > 20. Elderly patients are predisposed due to decreased thirst response, impaired sodium retention, impaired renal concentration. Treat with NS, but caution: Na loading unmasks subclinical CHF. Aortic Stenosis: causes exertional syncope along with ventricular tachycardia and HOCM. AS will have symptoms of CHF (fatigue, dyspnea on exertion). Symptomatic with valve area < 1. Have systolic murmur at R 2nd ICS with carotid radiation, pulsus parvus et tardus, and prolonged PMI. Neurocysticercosis: MC parastitic infection of the brain caused by larval Taenia solium. Adult lives in intestine -> eggs -> animal consumed -> larvae encyst in tissue -> eat animal -> adult tapeworm in intestine. If person consumes eggs -> embryos in intestine -> invade wall -> disseminate to brain, muscle, SQ tissue, eye. Multiple, small, fluid filled cysts with invaginated scolex on neuroimaging. Usually asymptomatic and found on autopsy. Hypercalcemia: abdominal pain/constipation, polyuria, psychiatric disturbances (usually calcium > 12). Treat with normal saline and then loop diuretic. Can be seen in MM with back pain and pancytopenia, due to osteoclast activating factor -> lytic lesions and hypercalcemia. Serum Sickness Like Reaction: can occur 1-2 weeks after administration of penicillin, amoxicillin, TMP-SMX, or cefaclor after viral illness. Fever, urticarial rash, polyarthralgia, LA. Distinct from immediate hypersensitivity reactions. Discontinue offending agent. Hematuria: initial hematuria = urethral damage. Terminal hematuria = prostate or bladder damage. Total hematuria = kidney or ureter damage. Clots not usually seen with kidney damage. Painless terminal hematuria -> investigate bladder cancer. Cavernous Sinus Thrombosis: occur in patients with infections of the skin adjacent to the eye or nose, ethmoid/sphenoid sinusitis. HA (neuropathic due to V1/V2) is MC early symptom. Fever, periorbital edema due to obstructed flow. Lateral gaze palsy due to CN VI involvement. CN III, IV, V1, V2 can be affected. Do MRI/CT of orbits. Use IV antibiotics. Hyperandrogenism: rapidly developing suggests androgen secreting neoplasm in adrenal or ovary. Look at testosterone and DHEAS. High testosterone with normal DHEAS = ovary. Normal testosterone with high DHEAS = adrenal. Lumbosacral Strain: MCC of acute back pain usually after physical exertion, absence of radiation, presence of paravertebral tenderness/contraction, (-) straight leg raise, normal neurological exam. Treat with NSAIDS and early mobilization.

Minor Thalassemia: alpha or beta will have impressive microcytosis with modest anemia (Hgb level, adult diagnosis, lack of severe symptoms), target cells, with no GI bleeding. Common in Mediterranean descent. Reassure and followup. ABCs: start in management of ANY patient coming into ER. Poor circulation evidenced by hypotension, pallor, tachycardia, delayed capillary refill -> volume resuscitate -> hemodynamically stable -> start with diagnosis. Anal Fissure: slit like tears of anal canal usually on anterior or posterior anal verge due to passage of large, hard constipated stools. Crypt abscesses, explosive diarrhea, perianal dermatitis/infection, IBD, trauma, sexual abuse can all be causes. Severe pain and bright red bleeding. Treat acute and chronic with high fiber, lots of fluids, stool softener, local anesthetic. GERD:patient with asthma like symptoms that occur only at night (especially those who eat late or go straight to bed), sore throat, horseness, wheezing. Start with lifestyle modification (avoid eating late, elevated head of bed), PPI. Ichthyosis Vulgaris: history of normal skin at birth with gradual progression to dry, scaly skin. Hereditary or acquired. Usually dry and rough with horny plates over extensor surfaces. Sparing of diaper/face in children. Worse in winter. Sometimes called lizard skin. Subacromial Bursitis: result of repetitive overhead motions -> chronic microtrauma to the supraspinatus tendon by compression between acromian and humeral head. Pain with active ROM, passive internal rotation/forward flexion (Neers). Atrial Flutter: sawtooth pattern of atrial impulses on EKG with large P waves that do not conduct all QRS complexes. Caused by re-entrant rhythm. Present with palpitations, CP, SOB, lightheadedness. Ventricular rate determined by AV node conduction. MC is 2:1 block, can have 3:1 or 4:1 (variable AV node conduction). Hyatid Cysts:due to infection with Echinococcus granulosus from close contact with dogs (definitive host). Causes unilocular cystic lesion in liver, lung, muscle, bone. Usually asymptomatic, or symptoms are due to compression. Have eggshell calcifications and can cause anaphylaxis. Treat with resection under cover of albendazole. OA: narrowed joint space, osteophytes, subchondral sclerosis or cysts, < 30 minutes morning stiffness, joint pain. Obesity is most readily modifiable RF for OA and can slow progression and improve joint pain and function. Herpes Zoster: reactivation of VZV in DRG in patient with previous chickenpox. Can be due to immunocompromise (HIV, chemo, diabetes), stress, old age. Pain and vesicular rash in dermatome. Pain may precede rash. CO Poisoning: colorless, odorless gas emitted automobiles, charcoal grills, furnaces. Acute exposure presents with HA, nausea, vomiting, abdominal discomfort, confusion, coma, with pinkish skin hue. Diagnosed by carboxyhemoglobin levels. Treat with hyperbaric O2. History is helpful. Hypercalcemia of Malignancy: due to production of PTH-rP by malignant cells. MC paraneoplastic syndrome usually associated with SCC of lung. Causes increased bone resorption, increased tubular calcium resorption, phosphate secretion. Outlier: extreme and unusual value observed in dataset. Means are extremely sensitive and shift towards them.

FAP: AD caused by mutations of APC gene. Causes hundreds of adenomatous polyps in colon and has 100% risk of cancer if not treated with elective proctocolectomy. MJ Intoxication: MC used illicit drug in US. History of slowed reaction time, impaired short term memory, increased appetite. Have conjunctival injection, dry mouth, hypertension, tachycardia. Involved in 10-50% of car accidents. White Out Lung: have opacification with mediastinal shift towards affected lung due to atelectatic volume loss. MC due to obstruction due to mucus plugging, tumor, foreign body, external compression. Causes dyspnea, tachypnea, diaphoresis, confusion, cyanosis. Urgent bronchoscopy for diagnosis and possible relief of obstruction. Hyperkalemia: removal of K from the body only done via dialysis, diuretics, or exchange resins like Kayexalate acts in GIT to exchange Na for K. Treatment also uses calcium gluconate, bicarb, insulin with glucose/dextrose, beta agonists. Graves Ophthalmopathy: MCC of exophthalmos in adults. Caused by autoimmune periorbital lymphocytic infiltration of extraocular muscles -> fibroblast proliferation, hyaluronic acid deposition, edema, fibrosis. Sclera seen above and below iris which is pronounced by sympathetic stimulation of lid retraction. Will have dry eye due to keratitis and exposure. Primary Syphilis: treatment is single intramuscular injection of benzathine penicillin. With penicillin allergic, use single dose azithromycin or 2 weeks of doxycycline or tetracycline. PJP Pneumonia: opportunistic pathogen and important cause of pneumonia in IC adults. Bilateral diffuse infiltrates on CXR in perihilar region. Have dyspnea, fever, non productive cough. Can have involvement of LN, spleen, liver, bone marrow. Rifampin: causes red/orange discoloration to bodily fluids and can cause discoloration of soft contacts. Do a UA to rule out more worrisome conditions, such as renal TB or TB associated glomerulopathy. Otherwise is a benign drug effect. Trigeminal Neuralgia: paroxysmal, lightning-like pain on the face which is severe, intense, burning, electric-shock like. Carbamazepine is the drug of choice for treatment. ALS: characterized by involvement of UMN (spasticity, bulbar symptoms, exaggerated DTR) and LMN (fasciculations). Weakness and wasting is characteristic of UMN and LMN lesions. Hypokalemic Alkalosis: 1) Vomiting: scars on dorsum of hand, dental erosions, hypovolemia, hypochloremia, hypochlouria. 2) Diuretic Abuse: same presentation but elevated urine chloride, history of diuretic use, positive urine assay for medication. 3) Bartter/Gitelmans: same as diuretic abuse. Echinococcus Granulosus: majority are asymptomatic infections. Liver is MC affected in 2/3, and lung in 1/4. Dogs are definitive hosts, sheep are intermediate hosts, humans are deadend accidental hosts. Seen where sheep are raised, transmission when dogs live close to humans and are fed viscera of slaughtered animals. Human ingestion -> intestinal penetration -> dissemination. Cysts are have germinal layer (can give rise to daughter cysts) and laminated layer. Case Control Study: pateitns with disease of interest (cases) and people without disease (control) are asked about previous exposure and exposure odds ratio is measured compared case rate to control rate. Cut Off Point: raising decreases sensitivity, increases specificity.

PBC: autoimmune destruction of intrahepatic bile ducts and cholestasis. Starts with pruritis especially at night, fatigue, hepatomegaly, xanthomas, jaundice, steatorrhea, portal hypertension, osteopenia. Elevated ALP, cholesterol, IgM, (+) anti-mitochondrial Ab. Increased risk of hepatobiliary malignancy. UDCA is treatment of choice: relieves symptoms and lengthens transplant free survival time. Nitrates: venodilation -> improves cardiac chest pain by reducing preload -> decreased myocardial O2 demand. Reduces ventricular volume and wall stress. Also cause some arterial dilation -> some decreased afterload and myocardial O2 consumption. Iron Deficiency Anemia: MCC of anemia in the elderly. Cause pallor and fatigue. Usually secondary to a nutritional deficiency. Can be due to chronic blood loss (gastritis, PU, diverticulosis). Cardiovascular Disease: MCC of death in patients on dialysis (50% of deaths, 20% due to MI, 60% to sudden death) and MCC of death in renal transplant patients. Osteomyelitis in SCD: Salmonella is the MCC (upto 70% of cases), Staph aureus for < 25%. Wernicke Korsakoff: caused by thiamine (B1) deficiency. Wernicke: encephalopathy, oculomotor dysfunction, gait ataxia. Can be induced by giving glucose without thiamine. Korsakoff: irreversible amnesia, confabulation, apathy. Cystitis: dysuria, frequency, suprapubic discomfort, no unusual vaginal discharge, no high risk sexual behavior, bacteriuria, pyuria = acute uncomplicated cystitis. Cultures are not needed. Oral TMP-SMX is best empiric threatment. Fluphenazine: high potency typical antipsychotic that is injected every 2-3 weeks that can cause hypothermia by disrupting thermoregulation and shivering mechanism. Patients taking antipsychotics should be advised to avoid prolonged exposure to extreme temperatures. ARDS: endothelial injury -> fluid leakage from capillaries -> fills interstitium and alveoli -> intrapulmonary shunting -> hypoxia refractory to O2. Acute onset, PaO2/FiO2 < 200, bilateral infiltrates, Swan Ganz < 18/absense of JVD/cardiomegaly (which indicates CHF). ASA Intoxication: mixed respiratory alkalosis (due to increased drive) and anion gap metabolic acidosis (accumulation of salicylate and decreased excretion of organic acids like lactic acid and ketoacid). Use Winters formula: PaCO2 = 1.5(HCO3)+8+2 to determine if its mixed or not. Mesenteric Ischemia: unexplained chronic abdominal pain especially after eating, weight loss, food aversion. Evidence of other atherosclerotic diseases and non-specific physical findings. 50% patients may have a bruit. Diagnosis requires angiography or Dopper US. Cardiac Tamponade: hypotension, tachycardia, JVD. ECG shows electrical alternans: amplitude of QRS changes. Needs massive fluid resuscitation and emergent pericardiocentesis. Wilsons Disease: AR, abnormal copper deposits in liver, basal ganglia, cornea. Liver disease (asymptomatic to fulminant), neuropsychiatric. Have low ceruloplasmin, increased copper excretion, Kayser-Fleisher rings. Malignant Otitis Externa: serious infection of the outer ear caused by Pseudomonas. Seen in elderly with uncontrolled diabetes, ear pain, drainage, granulation tissue in ear canal. Can

y y

develop osteomyelitis of the skull base, TMJ (worse with chewing), CN involvement. Give IV ciprofloxacin. y Hodgkins Disease: curable lymphoma of young patients. Due to chemo/radiation, can develop secondary malignancies (usually lung or breast). Occurs in 3.2% of patients within 20 years. Liver Mass: isolated mass is more likely to be metastatic than primary. Primary tumors of GIT, lung, breast are MC. Usually asymptomatic and present with symptoms of primary malignancy. With chronic abdominal pain -> colonoscopy. Ventilation: RR x Vt. Respiratory alkalosis (pH > 7.4, decreased CO2) results from hyperventilation. In setting of appropriate Vt, lower RR (decreased Vt -> increased RR -> worsens situation). Normal Vt is 6 mL/kg ideal body weight. Ulcerative Colitis: bloody diarrhea, tenesmus, cramping, weight loss, anemia. Complications are PSC, uveitis, erythema nodosum, spondyloarthropathy, toxic megacolon, colon cancer. Routine colonoscopies beginning 8 to 10 years after diagnosis. PPV: depends on prevalence of disease of interest in population and increases with increases in prevalence. The more common a disease, the greater probability that a patient from the population with a positive test actually has the disease. Opposite is true for NPV. New Drugs: consider natural history of a disease in evaluating effectiveness of a new drug in a trial. Control groups help prevent this. Spinal Cord Compression: signs and symptoms of UMN dysfunction distal to site of compression (weakness, hyperreflexia, decreased sensation, bowel/bladder dysfunction). Medical emergency requires prompt diagnosis with MRI. Could be herniation, abscess, trauma, malignancy. Adrenal Deficiency: hyperpigmentation of skin and mucous membranes is characteristic of primary deficiency due to increased ACTH. Not seen in secondary deficiency which is due to hypothalamic-pituitary failure. Can also have other manifestations of pituitary insufficiency. Aortic Dissection: suspect with acute retrosternal pain and normal EKG. Check BP in both arms and listen for diastolic murmur of AR. TEE is preferred diagnosis to MRI (takes too long) or CT. HTN should be controlled before TEE. Sjogrens Syndrome: subjective and objective evidence of dry eyes (keratoconjunctivitis sicca) and mouth (xerostomia, increased caries) exists with histologic evidence of lymphocytic infiltration of salivary glands or SSA (Ro)/SSB (La) Ab. AAA:usually asymptomatic and discovered incidentally. Life threatening complication -> rupture. Ultrasound has nearly 100% sensitivity and specificity, facilitates measurement of size, shows presence of thrombus. Myasthenia Gravis: MC manifestation is weakness of muscles that lift lid (ptosis) or move eyes (double vision). SOB and dysphagia are worrisome. Does not produce pain or numbness. EMG and Ach receptor test are diagnostic. Use CT to look for thymoma after diagnosis is established. Pseudomonas Pneumonia: G(-) bacilli in sputum in intubated ICU patient with fever and leukocytosis. MC considered G(-) aerobic bacilli and common cause of nosocomial pneumonia. Linked to contaminated water faucets, respiratory therapy equipment, therapy

pools, plant products. Cefepime, azotreonam, ciprofloxacin, tobramycin, gentamycin, amikacin, piperacillin/tazobactam. y

imipenem/cilastatin,

HOCM: sudden cardiac death in young individual, usually during exertion. MC in African Americans and usually have no prior symptoms. Can have ventricular tachycardia or ventricular fibrillation due to abnormal myocytes and myocardial scarring. Can also have heart failure and stroke but would not cause sudden death. Dubin Johnson Syndrome:conjugated chronic hyperbilirubinemia not associated with hemolysis. Asymptomatic, jaundice, non-specific complaints. Icterus can be worse during stress. Have normal amounts of total urinary coproporphyrin but have > 80% type I (vs. normal individuals with majority type III). Liver is usually black due to dense pigment of epinephrine metabolites in lysosomes. Chlamydial Urethritis: presence of mucopurulent urethral discharge, history of multiple sexual partners, dysuria, frequency. UA has no bacteriuria, UCx < 100 colonies/mL. Succinylcholine: depolarizing neuromuscular blocker that can cause life threatening hyperkalemia and arrhythmias. Should not be used in patients with high risk for hyperkalemia: crush or burn injuries > 8 hours old (rhabdomyolysis), GBS and other demyelinating syndromes, tumor lysis syndrome. Non-depolarizing blockers are better. NMS: fever, muscle rigidity, autonomic instability, mental status change, elevated CK. Dantrolene (a muscle relaxant) is used to treat followed by bromocriptine (DA agonist) and amantadine (antiviral with dopaminergic properties). Usually seen with typical antipsychotics and usually start within 2 weeks of starting medication. Stop medication. Mitral Regurgitation: holosystolic murmur that radiates to the axilla. MCC is MVP (can hear mid systolic click). Can cause left atrial dilation and atrial fibrillation (intermittent palpitations). Due to myxomatous degeneration of the valve. Case Control Study: exposure-odds ratio is the measure of association (odds of exposure in cases to odds of exposure in control) and is not the same as relative risk (risk in exposed vs. risk in unexposed). If population is small, RR can equal odds ratio. PE: signs and symptoms are non specific and variable. Suspect in patient with sudden onset SOB, pleuritic chest pain, low grade fever, hemoptysis, tachypnea, tachycardia, hypoxia. Calf swelling and Virchows triad not always present. Low O2 and atrial fibrillation = poor prognosis. Intraocular Foreign Body: suspect in patients with high velocity injuries (drilling, grinding). If initial pen light exam does not reveal anything, do fluorescein exam with Woods lamp or slit lamp. Non Ketotic Hyperosmolar State: occurs in T2DM. Insulin is enough to prevent ketosis but not hyperglycemia. Have glucosuria and severe dehydration. High osmolarity -> lethargy, weakness, altered mental status, focal neurological deficits, coma. Usually some kind of precipitant event (infection, MI, stroke). Hyperglycemia (>600), hyperosmolarity (>320), absent ketonemia. Macrovascular Hemolysis: elevated reticulocyte count, increased LDH, low haptoglobin -> iron loss -> microcytic anemia. Occurs with valve replacement or severely calcified aortic valves. Helmet cells or fragmented RBCs on smear.

PE: patients with recent orthopedic surgery are at higher risk for DVT and PE and anticoagulation will be needed. Will have elevated A-a O2 gradient due to impaired gas exchange (also seen in interstitial disease, and other processes that alter V/Q). Statin Side Effects:elevated liver enzymes and myopathy. Inhibition of HM-CoA reductase. Cannot make mevalonate -> dolichol, CoQ10 (reason for myopathy). Obesity Hypoventilation: long term consequence of severe obesity and untreated OSA -> chronic hypercapneic/hypoxic respiratory failure, secondary erythrocytosis, pulmonary HTN, cor pulmonale. To keep pH, bicarbonate is retained -> decreased choride absorption. Alpha 1 Antitrypsin Deficiency: inhibits many different proteolytic enzymes, acute phase reactant, highly pleomorphic gene on chromosome 14. Usually northern European. Liver cells will have PAS(+) granules, resist digestion by diastase. Develop panacinar emphysema (MCC death) and liver disease (2nd MCC death). Diagnose by serum measurement and genetic testing. Usually done in patients with early onset emphysema. Treat with purified A1AT or lung/liver transplant. Atrial Fibrillation: irregularly irregular, narrow QRS, no P waves. Can present with chest pain, palpitations, weakness, SOB. Due to cardiac, pulmonary, metabolic (hyperthyroidism), or drugs. Atracurium: neuromuscular blocking agent that is metabolized by serum esterases and degrades spontaneously. Safe for use in patients with renal/liver failure. Bullous Pemphigoid: tense blisters in flexural areas. Elderly patients with pruritis, urticaria. Due to UVR, NSAIDs, antibiotics. Auto Ab formed against basmement membrane proteins BP230, BP 180. See IgG and C3 and dermal epidermal junction. Treat with steroids. Minimal BRBPR: on toilet paper, drops in toilet bowl, some on outside of stool, not intermixed. MCC hemorrhoids, anal fissure, polyps, proctitis, rectal ulcers/cancer. If patient < 50 with no risk factors, do anoscopy or proctoscopy, then colonoscopy if no etiology found. Diabetic Ketoacidosis: when treating, serum/urine ketones falls behind changes in pH or anion gap and are more reliable indicators of recovery. Central Retinal Vein Occlusion: subacute monocular vision loss with blood and thunder appearance on fundoscopy of optic disc swelling, retinal hemorrhage, dilated veins, cotton wool spots. Caused by coagulopathy, hyperviscosity, atherosclerosis, chronic glaucoma. Central Retinal Artery Occlusion: sudden, painless loss of vision in one eye with optic disc pallor, cherry red fovea, boxcar segmentation of blood in retinal veins. COPD: progressive expiratory airflow limitation -> air trapping, decreased VC, increased TLC/residual capacity and FEV1 is disproportionately decreased. Accompanied destruction of alveolar-capillary membrane. Nonketotic Hyperglycemic State: fluid replacement is the most important step, especially when hypovolemia is present. Start with NS, then NS. May need 8-10 liters. 5% dextrose given when blood glucose < 250 to prevent cerebral edema. MCA Infarct: with aphasia, usually cerebral cortex on the left. Brocas is common and patients will have word finding difficulties. Rapid irregular rhythm -> atrial fibrillation -> cardiogenic source of embolus (could be caused by MI due to CAD).

Infectious Mononucleosis: fever, sore throat, toxic symptoms, pharyngitis, tonsillitis with exudates, LA usually in posterior chain, inguinal, axial. Can have jaundice and hepatitis. Can develop hemolytic anemia and thrombocytopenia due to anti-I Ab and usually Coombs (+). Non Inflammatory Chronic Prostatitis: afebrile with irritative voiding symptoms. Expressed secretions show no bacteria and normal WBCs. No history of UTI, but voiding problems may have been present in past. Bronchoalveolar Lavage: useful with suspected malignancy or opportunistic infection. >90% sensitive and specific for PJP (HIV, CD4 < 200) and less useful for diagnosis of interstitial disease. Can use sputum induction with hypertonic saline (high specificity, 50% sensitivity). ARDS: develops in setting of sepsis, pneumonia, toxins, trauma, burns. Alcoholism is further RF. PCWP < 18 (normal) indicates non-cardiogenic pulmonary edema. Serous Otitis Media: middle ear effusion without active signs of infection, dull TM that is hypomobile. MC middle ear pathology in AIDS. HIV LA or obstructive lymphomas -> auditory tube dysfunction. MC symptom is conductive hearing loss. Clopidogrel: secondary prevent in UA/NSTEMI for at least 12 months along with ASA, beta blocker, ACE, statins. Used for 30 days with bare metal stents and 1 year for drug eluting stents (epithelialization occurs slowly). Antagonize ADP as antiplatelet. Good in place of ASA in those who cannot tolerate. Pumonary Mechanics: compliance calculated by doing end inspiratory hold maneuver (elastic pressure is pressure at end of inspiration, higher with decreased compliance), airway resistance calculated by PAP, PEEP calculated by end-expiratory hold maneuver. Aortic Dissections: beta blockade is most appropriate initial intervention (lower HR and BP > decreased wall stress). Type A (ascending) need medication and surgery. Type B (descending) need medication only. HTN is leading risk factor. CT is good for diagnosis, TEE for those who cannot tolerate contrast. Malaria Prophylaxis: for chloroquine resistant (sub Saharan Africa, Indian subcontinent), mefloquine is the drug of choice. Use chloroquine for sensitive areas. Start 1 week before, and continue for 4 weeks after returning. Wegeners Granulomatosis: triad of systemic vasculitis, upper and lower airway granulomatous inflammation, GN (RBC casts, proteinuria, sterile pyuria). Nasal cartilage destruction (saddle nose, purpulent rhinorrhea, epistaxis, otitis, sinusitis) and vasculitic cutaneous lesions (tender nodules, palpable purpura, ulcerations). Positive c-ANCA to proteinase 3 and elevated CRP. Treat with cyclophosphamide. Treatment of Hepatitis: for hepatitis C: elevated ALT, detectable HCV RNA, histologic evidence of chronic hepatitis are candidates for treatment interferon and ribavirin. Interferon and lamivudine used for hepatitis B. Systemic Sclerosis: MC underlying mechanism of pulmonary disease is interstitialfibrosis. Vascular lesions can develop as well, but uncommon to be without fibrosis. Increased risk of aspiration due to esophageal dysmotility. Increased risk of lung cancer. Gonnococcemia: triad of polyarthralgia, tenosynovitis, painless vesiculopustular skin lesions. Can have fever and chills. History of recent unprotected sex with new partner. Usually no symptoms of symptomatic venereal disease.

Angioedema: ACE I are the MCC of acquired, usually one week after stopping drug. Edema in the face, lips, tongue, glottis, larynx. Occurs due to accumulation of bradykinin. Check for airway compromise and vasomotor instability -> epinephrine. Crohns Disease: suspect in young patient with diarrhea, abdominal pain, weight loss. Involves entire GIT. Associated with fistulae, structures, anal disease. Have anemia and reactive thrombocytosis. Asbestosis: pneumoconiosis from inhalation of particles. Progressive dyspnea, clubbing, endinspiratory crackles, restrictive lung pattern, decreased lung volumes, decreased DLCO, normal FEV1/FVC. Analgesic Nephropathy: MCC of drug induced chronic renal failure. Papillary necrosis and tubulointerstitial nephritis. Usually seen after 2-3 kg of drug ingestion. Polyuria and WBC casts, microscopic hematuria, renal colic. HTN, mild proteinuria, impaired urinary concentrating ability in late disease. Develop premature aging, vascular disease, urinary tract cancer. Acute Appendicitis: initial peri-umbilical pain is referred and visceral in nature. Pain shifts to RLQ with involvement of parietal peritoneum and becomes somatic in nature. NE Induced Vasospasm: alpha 1 agonist -> vasoconstriction, useful when trying to increase BP of hypotensive patients. Vasoconstriction -> ischemia/necrosis of distal fingers/toes that is symmetric. Can occur in intestines (mesenteric ischemia) or kidneys (renal failure). Cyclophosphamide: immunosuppressant used in SLE, vasculitis, cancers. SE are hemorrhagic cystitis, bladder carcinoma, sterility, myelosuppression. Drink fluids, void frequently, taking MESNA help prevent all complications. Male Incontinence: MCC in older men is bladder outlet obstruction due to BPH or carcinoma of the prostate. Present with post void dribbling, poor stream, hesitancy, urgency, nocturia, urinary retention. Will have enlarged prostate with high PVRV. T2DM: most patients require more than one oral agent, and some eventually need insulin. Metformin plus sulfonylurea (glyburide) is good combination. Assess renal status, metformin causes lactic acidosis. Also helps some weight loss. Bradyarrhythmia: SSS or conduction abnormality -> recurrent syncope (when HR < 30). Prolonged QRS suggests this (vs. prolonged QT -> tachyarrhythmia). CREST Syndome: calcinosis cutis (deposition of calcium in skin that manifests as nodules that may ulcerate and drain chalky material), Raynauds (white, blue, red), esophageal dysmotility (food stuck, GERD), sclerodactyly (fibrosis of skin distal to MCP joint -> shiny appearance, flexion contractures, joint pain), telangiectasias (mat like patches on face/palms). Limited form of systemic sclerosis. PE: proximal deep leg veins (iliac, femoral, popliteal) are MC source of symptomatic PE. Calf, renal, pelvic, upper extremity, and right heart are also possible locations. Ulcerative Colitis: most likely in a patient with subacute to chronic presentation of abdominal pain, tenesmus, bloody diarrhea. If symptoms are worsening, with signs of sepsis, toxic megacolon should be investigated with x ray. Carcinoid Syndrome: classic triad of flushing, diarrhea, wheezing. Tumors are in SI, appendix, colon, bronchi. Serotonin causes vasodilation. May also have abdominal pain,

heart palpitations, hypotension. Surgery to treat. If cannot be removed, use octreotide. Plaques of fibrous tissue can deposit on endocardium of right heart. y Nasal Polyps: chronic rhinosinusitis, asthma, ASA/NSAID induced bronchospasm (aspirin exacerbated respiratory disease, AERD). Symptoms of bilateral nasal obstruction, nasal discharge, anosmia. Bilateral gray glistening mucoid masses in nose. Diffuse Esophageal Spasm: spontaneous pain, odynophagia for hot and cold foods. Nitrates and CCB also alleviate chest pain. Do esophageal manometry to show repetitive, nonperistaltic, high amplitude contractions spontaneously or after ergonovine stimulation. CLL: MC type of leukemia in western countries. Older patients with incidental lymphocytosis. Lymphadenopathy, infections (low IgG), small over mature lymphocytes, smudge cells. Do LN biopsy to confirm. Pituitary Tumor:prolactinoma is the MC and present with galactorrhea and hypogonadism. Others: somatotroph, corticotroph, thyrotroph, gonadotroph, craniopharyngioma. Due to rich blood supply, it is susceptible to metastases. Hypothyroidism: important cause of reversible change in memory and mentation. Accompanied with weight gain, fatigue, constipation, hoarseness. Triptans: pregnancy testing should always be done in women of reproductive age. It is a CI. Other CI: familial hemiplegic migraine, uncontrolled HTN, CAD, Prinzmetals angina, ischemic stroke, basilar migraine. Aspergillosis: occurs in immunocompromised patients with fever, cough, dyspnea, hemoptysis. CXR shows cavitary lesion, CT shows nodules with halo sign or lesions with air cresecent. Leprosy: suspect in Asian patient with insensate hypopigmented patch of skin caused by Mycobacterium leprae. Peripheral nerve damage -> muscle atrophy. Diagnosis made by acid fast bacilli on skin biopsy. Lymphadenopathy: small (< 1 cm) cervical LN are common in children and young adults. Asymptomatic soft LN can be observed. MC due to URI. Malignant/granulomatous disease are hard and immobile, > 2 cm. Fevers, chills, weight loss, enlarging are worrisome. In older smoker -> metastatic or oropharyngeal cancer. Mycoplasma Pneumonia: atypical with indolent course, non productive cough, and higher likelihood of extrapulmonary manifestations. CXR out of proportion to PE. Erythema multiforme (dusky red target lesions over extremities). No cell wall = no stain. Only PMN in sputum. MCC of atypical pneumonia. Respiratory Alkalosis: increased pH with primary decrease in PaCO2. Commonly due to hyperventilation due to pneumonia, high altitude, salicylate intoxication. Bicarbonate will decrease slowly due to renal compensation. Spinal Stenosis: MC caused by degenerative disk disease with low back and leg pain. Also called neurogenic claudication. Pain worse with walking, but leg pain is position dependent and persists when standing still. Claudication is exertion dependent. Diagnosed by MRI. Treated conservatively or with laminectomy. Community Acquired Pneumonia: levofloxacin or moxifloxacin are first choice for inpatient treatment. Azithromycin or doxycycline for outpatient. Pneumonia Severity Index determines inpatient vs. outpatient. MCC is pneumococcus. Also H flu and Moraxella.

Diphenhydramine Overdose: antihistamine effects of drowsiness, confusion, and anticholinergic effects like dry mouth, dilated pupils, blurred vision, decreased bowel sounds, urinary retention. Physostigmine (cholinesterase inhibitor) can help reverse. Open Angle Glaucoma:more common in AA and is asymptomatic in the beginning. Gradual loss of peripheral vision -> tunnel vision. High IOP, optic disc cupping. Do annual eye exams. Use timolol drops initially. Then can do laser or surgical trabeculectomy. TTP HUS: unexplained normocytic hemolytic anemia with reticulocyte response and thrombocytopenia in patient with renal failure and neurological symptoms. HIV increases risk (but causes FSGS independently). Fever does not have to be present. MAHA can occur in DIC (abnormal coagulation) and malignant hypertension (high BP and retinopathy). CHF: low CO -> increased pulmonary vascular pressure -> transduction of fluid into air spaces -> edema and effusion -> absence of lung sounds, dullness to percussion. Pagets Disease: osteoclast dysfunction & compensatory bone formation -> mosaic bone pattern, high ALP, femoral bowing. Bone, joint pain, skeletal deformities, hearing loss (CN VIII trapping), increasing hat size are common. Can have fractures and osteosarcoma. Mitral Stenosis: atrial fibrillation, signs of pulmonary edema. Rheumatic fever is MCC. Due to strep pyogenes infection, common in countries without antibiotics. Presents during pregnancy due to increased intravascular volume. Have diastolic rumble and opening snap. Acid Base Status: pH and PaCO2 are best values to determine status. HCO3 is calculated from Henderson-Hasselbalch equation. pKa of CO2/HCO3 pair is 6.1. Ventricular Free Wall Rupture: occurs during remodeling post MI. MC presents 3-7 days after (along with papillary muscle rupture), upto 2 weeks. Rapid onset PEA is a result of tamponade -> shock -> sinus tachycardia. Do pericardiocentesis. Drug Induced Pancreatitis: usually mild. CT is diagnostic. Diuretics (furosemide, thiazides), IBD (sulfazalazine, 5 ASA), immunosuppressants (azathioprine, L-asparaginase), seizures or bipolar (valproic acid), AIDS (didanosine, pentamidine), antibiotics (metronidazole, tetracycline). MI: ischemia -> diastolic dysfunction and stiff LV -> atrial gallop (S4). Vasovagal Syncope: also called neurocardiogenic, due to excessive vagal tone. Preceded by nausea, diaphoresis, tachycardia, pallor. Pain, stress, situations with needles and urination can precipitate. Common in young women. Diagnosed with tilt table test. Parvovirus B19: arthritis of MCP, PIP, wrist, ankle joints. Anti-B19 IgM is diagnostic. Frequent contact with children is diagnostic. MCC of viral arthritis (polyarticular and symmetric), also HIV, hepatitis, rubella. May not have other symptoms, resolve in 2 months. Wernickes Encephalopathy: patients with acute delerium or acute ataxia, especially in low BMI or alcoholism. Other treatments for acute delerium: dextrose for hypoglycemia (thiamine before), oxygen for hypoxia, naloxone for opiate overdose. Primidone: anticonvulsant used to treat essential tremor. Can precipitate acute intermittent porphyria -> abdominal pain, neurologic, psychiatric abnormalities. Diagnosed by checking urine porphobilinogen. Adrenal Tuberculosis:clinical features of adrenal insufficiency and calcifications in adrenal glands. MCC of primary insufficiency in developing countries. Autoimmune is MCC in

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developed countries. Fungal, CMV are other causes. Treatment of TB does not help adrenal. Need lifelong glucocorticoid and mineralocorticoid treatment. y Acute Iron Intoxication: 5 phases: GI phase (30min-6hrs) of direct mucosal damage, latent phase (6-24hrs) is asymptomatic, shock and acidosis (6-72hrs), hepatotoxicity (12-96hrs), obstruction (several weeks) due to scarring. Serum iron to diagnose (usually > 350 mcg/dL). Airway Obstruction: always rule out first with sudden onset SOB. Will have dyspnea, difficulty swallowing, may have history of food allergies, urticaria, laryngeal edema. May have stridor and harsh respiratory sounds. Atrial Fibrillation: MC chronic arrhythmia in adults, irregularly irregular with rapid heart rate. Need rhythm/rate control and anticoagulation. Flash Pulmonary Edema: usually due to acute heart failure (MI). Use diuretic such as furosemide -> decreases preload and venodilates. Beta blockers are CI because they can worsen heart failure. Also give morphine, nitrates, oxygen, PTCA/thrombolysis, anticoagulation. Lower Extremity Edema: venous hypertension (not likely in dehydrated patient), lymphatic obstruction (with history of lymphadenectomy, lymphadenopathy, lymphangitis), capillary leak (will have hemosideran depisition), trauma, infection. In malnourished patient, decreased oncotic pressure -> edema. Thyroid Cancer: MC is papillary carcinoma and has best prognosis. Papillary, follicular, and anaplastic all arise from follicular/epithelial cells. History of radiation and family history are important risk factors. More common in women. Compression Fracture: occur with decreased bone mineralization and density. Diagnosing underlying cause is important in decreasing risk of future fractures. Bartters Syndrome: hypokalemia, urine chloride > 20, metabolic alkalosis, normal BP. Have polyuria, polydipsia, growth & mental retardation. Defective sodium and chloride reabsorption in LOH -> hypovolemia and activation of RAAS -> K and H excretion. Metformin: causes lactic acidosis (which is potentiated by renal failure) and should be discontinued in setting of renal failure, hepatic failure, sepsis. PAC: premature activation of atria from ectopic source. Early P wave, single or bigeminy. Can cause palpitations. Can result in SVT. Treatment needed if cause distress or SVT. Tobacco, alcohol, caffeine, stress can all precipitate. Beta blockers are helpful in symptomatic patients. Interstitial Nephritis: cephalosporins, PCNs, sulfonamides, NSAIDs, rifampin, phenytoin, allopurinol. Can have fever and rash. Discontinue offending agent. Gluconeogenesis: main substrates are alanine, lactate, and glycerol-3-phosphate. Pyruvate is an intermediate of alanine during the process (via ALT). Orthostatic Hypotension: postural decrease in BP by 20 mmHg systolic or 10 mmHg diastolic. Due to inefficient constriction of resistance and capacitance vessels in LE due to defect in reflexes, medications, low volume state. Arterial stiffness, decreased NE content of nerve endings, and decreased myocardial sensitivity contribute. Prerenal ARF: due to insufficienct arterial perfusion (dehydration). Reversible with fluids, but prolonged hypoperfusion -> renal failure due to ischemia. Elderly at greatest risk. Worse with ACE, diuretics, NSAIDs which blunt response to low volume.

Insulinoma: classic symptoms of hypoglycemia. MC pancreatic tumor. Have high insulin and high C peptide. Whipple Triad: episodic hypoglycemia, temporary CNS dysfunction, reversal of CNS abnormalities by glucose administration. Pericardial Effusion: enlarged, water bottle shaped cardiac silhouette. Diminished heart sounds, difficult to palpate PMI. Anserine Bursitis: localized pain over the anterior medial tibial plateau just below the medial joint line. Valgus stress and x rays are normal. Can be caused by abnormal gait, overuse, trauma. Pain may present overnight. Rest, ice, steroid injections. Iron Poisoning: disrupts basic cell processes (free radial and lipid peroxiation) -> hematemesis, abdominal pain, shock, metabolic acidosis. Occurs in children of pregnant mothers (supplements are brightly colored). Treat with deferoxamine which binds iron and allows urinary excretion. Secondary Amyloidosis (AA): result of chronic systemic inflammation with AI, chronic infections, IVDA, psoriasis, IBD. Causes nephrotic and palpable kidneys, hepatomegaly, cardiomyopathy, pseudohypertrophy, peripheral neuropathy. Proteins deposit as beta pleated sheets in tissue. New Drugs: if prolongs survival, incidence does not change, prevalence increases. Water Disturbances: DI: polyuria, polydipsia, excretion of dilute urine with elevated serum osmolarity. Primary polydipsia: excessive water drinking, both plasma and urine are dilute. SIADH: hyponatremia, serum dilute, urine very concentrated. MI: strongest influence on long term prognosis of STEMI is duration that passes before blood flow is restored via PTCA or fibrinolysis. PTCA is choice treatment and should be done within 90 minutes. Fibrinolysis should be done within 30 minutes. Corrected Calcium: 0.8 (4 measured albumin) + measured calcium. Suspect in patients with liver disease. Polycythemia Vera: increased RBC mass and totcal circulating volume. Old male with pruritis after bathing. Hyperviscosity symptoms. Thrombosis and bleeding due to elevated platelet count and low functionality. Reversible moderate HTN. Granulocytosis, splenomegaly, hypercelluar bone marrow, elevated LAP, normal O2 saturation. Low serum/urine erythropoietin. Cutaneous Larva Migrans: common in travelers to tropical regions. Have pruritic, elevated, serpiginous, brown-red lesions on the skin which elongate. Infection often acquired by contact with sand. Caused by dog and cat hookworm and infection occurs by contact with feces. SIADH: euvolemic hyponatremia, decreased serum osmolarity, elevated urine osmolarity (> serum), high urine sodium, failure to correct with NS. Non Alcoholic Steatohepatitis: RF are obesity, DM, hyperlipidemia, TPN, use of certain medications (steroids, amiodarone, diltiazem, tamoxifen, HAART). Impaired responsiveness of fat cells to insulin -> steatosis -> steatohepatitis -> fibrosis due to lipid peroxidation and oxidative stress. Mild ALP elevation, AST/ALT < 1. Control underlying condition. UDCA helps decrease transaminase levels.

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Arrhythmia: sudden onset syncope without warning, presence of heart disease (post infarction, ectopic beats. Diuretics -> electrolyte abnormalities -> arrhythmia. Clonic jerks can occur due to brain hypoxia. G6PD Deficiency: XLR common in AA men. Episodic hemolysis in response to oxidant drugs, infections, fava beans. Heinz bodies seen on blood smear. G6PD needed to make NADPH to make glutathione to prevent Hgb oxidation. Otherwise denatures into Heinz bodies -> disrupts RBC membranes -> hemolysis. PE: common cause of pleuritic chest pain. Young person with tachycardia, dyspnea particularly if on OCP. Will have subsequent minor or massive infarction. CLL: see smudge cells on smear with small mature lymphocytes. Can have splenomegaly, anemia, thrombocytopenia (associated with poor prognosis). Allergic Contact Dermatitis: can be due to exposure to toxic plants, appear in linear fashion > edema, vesiculation, erosion with weeping drainage. Type IV cell mediated hypersensitivity. Lateral Epicondylitis: pain with supination or extension of the wrist and point tenderness just distal to the lateral epicondyle. Due to repeated forceful wrist extension and supination (tennis, screwdriver) from degeneration of extensor carpi radialis tendon. Septic Shock: distributive shock due to vasodilation. Hyperdynamic circulation and elevated CO. Normal MVo2 due to hyperdynamic circulation and improper distribution of CO. Indicates not normal tissue perfusion! Also have low RAP and PCWP. Psoriatic Arthritis: usually involves DIP joints. Morning stiffness, deformity, dactylitis (sausage digit), nail involement. NSAIDs, anti-TNF, methotrexate. Steroids are CI. Can also see classic psoriasis lesions on hands (red plaques with silvery scale). Klebsiella: encapsulated, G(-) bacillus that can cause pneumonia in subjects with debilitating conditions such as alcoholics. Also called Friedlanders pneumonia usually affects upper lobe and has currant jelly sputum. Usually due to microaspiration. G(-) pneumonia more common in infants, elderly, alcoholics, immunocompromised. Grows as mucoid colonies. Cardiac Tamponade: deadly consequence of aortic dissection. Hypotension, tachycardia, heart failure. Blood impairs filling -> decreased preload and CO. Syncope from decreased cerebral blood flow. Pulsus paradoxus: disappearance of pulse on inspiration. Pseudogout: acute inflammatory arthritis due to CPPD crystals which are rhomboid shaped and (+) birefringent. Also have radiographic evidence of chondrocalcinosis (calcified cartilage releases crystals). Occurs during recent surgery or medical illness. Nocardia: filamentous, aerobic, G(+) soil bacterium that is partially acid fast and causes pulmonary or disseminated disease in immunocompromised hosts. Treat with TMP-SMX. Can be confused with TB or Actinomyces. Have cough with purulent sputum. Can have alveolar infiltrates with nodules and cavitation. Can have SQ or brain abscesses. Beta Blocker Overdose: AV block, bradycardia, hypotension, wheezing, potential cardiogenic shock. Treat with atropine and IVF, if not, treat with glucagon -> increased cAMP and higher calcium levels -> cardiac contractility augmentation. G6PD Deficiency: acute hemolysis after ingesting primaquine or sulfa drugs. G6PD activity is normal during acute hemolytic episode. Smear reveals bite cells.

Febrile Neutropenia: medical emergency with single temperature > 38.3/101.3 or > 38/100.4 for 4 hours in neutropenic patient. ANC < 500. Chemotherapy -> impaired immune function & disruption of skin/mucosal barrier. Seen in GIT and are usually G(-) and Pseudomonas. Take blood cultures and start 3rd or 4th generation cephalosporin (ceftazidime or cefepime). Brain Death: total loss of brain function and legally acceptable as definition of death. Absent CN reflexes, fixed dilated pupils, no spontaneous breaths. Confirm with another physician first. SLE: pancytopenia is common. Occurs due to formation of autoantibodies against blood cells (Type II hypersensitivity). Anemia due to autoimmune hemolysis due to warm IgG Ab against RBCs. Thrombocytopenia is ITP like. Neutropenia is less common. Central Hypogonadism: low testosterone and low or inappropriately normal FSH/LH. Uncontrolled diabetes -> low GnRH. With well controlled diabetes, measure prolactin which inhibits GnRH release (possible pituitary adenoma). Molluscum Contagiosum: multiple dome shaped lesions with central umbilication caused by pox virus. Opportunistic skin infection in HIV infected patients but can occur in normal individuals. Occurs with CD4 < 100. Conjunctivitis can occur if lid margins are involved. Parkinsons Disease: resting tremor that improves with activity is often presenting symptom. Usually starts in one hand and then involves all extremities. Loss of DA neurons in basal ganglia that causes tetrad of rigidity, tremor, bradykinesia, postural instability. Tremor will not involve entire head, unlike essential and cerebellar tremors. Pseudodementia: suspect in elderly patients with dementia in setting of severe depression. Treat with antidepressants. Herpetic Whitlow: common viral infection of the hand caused by HSV 1 or 2. Self limiting. Health care workers that come into contact with orotracheal secretions (dentists) are increased risk. Seen also in women with genital herpes or children with herpetic gingivostomatitis. Throbbing pain in pulp space, (+) exposure history, multinucleated giant cells on Tzank smear. PE: CXR is normal in most cases. Sinus tachycardia is MC EKG finding. Tophaceous Gout: urate crystals can deposit in skin resulting in formation of chalky white tumors. Starts with asymptomatic hyperuricemia -> monoarticular arthritis, podagra (great toe), nephrolithiasis of uric acid stones. Tophi can ulcerate and drain chalky material. Can be seen in RA and calcinosis. Diuretics are RF due to hypovolemia associated uric acid reabsorption. G6PD Deficiency: can have positive Prussian blue stain in urine due to hemosiderin due to hemolysis. Attacks precipitated by sulfa drugs, antimalarials, nitrofurantoin. Addisons Disease: aldosterone deficiency -> non anion gap hyperkalemic hyponatremic metabolic acidosis. Can be caused by TB -> adrenals. Histo, coccidio, crypto, sarcoid can also cause. Normally, aldosterone reabsorbs Na for K/H. If deficienct, holds on to K/H. 3rd Degree Heart Block: complete independence of P waves from QRS. Needs pacemaker placement due to risk of VT or VF. QRS usually > 120 msec. V rate is usually low -> dizziness and hypotension.

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Aortic Dissection: pregnancy is associated due to connective tissue changes. Bicuspid valve, Marfans, coarctation are also risks. If HTN is present, must be controlled before any other studies are done. ECG changes due to involvement of ostia (usually RCA) -> inferior ischemia. TIA: cerebral ischemia -> focal neurological dysfunction < 24 hours. Always do head CT to distinguish ischemia from bleed. If thrombosis is suspected, give antiplatelet agent (ASA). Warfarin good for cardiogenic emboli. Treatment is important due to high risk of another. Sleep Apnea: morbidly obese middle aged man with daytime sleepiness, morning HA, increased fatigability and snoring. Can see mild HTN which improves with treatment. Treat with weight reduction, avoid sedatives/alcohol, avoid supine sleeping as first step. CPAP and UPPP also help. Ankylosing Spondylitis: seronegative spondyloarthropathy that affects men < 40. Classically back pain is worse in morning and gets better during day. Low back pain and stiffness that limits back motion and chest expansion. Also have arthritis of peripheral joints and uveitis. X ray shows SI inflammation. Elevated ESR, negative RF, associated with HLA-B27. Anti-TNF used for treatment. Hypercalcemia of Malignancy: due to osteolytic metastases, increased production of PTHrP, increased Vit D production, increased IL-6. Usually have low PTH levels. Higher calcium than in hyperparathyroid. MCC of hypercalcemia in inpatients. Asymptomatic Thrombocytopenia: presenting symptom of HIV in upto 10% of people. May have a history of travel -> possible multiple sexual partners. Mammogram: perform every 2 years starting at age 50 with average risk, and not beyond 75. SBE is no longer emphasized. Cholesterol Screening: age 35 in men, 45 in women in those with average risk. Yield decreases in the elderly. Check every 5 years in patients with normal risk and previously normal lipids. Acute Pyelonephritis: present with fever, chills, nausea, vomiting, flank/suprapubic/ costovertebral angle tenderness. Require hospitilization and IV antibiotics for complicated cases like with hypotension. Atrial Fibrillation: patients are at risk for strokes and need anticoagulation. With no other RF, use ASA. With CHF, HTN, age > 75, DM, previous stroke/TIA, valvular disease, use warfarin. ED: in the setting of pelvic fractures with urethral injuries, usually caused by parasympathetic nerve injury and altered arteral supply. Failure to achieve erections during sleep (REM) and morning is pathognomonic. Venogenic can occur after penile fracture. Sysetmic can be due to low testosterone or high prolactin. Nephrotic Syndrome: membranous is the most common associated with malignancy. MCD is a common association with Hodgkins lymphoma, but can also see FSGS. Will resolve with lymphoma treatment. Angiofibroma: male adolescent with epistaxis, localized mass, bony erosion on back of nose. Usually found in nose or nasopharynx. Only treated by specialists. Sometimes no treatment is needed. If enlarging, obstructing the airway, frequent epistaxis -> removal, but high recurrence.

Sarcoid: presents in black females with hilar LA presenting with dyspnea, fever, weight loss. High association with erythema nodosum (painful skin lesions on the shins). Non caseating granulomas on biopsy, serum Ca and ACE are elevated. Treat with steroids. Metabolic Acidosis: always calculate AG [Na (Cl+HCO3)] to narrow DD. Normal is 6-12. Increase means there is an accumulation of non chloride acids -> lactic acidosis, ketoacidosis, methanol ingestion (formic acid), ethylene glycol (oxalic and glycolic acid), salicylates, uremia (NH4). Cataract: vision impairing disease characterized by blurred vision and glare (night driving) due to lens thickening. Oxidative damage occurs with aging. Treat with lens extraction. Will have loss of transparency of the lens. Nail Puncture Wound: if results in osteomyelitis in an adult, likely Pseudomonas, especially through rubber sole. Do blood culture or bone biopsy. Treat with IV quinolones and surgical debridement. Staph aureus is MCC of regular osteomyelitis in children and adults. Tetanus does not cause osteomyelitis. SBP: can have subtle presentation and should be considered in cirrhotic patients with ascites and fever/mental status changes. TOC is paracentesis (before antibiotics) with (+) culture and > 250 PMNs. Abdominal pain is often less prominent. E coli and Klebsiella are common. Give 3rd generation cephalosporin. Thyroid Nodule: first step in management is TSH level. Chronic Hepatitis C: can cause membranoproliferative (or membranous) GN characterized by proteinuria. Can cause cryoglobulins, B-cell lymphoma, plasmacytomas, AI disease, lichen planus, porphyria cutanea tarda, ITP. Alzheimers Disease: MCC of dementia in US. Early signs are visuospatial defetcs (getting lost in neighborhood) and anterograde memory loss. Personality and behavior changes may occur as disease goes on. Hallucinations, change in alertness, gait impairment, urinary incontinence are late findings. X Linked Hypophosphatemic Rickets: suspect in patients with rickets with normal calcium, ALP, PTH, 25 vitamin D. Have low phosphate due to renal wasting. May be deficit in 1 hydroxylase and can have low calcitriol. Hypercalcemia of Immobilization: prolonged rest -> accelerated bone resorption likely due to osteoclastic activation. Usually occurs within days, upto weeks. Develop severe osteopenia, and bisphosphanates decrease osteoclast activity and reduce risk of osteopenia. Renal failure usually -> hypocalcemia due to binding of phopsphate. Wilsons Disease: AR, also called hepatolenticular degeneration. Low formation and secretion of ceruloplasmin and low secretion of copper in biliary system. Causes free radical formation. Likely in patient < 30 with unexplained chronic hepatitis. Low ceruloplasmin, increased copper excretion, and Kayser-Fleisher rings are diagnostic. Have neuropsychiatric symptoms due to deposition in basal ganglia. Treat with d-penicillamine, trientene to chelate copper. Zinc also prevents copper absorption. Can have liver transplantation. Multiple Sclerosis: female with recurrent attacks of focal neurological dysfunction with nonpredictable time intervals. Focal demyelination usually in periventricular or subpial white matter of cerebrum, optic nerves, brain stem, spinal cord. Do MRI to diagnose. Steatorrhea: diarrhea secondary to fat malabsorption -> pale, malodorous, voluminous stools that are difficult to flush. If accompanied with epigastric pain -> chronic pancreatitis

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(alcohol is MCC). Do 72 hour quantitative fecal fat to diagnose. Can have glucose intolerance. CT can show calcifications and ductal dilation. y Schilling Test: differentiates dietary deficiency from pernicious anemia. Dietery deficiency: oral radiolabeled B12 is absorbed in gut and excreted in urine in normal amounts. Diminished excretion -> impaired absoroption. Give next dose with IF. Normal excretion = pernicious anemia. Low excretion = short gut, pancreatic insufficiency, bacterial overgrowth. Steroids: cause neutrophilia by increasing bone marrow release and demarginating neutrophil pool. Eosinophils and lymphocytes are decreased. Cryptosporidium: major cause of chronic diarrhea in HIV patients with CD4 < 180. Modified acid fast stain of stool shows oocysts. Can occur in immunocompetent and HIV with CD4 > 180 but is self-limited. ESRD: treatment options are transplant or dialysis. Renal transplant has better survival rates and QoL. Living related > living non-related > cadaver. Anemia, bone disease, HTN persist with dialysis. Transplant patients have better return to normal function. Autonomic neuropathy is worse with dialysis. Survival 95% at 1 year, 88% at 2 years. Hypertrophic Pulmonary Osteoarthropathy: clubbing and sudden onset arthropathy in a chronic smoker or other pulmonary disease (cancer, TB, bronchiectasis, emphysema). Associated with lung cancer, do a CXR to rule out or look for other pathology. DKA: causes anion gap metabolic acidosis. Have polyuria, polydipsia, nausea, vomiting, abdominal pain that may present like surgical abdomen. Graft vs Host Disease: common after bone marrow transplant. Caused by recognition of major and minor MHC by donor T lymphocytes and cell mediated immune response. Affects skin (maculopapular rash on palms, soles, face), intestine (bloody diarrhea), liver (abnormal LFTs and jaundice). H1 Antihistamines: decrease nasal inflammation and PND (dry cough) in patients with allergic rhinitis by blocking nasal secretions. Chlophenirimine blocks H1 receptors and is anti-inflammatory blocking histamine release from mast cells. Cerebellar Tumors: ipsilateral ataxia, nystagmus, intention tremor, loss of coordination, ipsilateral muscular hypotonia, difficulty performing rapid alternating movements. Fall towards side of lesion. Sway to affected side. Obstruction of CSF -> HA, nausea, vomiting, papilledema. Central Retinal Artery Occlusion: painless loss of monocular vision due to embolism. Ophthalmic artery is first intracranial branch of ICA -> CRA and ciliary branches to the anterior globe and choroid. Associated with amaurosis fugax before occlusion. May have retinal whitening or cherry red spots. Treat with high flow O2 and ocular massage. Dacryocystitis:inflammatory changes at medial canthus, infection of the lacrimal sac. Occurs in infants or > 40. Staph aureus and beta hemolytic strep are MCC. Responds to systemic antibiotics. Aspiration Pneumonia: consider in patient with recurrent pneumonias, usually due to excessive alcohol intake. Foul smelling sputum and RLL pneumonia. Also occurs in altered consciousness, dysphagia, neurological disorders, sedation. Factitious Thyrotoxicosis: ingestion of exogenous thyroid hormone. Have signs or symptoms of hyperthyroid but no goiter or exophthalmos. TFT shows low TSH, high T3 and T4.

Diffusely decreased radioiodine uptake. Biopsy shows follicular atrophy. Consider in patient trying to lose weight, psychiatric disease, low BMI. y DKA: teenager presenting with metabolic acidosis, polyuria, dehydration, decreased consciousness, abdominal pain in setting of ongoing infection (releases cortisol and catecholamines which are anti-insulin). Excess glucagon -> hyperglycemia, ketonemia, osmotic diuresis -> loss of potassium stores even with normal/high serum K. Acidosis and low insulin pushes K into extracellular fluid. DM: fasting blood glucose is MC screening test. Diagnosis requires 2 separate FBG measurements > 126. Pernicious Anemia: MCC B12 deficiency -> macrocytic anemia, glossitis, peripheral neuropathy. Anti-intrinsic factor decreases absorption, also develop chronic atrophic gastritis -> increased risk of intestinal type cancer and carcinoid tumors by 2-3x. Period FOBT for cancer is needed. Heat Stroke: defined as temperature > 105. Exertional type occurs in healthy individuals exercising in extreme heat. Dehydration, hypotension, tachycardia, tachypnea. Seizures, ARDS, DIC, hepatic/renal failure may also occur. High humidity may prevent sweating, can be exacerabated by medications with anticholinergic activity. Dejerine Roussy Syndrome: thalamic stroke. Usually VPL thalamus which transmits sensory information from contralateral side of body. Contralateral hemianesthesia with transient hemiparesis, athetosis, ballistic movements. Severe dysesthesia (thalamic pain) is common. OA: non-inflammatory arthritis presenting with pain worse with activity improved with rest X rays show joint space narrowing and osteophytes. Synovial fluid analysis shows WBC < 2000, no organisms, no crystals. Increasing age is leading RF. Morning stiffness < 30 minutes. Chronic Hepatitis B: elevated ALT, detectable HBsAg, HBeAg, and HBV DNA should be treated with interferon and lamivudine. Degree of ALT elevation indicates response to medication. ALT 2x normal is likely to respond versus normal ALT. Lamivudine is oral and has less SE. Loop Diuretics: cause reversible or permanent hearing loss or tinnitus. Typically occur in those taking high dose, those with renal failure, or patients taking other ototoxic drugs (aminoglycosides, chemotherapy, ASA). Neonatal Hepatitis: newborns of mothers with active HIV infection should be passively immunized with HBIG followed by active immunization with the recombinant HBV vaccine. Common in infections during 3rd TM. Higher with HBeAg(+), high chance of chronic hepatitis. Nocardia: crooked, branching, beaded, G(+), partially acid fast filaments on microscopy. Treat with TMP-SMX (prophylaxis too). Minocycline is alternative. Present in soil, causes pulmonary, CNS, skin infections. Deficiency cell immunity at high risk. Usually starts as subacute pneumonia. Amebic Liver Abscess: contain debris described as anchovy paste, but cyst aspiration is not recommended. Treatment is oral metronidazole. Recent immigration, RUQ pain, tender solitary abscess. Caused by Entamoeba histolytica, can cause dysentery, brain, cardiac, pulmonary involvement. CT or MRI plus leukocytosis and elevated ALP. Also serum testing. Primary Hyperparathyroidism: MCC hypercalcemia in ambulatory patients. Usually asymptomatic and found on routine screening. Usually solitary adenoma. Could be hyperplasia, multiple adenomas, cancer. May have stones and low bone density.

Correlation Coefficient: shows the strength and direction of a linear association between two variables and does not imply causality. Respiratory Acidosis: acidosis with hypercarbia and normal/elevated bicarbonate. Hypoventilation is a major cause, especially in the post-ictal state (could be due to aspiration). Can also have hypoxia. Lupus Anticoagulant: also called anti-phospholipid antibody. Prothrombotic Ab that causes a long PTT. Present with VTE and lupus symptoms, previous miscarriages. IgM or IgG that binds to phospholipids used in assay (laboratory effect). Will not correct on mixing study. Russell viper venom test is prolonged. Sarcoidosis: MC in AA women during 3rd or 4th decades. Lungs are MC affected. Cough, erythema nodosum, anterior uveitis (red eye with leukocytes in anterior chamber), arthritis. Hilar LA and reticular opacities on CXR. Microcytic Anemia: iron studies are always indicated. Useful in diagnosis of iron deficiency as the cause. Thalssemia (normal to high iron and ferritin), ACD (low TIBC, normal or high ferritin), sideroblastic (normal to high iron and ferritin) are also causes. Pneumococcal Vaccine: 23 valent capsule polysaccharide pneumococcal vaccine induces a T cell independent B cell response. Recommended over 65, infants/young children, < 65 with heart failure, renal failure, cirrhosis, chronic lung disease. Polysaccharides cannot be presented to T cells, only peptides. DEXA scan: USPSTF recommends one time screening for all women > 65, > 60 with RF. T score compared to younger individual of same gender and race. -1.5 to -2.5 is osteopenia, < 2.5 is osteoporosis. High risk in post menopausal women. Diabetic Neuropathy: TCAs are DOC. Can worsen urinary symptoms and cause orthostatic hypotension. Gabapentin is the alternative. Usually present at rest and worse at night. As it progresses, pain subsides and disappears, whereas sensory deficit stays. Small fiber is more pain and allodynia, large fiber is more sensory loss, low proproceiption, no ankle jerk. Dysphagia: do a barium esophagram first before endoscopy. Dysphagia for liquids and solids suggets a motility disorder whereas obstruction presents with solid dysphagia -> progresses. Barium study is safer in those with upper esophageal lesions or stricture. Condyloma Acuminata: verrucous, papilliform anogentical lesions that are skin colored or pink versus condyloma lata which are flat and velvety. Treat with chemical/physical agents (tricholoacetic acid, 5FU epinephrine gel, podophyllin), immune therapy (imiquimod, interferon alpha), surgery (cryosurgery, excision, laser). Neonatal Conjunctivitis: chemical is usually mild and due to prophylactic silver nitrate drops. Gonococcal is purulent copious drainage 3-5 days after birth. Chlamydial is milder and is > 5 days after birth. Gonococcal -> contact with infected secretions -> ulceration and blindness. Can do stain and culture on Thayer Martin agar. Primary Hyperaldosteronism: persistently elevated BP, hypokalemia, metabolic alkalosis, mild hypernatremia, low renin, absent edema. Increased salt and water retetion with aldosterone escape and natriuresis. Acute Pericarditis: typically occurs in first several days after an MI. Sharp pleuritic pain worse when lying down and better when sitting up and leaning forward. Diffuse ST elevations with PR depression is common. Friction rub may be heard.

Bacillary Angiomatosis: Bartonella is the cause in immunocompromised individuals. Present with cutaneous and visceral angioma like blood vessel growths. Antibiotics lead to regression. Whipples Disease:multisystem disorder caused by G(+) bacillus, Tropheryma whippelli. Chronic malabsoptive diarrhea, migratory non deforming arthritis, LA, low grade fever, damage to eye, CNS, myocardium. SB biopsy with PAS(+) macrophages. Vomiting: produces metabolic alkalosis due to unbalanced loss of H+ ions and due to contraction alkalosis. Produces a compensatory respiratory acidosis with hypoventiation. Esophageal Varices: do screening endoscopy in all new diagnoses of cirrhosis to detect varices. If detected, use beta blocker as prophylaxis to reduce hemorrhage risk. Nitrates are sometimes added. Hypernatremia: MCC is hypovolemia. Mild cases can be treated with D5W NS. Severe cases should be treated with NS switched to NS. Correct at 1 mEq/L/h. Greater can cause cerebral edema. Hyperkalemia:give IV calcium gluconate to stabilize cardiac membrane. Use insulin, glucose, sodium bicarbonate and beta-2 agonists (albuterol) to drive K intracellularly. Craniopharyngiomas: benign tumors of Rathkes pouch. More common in children and older adults. Presents with hypopituitarism -> retarded growth in children (GH and TH deficiency) and sexual dysfunction in adults (amenorrhea). Have bitemporal hemianopsia and HA. Treat with surgery or radiotherapy. Alpha 1 Antitrypsin Deficiency: non smoking adults < 45 years old with pan lobular emphysema (centrilobular in smoking). Causes liver disease (may present as neonatal hepatitis, cirrhosis, liver failure). Measure serum A1AT. SAH: vasospasm is major cause of M&M. CCB (nifedipine) are used to prevent vasospasm. Signs of ischemia appear 7 days after bleed. Postictal Lactic Acidosis: transient anion gap metabolic acidosis that resolves without treatment after 60 to 90 minutes after cessation of seizure activity. Excess production of lactic acid and decreased hepatic uptake. Observe and repeat chemistry panel in 2 hours. Prolactinoma:< 10 mm is a microadenoma. Presents as amenorrhea and galactorrhea, hypogonadism in males. Primary treatment is DA agonists such as bromocriptime or cabergoline (better drug). Emphysematous Cholecystitis: secondary infection of the GB wall with gas-forming bacteria. Typically older males. RF are vascular compromise, immunosuppression, gallstones. Complications are gangrene and perforation. Air fluid levels in GB. Treat with fluids, electrolytes, early surgery, and antibiotics. Normal Aging: tiredness, occasional forgetfulness, occasional word finding difficulty, trouble falling asleep. Dementia not diagnosed until there are functional impairments. Cellulitis: caused by beta hemolytic strep and Staph aureus. With systemic signs of fever, chills, malaise, fatigue, treat with IV nafcillin or cefazolin. Vancomycin for MRSA. Chronic fungal foot infections serve as a nidus for celluitis and eradicate in patients with recurrance.

Cancer Pain Management: try non-narcotic measures first unless patient is in severe pain. Do not be afraid to give narcotics. Prescribe adequate amounts. After NSAIDs, try short acting morphine until under control, then use long acting patches or narcotics. MS: patchy neurological problems, optic neuritis (painful loss of vision in one eye with central visual defect. Do MRI to see cerebral or cerebellar plaques. Sheehans Syndrome: postpartum failure to lactate and other features of hormone deficiency. Other cause is lymphocytic hypophysitis. MEN Type I: hypercalcemia/hypophosphatemia due to hyperparathyroidism, and intractable ulcers due to ZE. May have parathyroid tumors. Cherry Hemangioma: small red cutaneous papules. Do not regress spontaneously and increase in number with age. Light microscopy shows proliferation of capillaries and PCV in papillary dermis. MC benign vascular tumor of adults. Acanthosis Nigricans: symmetrical hyperpigmented velvety plaques in axilla, groin, neck. Associated with DM in younger adults, and GI malignancy in older adults. Also associated with Addisons Disease. Hypertensive Intraparenchymal Hemorrhage: MC in basal ganglia, thalamus, pons, cerebellum. Present initially with focal symptoms that deteriorate into symptoms of increased ICP. Do noncontrast CT. Precision: measurement of random error. Tighter the CI, the more precise. Increasing sample size increases precision. SCC: second most common non-melanoma skin cancer. Single most important factor in development is sunlight. Have polygonal cells with atypical nuclei at all levels of epidermis with zones of keratinization. Endocarditis: viridans type strep (MC is strep mutans, also causes caries) is MCC of endocarditis after dental procedures. Pre existing MS is RF. Other viridans are mitis, sanguis, salivarius. Staph epidermidis causes prosthetic valve endocarditis. Cauda Equina Syndrome: serious neurological disorder characterized by saddle anesthesia, bowel and bladder dysfunction, low back pain, variety of LE findings. Consists of spinal nerves before they leave spinal canal. Emergent MRI. Can be caused by trauma, lumbar disc, malignancy, abscess. Nerves have poorly developed epineurium. Pancreatic Pseudocyst: encapsulated area of enzyme rich fluid, tissue, debris that accumulates in pancreas -> inflammation. Occurs in acute < chronic, diagnosed by US, and resolves on its own. Usually a few weeks after attack. Amylase can be high due to leakage. Drain if > 6 weeks, > 5 weeks, becomes infected. Can erode into blood vessels. Diabetic Neuropathy: MC is symmetric distal polyneuropathy with classic stocking glove distribution of sensory loss. Also mononeuropathies of CN and peripheral nerves, proximal neuropathy, and autonomic neuropathy. DKA: suspect in stuperous patients with rapid breathing, history of weight loss, polydipsia, polyuria. Can be triggered by infection. Kussmauls respiration (rapid deep breathing) due to acidosis. Measure glucose first. Then chemistry, CBC, ABG.

COPD Exacerbation: acute worsening of symptoms in a patient with COPD. Classically caused by URI (cough and fever). Bilateral wheezes, respiratory acidosis and hypoxia, accessory muscle use, prolonged expiratory phase. Diabetic Foot Ulcers: RF are diabetic neuropathy (80%), PVD, poor glycemic control, bony abnormalities, male sex, smoking, > 10 years, history of previous ulcer or amputation. MCC of non traumatic amputations. Will have loss of monofilament sensation. Drug Induced Interstitial Nephritis: caused by cephalosporins, penicillins, sulfonamides, NSAIDs, rifampin, phenytoin, allopurinol, trimethoprim, diuretics, captopril. Have arthralgias, rash, renal failure. UA will show eosinophils. Hemochromatosis:vulnerable to Listeria infections. High iron is also a RF for infection with Yersinia enterolitica, septicemia from Vibrio vulnificans. Dermatomyositis: proximal symmetric muscle weakness with skin rash. Normal sensation and reflexes. Elevated CK, myopathic EMG to diagnose. Can be paraneoplastic from lung cancer. Often manifests as muscle weakness at different levels, determine by H&P. AS: if severe, can have anginal CP due to increased myocardial O2 demand. Exertional CP with systolic murmur and 2nd R ICS. In young, due to bicuspid valve. Prolonged contraction and impaired filling due to LVH reduces CA blood flow. Also consider HOCM. Amebic Liver Abscess: history of travel with dysentery (bloody diarrhea) and RUQ pain due to cyst in RIGHT lobe of liver. Caused by Entamoeba histolytica, Primary colon infection -> portal circulation. Can be on superior surface -> shoulder pain. Aspirate is sterile. Flagyl. Isolated Systolic Hypertension: important cause in elderly. Caused by decreased elasticity of arterial walls (may cause decreased diastolic BP). Always treat. Decreased dumping by arteries -> widened pulse pressure (important CV RF). HCTZ is DOC. External Hordeolum: also called stye. Staph abscess of eyelid. Localized small swelling along margin of eyelid. Use warm compresses. I&D is done if no resolution in 48 hours. Menieres Disease: cause of vertigo (sensation of spinning with nausea) if patient also has sensation of ear fullness. Abnormal accumulation of endolymph in the ear. Often have hearing loss and tinnitus. Peripheral cause. Central vertigo lasts longer. Nephrotic Syndrome: heavy proteinuria (>3g/24h), hypoalbuminemia, peripheral edema. Many cases due to systemic disease (diabetes, amyloidosis). MCC intrinsic are MCD, membranous, FSGS (more common in AA, obesity, heroin use, HIV). ARDS: hypoxemia refractory to high O2 administration. Adequate oxygenation requires PEEP (prevents collapse and reopens collapsed alveoli). High FiO2 could be used, but can cause pulmonary oxygen toxicity (below 40% required). Carbamazepine: used to treat atypical bipolar and trigeminal neuralgia. Aplastic anemia can occur, follow with CBC. If medication fails, can do surgical gangliolysis or suboccipital craniectomy. PVCs:common in post MI patients. Even though they may indicate worse prognosis, should not be treated unless causing symptoms (can worsen survival). Beta blockers are first line. ED: nocturnal penile tumescence helps differentiate psychogenic from organic ED. Indicates intact vascular and nervous supply. (+) in psychogenic, (-) in organic. Do sleep study or use RigiScan device.

Osteomalacia: low to low normal calcium, low phosphorus, low 25 Vit D, high PTH (makes calcium near normal in beginning and worsens hypophosphatemia). Have symmetrical looser zones, pseudofractures, blurring of the spine. Diabetic Retinopathy: background/simple (microaneurysms, hemorrhages, exudates, retinal edema), pre-proliferative (cotton wool spots), proliferative/malignant (new blood vessel formation). Macular edema -> vision loss. Use photocoagulation to prevent complications. Leading cause of blindness in USA. Torticollis: focal dystonia involving SCM. Can occur idiopathically, but can be medication related (typical antipsychotics, metoclopramide, procholperizine), congenital, secondary to trauma or inflammation. Dystonia = sustained muscle contraction -> twisting repetitive movements or abnormal posturing. B12 Deficiency: suspect in vegetarians with anemia and neurological complications. FA will correct anemia, but not neurological dysfunction. Also have fatigue, weight loss, constipation, decreased appetite. Kidney Stones: patients with recurrent hypercalciuric stones should be treated with increased fluid intake, sodium restriction, thiazide diuretic. Calcium restriction is not advised. Treatment of first stone is hydration and observation. Molluscum Contagiosum: single or multiple rounded dome shaped papules with central umbilication caused by poxvirus. Self limited and resolves spontaneously in immunocompetent individuals. Genital lesions should be treated to prevent spread. Curretage and apply liquid nitrogen. Considered an STD. Seen in AIDS with CD4 < 100. Iron Deficiency Anemia: MCC in elderly patients is GI blood loss. Do a colonoscopy. 1 (-) FOBT is not enough to rule out occult blood loss. Do iron studies to confirm. If colonoscopy is (-), do endoscopy (NSAID history, H pylori). If (-), do capsule endoscopy. Obesity Hypoventilation Syndrome: severe obesity (> 150% ideal body weight), alveolar hypoventilation during wakefulness. Have hypercapnea, hypoxia, respiratory acidosis due to decreased lung and chest wall compliance. Weight loss, ventilator support, O2 therapy, progestins (respiratory stimulants). Thick neck, distant heart sounds, low voltage QRS on EKG, poor quality CXR = obesity. Respiratory wall weakness is not major cause. Herpes Encephalitis: MC affects temporal lobe -> bizarre behavior and hallucinations. Abrupt onset, fever, MS changes. No meningeal signs. CSF: low glucose, high lymphocytes). Do PCR for herpes, and start IV acyclovir immediately. Esophageal Adenocarcinoma: chronic GERD and Barretts are RF along with obesity, high calorie/fat intake, smoking. Barretts has 1% per year risk of carcinoma. Major RF for SCC are smoking and alcohol along with hot food and drink, N-nitroso foods. Asthma Exacerbations: use inhaled B2 agonists/anticholinergics, IV steroids. Respiratory failure (with hypercapnea and hypoxia) and somnolence need intubation and ventilation. CO2 retention is bad. Hyposthenuria: impairment in kidneys ability to concentrate. Found in patients with SCD and less commonly, SCT. AA with family history of blood disorder. Thought to be due to RBC sickling in vasa rectae which impairs countercurrent exchange and free water absorption. Wenckebach: or mobitz type I. Narrow QRS, increase in PR until beat is dropped. Benign and transient. Unless patient is symptomatic, no treatment needed. Seen in digitalis toxicity, increased vagal tone, inferior wall MI. Pacing may be needed.

Cluster Headache: men>women. Hypothalamic dysfunction -> alterations in circadean pacemaker. Repetative episodes. Unilateral, sudden, severe, deep, excruciating, continuous, explosive. Wake from sleep. Retroorbital -> hemicranium spread. Associated with lacrimation, rhinorrhea, red eye, stuffy nose, pallor, Horners. 100% O2 is the best treatment. GBS:2/3 have antecedant respiratory or GI infection. Campylobacter is MCC. Herpes, Mycoplasma, Haemophilus are other causes. MC in patients with lymphoma, sarcoid, lupus. Recent HIV infection and immunization also. Mucormycosis: MC agent is Rhizopus species. Poorly controlled diabetes is risk. Fever, bloody nose, congestion, chemosis, proptosis, diplopia. Necrotic turbinates. Can cause blindness, cavernous sinus thrombosis, coma. Partial Seizures: auras are common manifestation of partial seizures. LOC means generalization. Post ictal state usually indicates a generalized seizure as well. Complex partial seizures have repetitive motion with no LOC/aura. NPH: caused by decreased CSF absorption or chronic increases in ICP -> enlargement without chronically increasing ICP. Dementia, gait disturbances, incontinence. Acute MS: usually treated with steroids. Usually used when patients have disabling symptoms. Not used for mild sensory symptoms. To reduce frequency of exacerbations, use interferon, plasmapheresis, cyclophosphamide, IVIG, glatiramer acetate. Bronchogenic Cyst: usually found in middle mediastium on CXR. Diagnosis made with CT scan. Tracheal tumors, pericardial cysts, lymphoma, LN enlargement, aortic aneurysms cause middle mediastinal masses. Neurogenictumors and esophageal leiomyomas are in posterior and thymomas and retrosternal thyroids are in anterior. Acute Limb Ischemia: consider in patient with 5 Ps. Angiography will show abrupt cutoff in blood supply. Start IV heparin. Needs surgical embolectomy or intra-arterial fibrinolysis/mechanical embolectomy. IV streptokinase is used for STEMI. Sarcoidosis: history, CXR with hilar LA with or without reticulonodular infiltrates, noncaseating granulomas on biopsy. Elevated ACE. Treat with steroids for symptomatic disease. Pulmonary Renal Syndromes: Goodpastures is due to anti-GBM Ab. Emergent removal by plasmapheresis minimizes kidney damage and improves prognosis. Wegeners is treated with cyclophosphamide and steroids. Plasmapheresis is used as adjunct. CHF Exacerbation: causes tachypnea as LV dysfunction -> pulmonary edema, effusion, hypoxemia due to decreased ventilation. Causes hypocapnea and respiratory alkalosis. Signs of fluid overload, S3/S4, cardiomegaly, bibasilar crackles. History of CAD, HTN, smoking. Can have cardiac asthma (wheezing). Can test for BNP and PCWP to confirm. SCC Lung: suspect in patient with smoking history, hilar mass, hypercalcemia (may have symptoms). Due to production of PTHrP -> increased bone and renal resorption of calcium. May be due to bone involvement in late cancer (serious implication). Conjugated Hyperbilirubinemia: mainly because of intra or extrahepatic obstruction or congenital impaired hepatic excretion of BRN. Defined as >50% BRN is conjugated (vs. unconjugated when > 90% indirect). Can be due to intrahepatic obstruction (viral, autoimmune, alcohol, drugs, pregnancy, post op), congenital (DJ or Rotors), obstruction. Elevated transaminases = liver problem. Elevated ALP = obstructive. Do US or CT first.

Dermatomyositis: classic cutaneous findings with proximal muscle weakness. > 10% will have internal malignancy (MC ovarian). Regular age-appropriate cancer screening is crucial. Have proximal extensor myositis and rash (heliotrope). Have shawl sign on chest and lateral neck. Gottrons sign on knuckles, elbows, knees. Gottron papules on joints are pathognomonic. Ab against anti-Mi-2 against helicase. PE: sudden-onset pleuritic CP, cough, dyspnea, hemoptysis. Chest CT will show wedge shaped infarction (CXR = Hamptons Hump). Can have transudative or exudative effusions. Angina: can sometimes be mistaken for epigastric pain. Keep high on differential especially worsening with activity. Do exercise stress without imaging if EKG is normal. SLE and steroid use = accelerated CAD. If stress is normal, think about GI problems. NMS: initiation of DA antagonists, fever, muscle rigiditiy, autonomic instability, mental status change. Elevated CK, leukocytosis, electrolyte abnormalities. It is a drug induced idiosyncratic reaction. Typical antipsychotics are MCC. Usually 2 weeks after starting. BPH: eventually can progress to obstruction and renal failure. Do US as initial test to look for hydronephrosis (if so, place catheter. TURP for long term correction). Will have smooth firm enlargement. Elevated Cr = renal failure. Situational Syncope: typical is middle aged or older male who has LOC after urination (may have BPH symptoms and nocturia) or during coughing fits. Due to autonomic dysregulation which can be explained by straining and rapid bladder emptying. Can have cardioinhibitory and vasodepressor mechanisms involved. OA: acetaminophen should be first line treatment in mild to moderate pain. Proven efficacy and good SE profile. Consider diagnosis in 40 y/o with knee pain aggravated by activity and relieved with rest. 10 minutes morning stiffness. Crepitus due to incongruent joint surfaces. MS: total protein is usually normal, but have high Ig levels, usually IgG but also IgM and IgA. Oligoclonal bands present in > 85-90%. Rest of CSF is normal. Elevated Ig also seen in neuropathies, CNS infections or viral syndromes. Not diagnostic for MS. Melanoma: suspect in older individual with changing mole and ABCDE. Diameter > 6 mm. Enlargement. Back is MC area in men, legs in women. Increasing in prevalence. Can be symptomatic. RF are fair skin, history of sunburns, family history, dysplastic/atypical nevi. Methotrexate: an antimetabolite agent withside effects are stomatitis, nausea, anemia, hepatotoxicity, myelosuppression. Give with folic acid to reduce SE. Hepatitis A: prodromal phase, icteric phase, convalescent phase. Recent travel to endemic country and sick contacts. RNA picornavirus that has fecal oral transmission. Malaise, fatigue, anorexia, nausea, vomiting, mild abdominal pain, aversion to smoking. Hepatomegaly, increases in AST/ALT followed by increases in ALP/BRN. Treat supportively. Give Ig to individuals in contact. Those at risk should be vaccinated. Pneumonia: placing consolidated lobe in dependent position (down) increases blood flow, increases right to left shunting -> drop in O2 saturation. Alveoli are filled with exudate and are perfused but not ventilated. Pancreatic Cancer: primary differential in patients with chronic pancreatitis. Do US (dilated ducts) in patients with jaundice, but CT is better for diagnosis of cancer. Older age and weight loss are common. Elevated BRN and ALP due to compression.

Acute Bacterial Meningitis: sick, elevated neutrophils, signs of meningitis. Vancomycin, ceftriaxone to cover Strep pneumo, H flu, Neisseria. Vancomycin needed for resisitant pneumococcus and does not penetrate brain well. Ampicillin for Listeria (> 55, immunocompromised, patients with malignancies, taking steroids). TSS: possibly fatal condition caused by toxins produced by certain strains of staph, including epidermal exfoliating toxin and is related to tampons and other intravaginal articles. Flu, high fever, hypotension, erythematous rash. After 1-2 weeks, skin of palms and soles will peel. Hydrate, debride wound, remove source of infection, anti-staph antibodies. Muscle Weakness: usually caused by muscle problem. Both hyper/hypothyroid can cause proximal muscle weakness. Look for other symptoms of thyroid dysfunction like fatigue, tremor (action tremor), anxiety, weight loss for hyperthyroid. Improve with thyroid. Carbon Dioxide Narcosis: alveolar hypoventilation (COPD) causes CO2 retention -> lethargy, somnolence, seizures, coma, death. Viral URI incites COPD exacerbation. Sedatives should be avoided. Venous Insufficiency:due to incompetent venous valves. Chronic edema, stasis dermatitis, ulceration are complications. Leg elevation, compression stockings, wound care are best treatment. Will have varicose veins. Endocarditis: cystoscopy can cause enterococcal bacteremia in patients with chronic GU infections. Underlying valvular lesions are increased risk. Fever, malaise, new murmur, painful lesions (Oslers nodes). Viridans usually from upper airway and staph from skin. Primary Adrenal Insufficiency: best screening test is cosyntropin stimulation test. Increase in levels above 20 30-60 minutes after 250 mcg cosyntropin rules out Addisons. Eosinophilia is seen. Steroids are used to treat especially for adrenal crisis while waiting for tests. PCV: myeloproliferative disease of pluripotent stem cell. Increased RBC mass, granulocytosis, elevated platelets, low erythropoietin. HTN due to increased volume. Increased ulcers (histamine release from basophils), gouty arthritis (increased cell turnover). Plethoric face and splenomegaly. Hypercellular bone marrow. Keep Hcrt < 45. Immunosuppressants: cyclosporine and tacrolimus are both calcineurin inhibitors (inhibit IL-2). Cyclosporine causes nephrotoxicity, hyperkalemia, HTN, gum hypertrophy, hirsutism, tremor. Tacrolimus does not have gum hypertrophy and hirsutism. Azathioprine has done related diarrhea, leukopenia, hepatotoxicity. Mycophenolate causes marrow suppresion. Warfarin: dose should be adjusted based on INR for condition. VTE (3 month treatment) and atrial fibrillation should be between 2 and 3 for good anticoagulation without bleeding risk. 2.5 to 3.5 in patients with prosthetic valves. Scleroderma: absence of peristaltic waves in lower 2/3 and low LES tone are characteristic for esophageal dysmotility due to scleroderma. Sticking sensation and dysphagia with heartburn. RAAS: renin made by JG cells when hypoperfused. Renin converts angiotensinogen to AT1. ACE in lung converts AT1 to AT2 -> vasoconstrictor, promotes ADH release, aldosterone production. Aldosterone promotes Na and H2O absorption in DCT and CD. Direct renin inhibitors will promote natriuresis, decrease AT2, decrease aldosterone. Hyperthyroidism: untreated, are at risk for rapid bone loss due to increased osteoclastic activity in bone cells. Also at risk for arrhythmias (atrial fibrillaion). Will have hypercalcemia and hypercalciuria.

Sphincter of Oddi Dysfunction: causes post cholecystectomy pain (also caused by CBD stones). Normal ERCP and US rule out CBD stones. Elevated sphincter pressure. RUQ pain, elevated LFTs. ERCP with sphincterotomy is most appropriate treatment. PE: CT angio is test of choice but V/Q scan is useful tool for those with contrast allergy or renal disease. Will have large perfusion defect without ventilation defect, called mismatched defect. < 50% have this. Non Alcoholic Steatohepatitis: insulin resistance plays central role -> fat accumulation by increasing rate of lipolysis and elevating circulating insulin levels. FA oxidation -> increased oxidative stress -> inflammatory cytokines -> inflammation, fibrosis, cirrhosis. Diabetic Nephropathy:glomerularhyperfiltration is the earliest abnormality and major pathophysiologic mechanism of disease. Intraglomerular HTN -> damage and functional loss. ACE I reduce intraglomerular pressure. Thick GBM is first change that can be quantitated. Stroke: new neurological defecits, occipital headache, history of vascular disease, HTN, atrial fibrillation. Do non contrast CT to decide of ischemic (thrombolysis) or hemorrhagic (surgery). Warfarin, HTN, occipial HA worrisome for bleed (hyperdense). Loop Diuretic: given to cirrhotic patients with volume overload and ascites. SE are hypokalemia, metabolic alkalosis, pre-renal renal failure. Inhibit Na/K/2Cl transporter. Promote Na, K excretion. Volume depletion -> renal failure. Aldosterone -> alkalosis. Acute Arthritis: gouty vs pseudogout vs septic cannot be accurately distinguished from each other based on clinical presentation. Synovial analysis is crucial. Tick Removal: should be removed promptly to reduce risk of tick borne diseases. Grasp the ticks mouthparts with tweezers and remove using slow constant pressure. Risk for disease is less if removed within 24 hours. Propranolol: DOC in patients with HTN and benign essential tremor (intention tremor). Sometimes AD inheritance. Inhibited by alcohol. Confounder: extraneous factor which has properties linking it with exposure and outcome of interest. MGUS: asymptomatic elevation of monoclonal protein on electrophoresis, usually < 3 g/dL. Differs from MM: absence of renal insufficiency, hypercalcemia, anemia, lytic bone lesions. Can progress to MM. Do bone scan after labs to look for lytic lesions. Congenital Rubella Syndrome: if women becomes pregnant within 3 months after rubella immunization, reassure. No cases reported with vaccines early in pregnancy. Second Degree Heart Block: identified by prolongation of PR interval with dropped beats. Due to AV node dysfunction. Aminoglycosides: antibiotics to treat serious G(-) infections (like complicated UTI). Nephrotoxic, so drug levels and renal function should be monitored. Hypernatremia: severe symptomatic hypernatremia requires 3% saline. Rapid correction -> CPM. Rate should be 0.5 to 1 mEq/L/hr. Peritonsillar Abscess: muffled voice makes for more than uncomplicated pharyngitis or tonsillitis. Needs IV antibiotics and needle drainage. Deviation of the uvula and cervical LA

help differentiate from epiglottitis. Can cause airway obstruction or spread into parapharyngeal space. Surgery if aspiration cannot relieve. y Folic Acid Deficiency: tea and toast diet predisposes. Folic acid is head sensitive (dont get from cooked foods). Causes macrocytic anemia. Can deplete in 4-5 months. Thyroid Myopathy: consider hypothyroidism in patients with elevated CK and myopathy. Can cause myalgia, hypertrophy, and rhabdomyolysis. Will have sluggish tendon reflexes. Measure TSH. Charcots Joint: also called neuropathic arthropathy. Due to neuropathy and repetitive joint trauma. Affects weight bearing joints and manifests with functional limitation deformity, degenerative joint disease, loose joints on imaging. Caused by diabetes, nerve damage, syringomyelia, spinal cord injury, B12 deficiency, tabes dorsalis. Use special shoes. Hemophilia: hemarthroses are MC manifestation. Treat by replacing missing coagulation factor. Hematoma after minor injury is suggestive, especially in males. Measure factor VIII and IX levels. Also have bleeding at mucosal sites. Will have history of joint swelling. PE: result in pulmonary hypertension with elevated RAP and PAP, can result in shock. Normal RAP is 4-6, normal PAP is 25/15. Will have sudden onset. COPD and L heart disease also cause pulmonary HTN. Chronic Liver Disease: should be up to date on childhood vaccinations, HAV and HBV, annual intramuscular influenza, invasive pneumococcal disease. And should get Td booster every 10 years. Exudative Effusion: low glucose is due to high metabolic activity of leukocytes and bacteria within fluid. < 30 suggest empyema or rheumatic effusion. 30-50 is malignancy, lupus, esophageal rupture, TB. Vomiting: causes hypokalemic hypochloremic metabolic alkalosis. Loss of H+ plus no use of HCO3 by the pancreas (due to no acid) retains it in the blood. Contraction alkalosis also occurs. Restore ECF with NS and potassium to treat. Rabies: if animal is not captured, it is assumed rabid and post exposure prophylaxis is needed (active and passive). If captured, but shows no signs of rabies, observe for 10 days. If develops signs, use PEP, and analyze brain. PEP for any exposure around head or neck. Left Atrial Enlargement: due to mitral stenosis. Can cause persistant cough and elevation of left main stem bronchus. MCC is rheumatic fever. Loud S1, opening snap, diastolic murmur. ECG will have atrial fibrillation or LAE. Echo confirms. Surgery to treat. Tamponade: pulsus paradoxus (inspiration -> more blood to RV -> IV septum to bow to left > reduces LV filling) and Becks triad: hypotension, JVD, muffled heart sounds. Ventricles cannot expand to receive fluid and preload decreases. Can have hepatojugular reflex. Stroke: can be a common manifestation of sickle cell disease due to sludging and occlusion. Do exchange transfusion to decrease percentage of sickled cells and prevent secondary infarct. CT can be negative. Continue hydroxyurea to increase Hgb F. Brown Sequard Syndrome: damage to the lateral STT -> contralateral loss of pain and temperature beginning two levels below the lesion. Fibers cross early in the cord.

Asbestosis: increases risk of malignancy, pulmonary fibrosis, and pleural plaques. Bronchogenic carcinoma and mesothelioma are both caused but bronchogenic is more common. Start with dyspnea with cough or sputum production. Aminoglycosides: cause nephrotoxicity and ototoxicity. Causes severe vestibulotoxicity (especially gentamycin) -> potentially permanent vertigo and ataxia. Damages hair cells of inner ear. HOCM: outflow obstruction due to septal hypertrophy and systolic anterior motion (SAM) of mitral valve (may be of more consequence). Disease is MC in AA. Murmur increases on Valsalva. Antithyroid Drugs: fever and sore throat while taking suggests agranulocytosis. Stop drug and check WBC count. Do not do routine CBC in patients on these drugs. Due to immune destruction of WBC. < 1000 warrants permanent cessation. > 1500 means drug not cause. Nodulocystic Acne: give oral isotretinoin with moderate to severe acne that is nodulocystic, those with scars, acne resistant to other therapy. Topical retinoids are for non inflammatory comedones. Benzoyl peroxide and topical antibiotic is for mild inflammatory acne. IBS: functional bowel disorder of GI tract characterized by pain, diarrhea, constipation. No pathologic or lab hallmark. Exacerbated by stress. More in women than men. Primary Hyperaldosteronism: hypertension, hypokalemia (muscle cramps, polyuria due to ADH resistance), low plasma renin, high glucose (due to impaired insulin secretion). MCC is aldosterone producing adenoma. Do morning PA/PRA, > 30 is suggestive. CAH, syndrome of apparent mineralocorticoid excess, glucocorticoid/licorice ingestion also causes HTN, low K. Chest Pain: in a young person with RF, warrants cardiac workup. First drug to give is ASA during suspicion of coronary event to prevent platelet aggregation. >35, family history, smoking, estrogen therapy increase risk of thrombosis. Toxoplasmosis: HIV patient with fever, HA, confusion, ataxia, ring enhancing lesion. Can have seizures and focal neurological deficits due to mass effects. Occurs < 100 CD4. Due to reactivation, look for Ab at diagnosis. Treat prophylactically with TMP/SMX if have Ab. Murmurs: diastolic, continuous, or loud systolic murmurs should be evaluated with Echo. Midsystolic soft murmurs (I to II/VI) do not need to be investigated if asymptomatic. Androgens:women produce androstenedione, DHEA, testosterone, DHEA-S. AS, DHEA, T are produced by the ovaries. DHEA-S is produced by the adrenals (elevated with tumors). DHEA/S are not true androgens, but can be converted. Overproduction -> hirsutism. Thiazides: cause hyperglycemia, increased LDL/TG. Also cause hyponatremia, hypokalemia, hypercalcemia. Still have desirable affects on CV mortality even in diabetics. Also causes hyperurecemia. Influenza Vaccine: all individuals > age 50 should get it yearly. Younger adults with medical problems, frequent exposure to small children, pregnant women, healthcare workers should also get it annually. COPD needs pneumococcal as well, but not annually. MG:fatigable muscle weakness involving the ocular and bulbar muscles. 15% have a thymoma which can be seen on CT chest, small % can be invasive. Choriocarcinoma: metastatic gestational trophoblastic disease. Occurs after molar pregnancy or normal gestation. Lungs are most frequent site of metastasis. Suspect in

postpartum woman with lung symptoms and multiple nodules on CXR. Elevated b-HCG. Will have enlarged uterus, bleeding > 8 weeks post partum, pelvic pain. y Hepatitis B: (+) HBsAg & (-) HBsAb means active infection. HBeAg indicates high infectivity. Needle stick in unvaccinated individual -> give HPV vaccine and Ig. Has higher rate of seroconversion than HCV and HIV. Photo Protection: important in high risk groups. Sun avoidance is best method of protection. Sunscreens should be applied 15-60 minutes before. Avoid outdoor activities between 10 AM and 4 PM. Vertigo: senseation of excessive motion compared to reality. MC due to vestibular dysfunction. Distinguish from imbalance, lightheadedness, syncope. Causes nausea and vomiting. Menieres, perilymphatic fistulas, BPV, labyrinthitis, acoustic neuromas. Hypocalcemia: occurs during or immediately after surgery in patients undergoing major surgery and transfusions. Hyperactive DTRs may be initial manifestation. Occurs due to hypoalbuminemia and dilution. Citrate from transfusions binds. Hypomagnesemia presents with hypocalcemia and causes decreased PTH secretion and decreased peripheral response to PTH. Macular Degeneration: common cause of blindness in US. Activities that require fine vision affected first. Straight grid lines may appear wavy. Increasing age is cause, smoking maybe. Driving or reading are first activities affected. See drusen deposits in the macula. Ovarian Cancer: no evidence that regular abdominal US help decrease mortality. Laryngeal Edema: causes fixed upper airway obstruction which decreases airflow during inspiration, active expiration, and passive expiration. Flow volume shows pancake. Asthma causes intrapulmonary obstruction and has scooped out patter on exhalation. Seizure: if results in LOC (complex partial or generalized) will be followed by post-ictal state. Rapidly return to baseline with syncopal event. Stress and poor sleep trigger seizures. Tongue biting and sore muscles indicate seizure. Needs CBC, drug screen, EEG, brain MRI. Intracranial HTN: diagnosed when ICP > 20. Presents with HA, vision changes, nausea, vomiting, changes in awareness, focal neurological defecits. Trauma, space occupying lesions, hydrocephalus, impaired CNS venous outflow. Worse in morning, unsteadiness, Cushings reflex (hypertension and bradycardia). Do CT or MRI. Alzheimers Disease: MCC dementia in western world. Memory loss, language difficulties, apraxia -> impaired judgement and personality changes. CT shows atrophy. Age, female, family history, head trauma, Downs. Psychotic features appear later. Cholecystectomy: indicated in all patients with symptomatic gallstones who are stable enough to undergo surgery. Gallstones are MC responsible in non-alcoholics. VTE: treat initially with heparin & warfarin combination. If INR is therapeutic, heparin is discontinued after 5 days. Warfarin should be continued for 6 months for first clot and lifetime for second. Presbyopia: common age related decrease in lens elasticity that leads to difficulty with near vision, prohibits accomadation. Middle aged individual who holds books at arms length is classic.

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Osteomalacia: defective mineralization of bones. Rickets is defective mineralization of bone bone and growth plate cartilage. Disordered skeletal remodeling in specific bones is Pagets disease. Osteoporosis is low bone mass, but normally mineralized per unit volume. Vit D deficiency -> decreased availability of calcium and phosphorus at mineralization sites -> softening. Carboxyhemoglobinemia: consider in patients with RF and headaches, nausea, dizziness, polycythemia. Susceptible when working in closed space with exposure to car fumes. Infectious Mononucleosis: fatigue, malaise, sore throat, fever, generalized maculopapular rash. Posterior cervical LA and palatal petechiae. Splenomegaly. Heterophile Ab are good test, but (-) in early illness. Repeat test. Transmitted by oropharyngeal secretions. FFP: given to patients with bleeding disorders and liver failure. Vitamin K will not work because of liver disease. Extreme LFTs: marked AST/ALT consistent with hepatocellular injury. Usually due to alcohol (2:1 AST:ALT) or medication induced. Usually acetominophen which can be compounded by alcohol. AST/ALT can be > 5000. Membranoproliferative GN: Type II, unique glomerulopathy caused by persistent activation of the compliment pathway. Dense intramembranous deposits of C3 are present. Also called dense deposit disease. IgG Ab (C3 nephritic factor) against C3 convertase -> constant active. PUD: hemorrhage is the MC complication. May have melena or hematochezia. Blood or coffee grounds on NG aspirate. Fluid and blood resuscitation, medical therapy, endoscopic when appropriate. CNS Lymphoma: HIV infected patient with altered mental status. EBV DNA in the CSF, and solitary weakly ring enhancing periventricular lesion on MRI. Null Hypothesis: always a statement of no relationship between exposure and outcome. SIADH: hyponatremia, elevated urine osmolarity in presence of decreased plasma osmolarity. Seen with SCC of the lung. Metastasizes early. Smoking is most important RF. Foot Drop: steppage gait. MCC are neuropathy, L5 radiculopathy (or radiculopathy of any of the common peroneal roots L4-S2), traumatic damage to common peroneal nerve. Charcot Marie Tooth disease has congenital foot drop. Marfans Syndrome: most dangerous complication is aortic dissection. Tearing chest pain that radiates to the back and neck. Causes aortic regurgitation -> early diastolic murmur. CXR may have wide mediastinum. Disease is due to fibrillin defect. Chagas Disease: caused by Trypanosoma cruzei protozoan. Causes megaesophagus, megacolon (both due to neural destruction) cardiac disease (CHF type due to prolonged myocarditis). Statin Induced Myopathy: CPK levels of anyone on statin with muscle pain. If highly elevated, stop the statin. Can progress to rhabdomyolysis (kidney failure). Also causes increased LFTs. Herpes Zoster Ophthalmicus: characterized by dendriform corneal ulcers and vesicular rash in CNV distribution. Due to VZV. May have fever, malaise, burning itching sensation in distribution. Treatment within 72 hours of high dose acyclovir reduces complications.

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OSA: common in obese population. Snoring, daytime sleepiness, apneic episodes. At rish for HTN, heart disease, cor pulmonale, accidents. Use nocturnal polysomnography to diagnose. Have morning headaches, poor concentration. Due to tonsillar hypertrophy, excessive soft tissue, micrognathia. Hypokalemia: causes weakness, fatigue, muscle cramps. Severe -> paralysis, arrhythmia, hyporeflexia, tetany, rhabdomyolysis. EKG may show U waves, flat broad T waves, PVCs, ST depression. Diuretics, diarrhea, vomiting, hyperaldosteronism are all causes. CMV: consider in patients after BMT with pneumonitis (after 2 weeks to 4 months, multifocal diffuse pathy infiltrates, multiple nodules on CT, diagnosed on BAL) and colitis (upper and lower GI ulcers) bone marrow suppression, arthralgias, myalgias, esophagitis. Wegeners Granulomatosis: vasculitis affecting small and medium sized arteries. Comination of GN and upper/lower airway disease. Diagnosed with c-ANCA and tissue biopsy (affected nasal mucosa). Treat with steroids and cytotoxic agents. CXR may have multiple nodular densities and alveolar/pleural opacities. Endocarditis: first draw blood for culture then give empiric antibiotics. IVDA and valvular abnormalities are RF. When culture is available, antibiotics can be changed. Calcium in Alkalosis: increased pH increases serum albumin affinity for calcium. Increases albumin bound and decreases ionized calcium -> clinical manifestations of hypocalcemia. Randomization: said to be successful when similar baseline characteristics are seen in treatment and placebo individuals. Pagets Disease of the Bone: osteitis deformans. Associated with normal calcium and phosphate levels and increased ALP and urine hydroxyproline, deoxypyridinoline, Ntelopeptide, C-telopeptide levels. Accelerated and disordered osteoclastic resorption -> disorganized woven and lamellar bone. Weight bearing bones have pain and bowing. Skull hypertrophy -> increased hat size and deafness. Solitary Pulmonary Nodule: first step is to find old x rays. Absence of growth over time rules out malignancy. If not available, decide if high or low risk (age, smoking). Low -> serial CT. Intermediate -> PET, or biopsy. High -> surgical removal. Influenza: treat with bed rest and analgesia. Antivirals decrease symptoms by 2-3 days but only effective if given within 48 hours. Amantadine and rimantadine are only active against Influenza A. Zanamivir and oseltamivir (neuraminidase inhibitors) active against both. Cancer Associated Anorexia: treat with megestrol acetate, synthetic progestin. Used as appetite stimulant in advanced malignancies. Prednisone may be added. Better to have oral than TPN. All efforts to make patient eat. Shingles: vesicular eruption that occurs in dermatomal distribution. Often preceded by pain for 48 hours. Caused by VZV which also caused chicken pox. Usually in elderly or immunosuppressed during periods of stress. Disseminates in very immunocompromised. SVC Syndrome: malignancy is MCC (smoking, weight loss). Lung cancer (SC) and NHL are usual causes. Fibrosing mediastinitis due to histoplasmosis or Tb infection or thrombosis due to central catheters. Do CXR to diagnose. Dyspnea, venous congestion, swelling of head, neck and arms. Thyrotoxicosis with low I Uptake: subacute painless thyroiditis, subacute granulomatous thyroiditis, iodine induced thyroid toxicosis, levothyroxine OD, struma ovarii.

HIV Esophagitis: start first with oral fluconazole directed against candidiasis. Failure to respond in 3-5 days needs endoscopy. Usually CD4 < 50. Painful swallowing and substernal burning. HSV and CMV are both causes as well. Lead Poisoning:microcytic anemia and basophilic stipping. Seen in children in old houses or lead based paint. Can have anorexia, behavior changes, clumsiness, nausea, vomiting. Do fingerstick in all suspcions. > 10 is abnormal. X ray may show lead lines at metaphyses. Uremic Pericarditis: absolute indication for dialysis. Pericardial fluid is usually hemorrhagic. Usually BUN > 60 and anemia. Other dialysis indications: fluid overload or hyperkalemia that is not responsive, refractory metabolic acidosis. Sometimes if GFR < 10 (< 15 in diabetes), Cr > 8 (> 6 in diabetes) or severe symtoms. Graves Disease: treatment is radioactive thyroid ablation, antithyroid drugs, thyroidectomy. Agranulocytosis is major SE of antithyroid drug therapy. MC SE is allergic reaction. PTU can cause hepatitis picture, ANCA vasculitis. MMI can cause cholestatic jaundice. Carcinoid Syndrome: at risk of niacin deficiency due to increased formation of serotonin from tryptophan. Classic triad is flushing, diarrhea, valvular disease. 5-HIAA present in blood and urine. Tryptophan is precursor of serotonin and niacin. Niacin deficiency -> pellagra. NFII: young patient with acoustic neuroma and caf au lait spots. MRI with gadolinium is best way to diagnose. Gradual tinnitus and hearing loss. Frequently bilateral. TB and HIV: Tb has a very high rate of progression. Positive PPD (> 5 mm in HIV) needs INH and pyridoxine (to cover INH neuropathy, but does not prevent hepatitis) for 9 months. Monitor LFTs. BZD OD: slurred speech, unsteady gait, drowsiness -> BZD or opioid. BZD do not have severe respiratory depression and no pupillary constriction. Alcohol and phenytoin intoxication are similar but have nystagmus. Lithium has tremor, hyperreflexia, ataxia, seizures. Lye Ingestion:effects are instantaneous, effects are most pronounced in the esophagus -> liquefactive necrosis. Early upper GI contrast studies and endoscopy are critical for evaluating damage and deciding on treatment. Have retrosternal pain, hypersalivation, dysphagia/odynophagia. Give IVH and receive serial abdominal and chest x rays. Gastrograffin study if rupture is suspected. Primary Syphilis:dark field microscopy is good for evaluation. Patients may be involved in high risk sexual activity so HIV counseling and screening with ELISA should be offered. HIT: seen in about 5-15% of patients with onset in 3-15 days and resolution 4-5 days after stopping. Elevated PTT is therapeutic, thrombocytopenia is adverse effect. Can have paradoxical thrombosis. Opioid Intoxication: does not always present with miosis. Coingestions can have normal pupil size or even mydriasis. Meperidine and propoxyphene do not cause miosis. Decreased RR, obtundation, hypothermia, decreased bowel sounds, hypotension. Needle marks on extremities. Administer naloxone. Otitis Externa: any diabetic patient with severe ear pain, otorrhea, evidence of granulation tissue in ear canal. Pseudomonas is MCC. Pain radiates to TMJ and worse with chewing. Worsening with antibiotics -> malignant. Inferior MI: right ventricular infarction -> right heart failure. Hypotension, JVD, clear lung fields, Kussmauls sign (increased JVD with inspiration). Preload dependent -> treat with IVF

and avoid nitrates and diuretics to decrease preload. STE in II, III, aVF and STD in I, aVL. Can use right sided EKG leads. Low HR -> possible SA node involvement. y Retroperitoneal Hematoma: can occur even with normal INR. Back pain and signs of hemodynamic compromise. Greater risk of bleed on warfarin in diabetics, age > 60, hypertension, alcoholism. CT will show isodense collection anterior to psoas, displacing kidney. Pancreatic Cancer: painless jaundice in a patient with conjugated hyperbilirubinemia and elevated ALP. Do CT of abdomen to confirm. No pain rules out acute obstruction such as choledocholithiasis. US can confirm GB pathology. Primary Hyperparathyroid: MCC of hypercalcemia in ambulatory patients. Have elevated or inappropriately normal PTH levels. Chronic renal failure -> secondary hyperparathyroidism. PTH is higher and calcium is normal (hypocalcemia is the stimulus). Priapism: always check medications first. MCC is prazosin. Major association with trazodone. Antidepressant used for sleep disturbances. Painful and long erection without stimulation. Other causes are SCD and leukemia, perineal/genital trauma, neurogenic lesions. ARDS: acute pancreatitis may be a cause (15%). Decrease FiO2 to nontoxic levels (< 60). PEEP may need to be increased to maintain oxygenation after FiO2 is decreased. PEEP and FiO2 determine PaO2. RR and TV determine PaCO2. Hypoparathyroidism: characterized by low calcium and elevated phosphorus levels with normal renal function. Causes are post-surgical, autoimmune destruction (APECED = autoimmune polyglandular endocrinopathy candidiasis ectodermal dysplasia), defective calcium sensing receptor, congenital absence. Pseudohypoparathyroid = PTH resistance. Dilated Cardiomyopathy: viral myocarditis (post partum) usually due to Coxsackie B. Echo shows dilated ventricles and diffuse hypokinesia -> systolic dysfunction (low EF). Will have antecedent URI. Can be due to direct viral damage or immune response. Toxins also cause. Opioid Intoxication: miosis, depressed mental status, decreased RR (best indicator, cause of mortality, improves with naloxone), decreased bowel sounds, hypotension (histamine release), bradycardia. Angiodysplasia: common cause of intermittent and occult lower GI bleeding in patients > 65. Can be missed on colonoscopy. Controversial association with AS. Common in cecum. Anemia with normal MCV = episodic (not chronic) bleeding. Fibromyalgia: chronic widespread pain disorder associated with fatigue, poor sleep, depression. Have multiple trigger points of tenderness. Women 20-50 years old. Sleep disorder, depression, viral illness can be cause. Improve with TCA and exercise. Normal labs. ASA Intoxication: triad of fever, tinnitus, tachypnea. Mixed respiratory alkalsosis (stimulates respiratory center) and anion gap metabolic acidosis (uncouples oxidative phosphorylation > increased O2 consumption/hyperpyrexia, inhibit carbohydrate and lipid metabolism -> accumulation of lactate etc., impairs renal function -> accumulation of sulfuric/phosphoric acid). Near normal pH, primary decrease in PaCO2, primary decrease in HCO3. Reliable Tests: gives similar results on repeat measurements. Reliability is maximal when error is minimal.

Osler Weber Rendu: hereditary hemorrhagic telangiectasia (AD). Develop pulmonary AVMs > AV shunting -> hypoxia -> erythrocytosis, increased Hgb/Hcrt. Suspect with recurrent nosebleeds and oral lesions. May be in liver, brain, lung. Can have massive hemoptysis. Myoglobinuria: suspect with large amount of blood on dipstick but few RBCs on UA. Usually caused by rhabdomyolysis -> ARF (high BUN, Cr, K). Seizures can be a cause. AAA: USPSTF recommends screening male active/former smokers between 65 and 75 years old one time with abdominal US (low cost, non-invasive, no radiation). Repair aneurysms > 5.5 cm. No recommendations for or against men 65-75 who have never smoked. Cerebellar Dysfunction: common in chronic alcoholics. Have gain instability/ataxia/broad based gait, difficulty with rapid alternating movements, intention tremor, dysmetria, nystagmus. Muscle hypotonia can result -> pendular knee reflex. Ulnar Nerve Syndrome:MC site of ulnar nerve entrapment is at the elbow where ulnar nerve lies at medial epicondylar groove. Decreased sensation in 4th and 5th digit. Weak grip due to intrinsic hand muscle denervation. Typically prolonged leaning on elbows at desk job. Can occur at the wrist. Occurs at forearm rarely, and mostly in diabetics. Transfusion Reactions: relatively common and life threatening. Acute hemolytic reaction due to transfusing mismatched blood and Ab reaction (ABO mismatch). Fever, chills, flank pain, hematuria, hemolysis, shock, ARF, DIC. Can occur in patients with acquired alloantibodies. Have positive Coombs test, plasma free Hgb is pink with Hgb > 25. Supportive treatment. Tinea Versicolor: pale velvety pink/white appearing hypopigmented macules that do not tan and do not appear scaly but scale on scraping. Topical treatment with selenium sulfide lotion and ketoconazole shampoo. Caused by Malassezia furfur (spaghetti and meatballs). Color change requires months to return to normal. Malignant Otitis Externa: seen in eldery and uncontrolled diabetics. MCC is Pseudomonas. Ear pain and drainage, granulation tissue in ear canal. Can cause osteomyelitis of skull base and destruction of facial nerve. Not responsive to topicals. CT or MRI. Use systemic cipro. OA: lack of physical exam findings and lab changes. Based on clinical impression and radiographic evidence. Age > 50, crepitus, bony enlargement, bony tenderness, lack of warmth/morning stiffness. If > 3, specificity is 69%. Epiglottitis: MC organisms are H flu and Strep pyogenes, especially in adults. Medical emergency and rapid treatment is needed to secure airway. Fever, sore throat, drooling, stridor (harsh thrill). Can be seen in adult immigrants with improper vaccination. Isolated Proteinuria: evaluation should begin by testing urine on at least two other occasions. Can be transient during period of stress or febrile illness. Conns Syndrome: primary hyperaldosteronism. HTN, mild hypernatremia, hypokalemia, metabolic alkalosis. Will have low renin, high aldosterone, high HCO3. Suspect in young nonobese, non-black person. Muscle weakness and exercise intolerance are due to hypokalemia. Strep Bovis Endocarditis: associated with colorectal cancer or upper GI malignany. Colonoscopy should be pursued for further evaluation and after do radiographic surgey for UGI cancer. Also can cause septicemia. Brain Hemorrhage: usually due to HTN. Putamen is MC place, and internal capsule is often involved -> hemiparesis. Cerebellum is 2nd MC place -> ataxia, vomiting, occipital HA, gaze

palsy, facial weakness, no hemiparesis. Pons is 3rd MC place -> deep coma, paraplegia, pinpoint pupils reactive to light, decrerebrate rigidity, no horzontal eye movements. y y New HIV Patient: VDRL, PPD, HAV/HBV serology, Ab titer for Toxoplasma are all indicated. Ankylosing Spondylitis: occurs in adults 20-30 years. Limited spine mobility and progression of back pain > 3 months. Pain and stiffness worse in morning, improve with exercise. Bilateral sacroiliitis on x ray. MC extraarticular manifestation is anterior uveitis. ED: in treating patient with sildenafil and an alpha blocker (usually zosin), give drugs 4 hours apart to decrease risk of hypotension. Diabetics are at high risk for ED. Vascular complications, neuropathy, medications are usual causes. First line is PDE inhibitors. CI in people taking nitrates, precaution in conditions with priapism, concurrent use with drugs that may increase life (erythromycin, cimetidine). Portal HTN: MCC of ascites. Usually due to cirrhosis from chronic liver disease (alcoholic or viral). IVDA -> cirrhosis due to possibility of HBV/HCV infection. AS: indications for AV replacement: symptomatic, severe AS undergoing CABG or other valve surgery, asymptomatic with severe AS and either poor LV function, LVH > 15 mm, valve area < 0.6, abnormal response to exercise. Symtoms are SAD (syncope, angina, dyspnea). GERD: retrosternal burning after eating and lying down. May have horseness and chronic cough especially when recumbent. Initial treatment is H2 receptor antagonist (ranitidine) or PPI. Refractory -> fundoplication or endoscopic treatment. Barretts and adenocarcinoma. May be trigger for asthma (upto 75% of cases). May have wheezing (all patients with asthma symptoms should be asked about GERD symptoms as well). Hypothyroidism: accumulation of matrix substances all over body causes many manifestations of hypothyroidism. Matrix accumulation in median nerve and tendons of carpal tunnel may cause carpal tunnel syndrome. Untreated -> generalized myxedema, myxedema psychosis, myxedema coma. IM: heterophile Ab test (Monospot) is sensitive and specific for diagnosis (appear within a week and may be positive upto a year). EBV specific Ab test is for patients with suspected IM and (-) heterophile Ab test. Atypical lymphocytes are seen but not specific. (-) heterophile Ab in the first few weeks does not rule out. PUD: melena is a common manifestation of UGI bleeding. Pain from duodenal ulcers gets better with food, pain from gastric ulcers gets worse. UGI proximal to hepatic flexure can cause melena. Have abdominal pain, nausea, vomiting, hematenesis. H pylori and NSAIDs. Hypertriglyceridemia: can cause acute pancreatitis when levels > 1000. May have eruptive xanthomas on PE. Diagnose with fasting lipid profile. Hypercalcemia, recent ERCP, trauma, infection, medications also causes. Euthyroid Sick: any patient with acute severe illness can have TFT abnormalities. MC pattern is fall in total T3, normal T4 and TSH (low T3 syndrome). Due to caloric deprivation and cytokine release. More severe -> lower T3. Longer sick -> T4 and TSH drop. Prognosis : severity of lab abnormalities. Rubella: maculopapular rash, posterior cervical and posterior auricular LA and polyarthralgia. Exposure -> fever, malaise, LA after 2-3 weeks -> rash 1-5 days later (starts on face and speads, usually for < 3 days). Treat with acetaminophen.

SBP: suspect in any patient with cirrhosis and ascites who presents with low grade fever (cirrhotics may be hypothermic), abdominal discomfort, altered mental status. Paracentesis with PMN > 250 and positive culture is diagnostic. SAAG > 1.1 = portal HTN as cause. Behcets Syndrome: multisystemic inflammatory condition with recurrent genital/oral ulcers, skin lesions (erythema nodosum), anterior uveitis, seen in Turkish, Asian, Middle Eastern. Treat with steroids -> do not prevent progression to dementia and blindness. Exercise EKG: recommended for patients with an intermediate pre-test probability of angina based on clinical features and RF. Anti-ischemics should be withheld (digoxin and meds that slow heart rate like beta blockers). Non Ketotic Hyperosmolar Syndrome: T2DM. Decreased consciousness is MC symptom. Blurred vision is caused by myopic increase in legs thickness and intraocular hypotension due to hyperglycemic hyperosmolarity. Usually triggered by infection. Stress -> increased cortisol and catecholamines -> insulin resistance. Viridans Group Strep: frequent cause of SBE in patients with pre-existing vascular disease. Staph aureus is cause of acute infective endocarditis and is seen in IVDA. Lithium: common cause of nephrogenic DI. Treated with salt restriction and discontinuation. Complete DI -> urine osmolarity < 300, partial DI -> urine osmolarity 300-600. Demeclocycline, foscarnet, cidofovir, amphotericin also cause DI. Power: the power of a study is its ability to detect the difference between two groups. Increasing the sample size -> more power ->makes CI of the point of interest tighter. Costochondritis: chest pain that is reproducible with palpation suggests musculoskeletal. Sharp, focal, long lasting, worsens with inspiration and movement. Hypokalemia: high levels of B2 agonists present with muscle weakness, arrhythmias, EKG abnormalities. B2 agonists can also cause tremors, palpitations, headaches. High levels of B2 agonists are used along with steroids in acute asthma. Do electrolyte panel. Herpes Encephalitis: temporal lobe affected, may present acutely (< 1 week) with focal neurological signs. Present with lymphocytic pleocytosis, increased number of erythrocytes, elevated protein. Do HSV PCR is gold standard for diagnosis. Usually HSV-1 beyond neonatal period. Can present as seizures. EEG -> intermittent high amplitude slow waves. IV acyclovir. Parkinsons: three cardinal signs are resting tremor (resting pill rolling usually focal to one hand and generalizes), bradykinesia, rigidity (lead pipe or cogwheel), postural instability. 2/3 signs on physical exam grounds for clinical diagnosis. Accumulation of alpha synuclein in substantia nigra. Amyloidosis: restrictive CM with thickened ventricles and preserved dimensions (diastolic dysfunction without systolic changes) as well as involvement of liver (easy bruisibility) and kidneys (proteinuria). Caused by MM (AL), chronic inflammation like RA (AA). Dehydration: elderly patients are particularly sensitive to fluid loss. Mild hypovolemia can predispose them to orthostatic syncope, especially on waking. BUN/Cr ratio is useful indicator (sensitive but not specific). Subconjunctival Hemorrhage: if spontaneous, is a benign finding and does not require treatment. May be due to trauma from rubbing eyes, coughing fits, hypertension, coagulopathy. If HTN, try lowering BP.

Acute Pancreatitis: serum amylase and lipase are considered most sensitive and specific tests for diagnosis. Early on there is dysfunction between synthesis-secretion. Cells keep making enzymes when no secretion -> leakage. Lipase is more sensitive and specific. Torsades des Points: polymorphic ventricular tachycardia that occurs in setting of prolonged QT: familial long QT, hypomagnesemia (malnourished alcoholics), drugs (TCAs), antiarrhythmics (amiodarone, sotalol), antiinfectives (moxifloxacin, fluconazole). Treat with stopping cause and starting magnesium sulfate. Papillary Necrosis: presentation of woman with hematuria and headaches = analgesic nephropathy. Years of analgesics -> chronic tubulointerstitial damange. Analgesics -> vasoconstriction. Sometimes clots form -> renal colic. Rosacea: suspect in 30 to 60 year olds with telangiectasias over cheeks, nose, chin. Flushing caused by hot drinks, heat, emotion, other causes of rapid body temperature change. Topical metronidazole is usually prescribed as initial therapy. May have papules and pustules. FSGS: most common type of glomerulopathy associated with HIV. Have nephrotic range proteinuria, azotemia, normal sized kidneys. Have rapid development of renal failure. More prevalent in blacks. Can manifest even if rest of HIV markers are normal. AS: three most common causes are senile calcific aortic stenosis, bicuspid aortic valve, rheumatic heart disease. Bicuspid valve considered in anyone < 70. May have CHF signs, S4. Measles: paramyxovirus. Exposure -> prodrome of cough, coryza, conjunctivitis after 10 days ->Kopliks spots that appear 48 hours before rash and fade as soon as rash appears -> erythematous maculopapular rash initially over face and then spreads. Complicated by pneumonia, vitamin A deficiency, bronchiectasis. Later by immunosuppression and SSPE. Papilledema: transient loss of vision for a few seconds with changes in head position, confirmed by ophthalmologic examination. Caused by increased ICP (morning HA, changes in HA intensity with position). When ICP increased -> transmitted to optic nerve head -> swelling. Enlarging blind spot. Aortic Dissection: tearing pain with radiation to the back and difference in BP of > 30 mm Hg between the arms. TEE or CT with contrast to diagnose. Collagen abnormalities also predispose to MVP. Haloperidol: good for treating agitation in elderly regardless of underlying cause of dementia. Can also use quetiapine and risperidone. Antipsychotics can be deadly in elderly but good for acute agitation. BZDs are not good. Do not use in Lewy Body dementia. Laxative Abuse: frequent, watery, nocturnal diarrhea. Characteristic finding of dark brown discoloration of the colon with lymph follicles shining through as pale patches (melanosis coli). Usually seen in those abusing anthraquinone containing (bisacodyl). Flecanide: used to treat ventricular arrhythmias and SVT like atrial fibrillation. Class IC (blocks Na channels), elongates depolarization -> slow conduction through AV node and bundle of His. Have use dependence where effect increases (QRS increases) as HR increases (not as much time to dissociate). Class IV also has use dependence but doesnt elongate QRS. Reactive Arthritis: Reiters syndrome. Seronegative spondyloarthropathy from enteric or GU infection. Also have conjunctivitis, urethritis, mucocutaneous lesions, enthesitis, asymmetric oligoarthritis. NSAIDs are first line therapy.

GI Manifestations of Autonomic Neuropathy: postprandial bloating, early satiety, constipation, diarrhea. Metoclopramide (DOC), bethanacol, erythromycin are used for gastroparesis (difficult to control glucose). Bacterial overgrowth occurs in SI. Constipation in LI. Lung Consolidation: bronchial breath sounds, dullness to percussion, increased fremitus, bronchophony, egophany, whispered pectoriloquy on PE. Bronchial sounds have full expiratory phase. Elderly patients with pneumonia may not have elevated temp or WBC. Bronchiectasis: identified on CT by presence of dilated bronchi with thickened walls. Can occur in any patient where there is a pulmonary infection accompanied by either decreased airway drainage or impaired immune defense. Hemoptysis is a potential complication. Presents similarly to COPD where abnormal aiways cause obstruction. Persistant cough. Antibiotics with some resolution. MM: hypercalcemia is a common finding -> constipation, anorexia, weakness, renal tubular dysfunction, neurologic symptoms. Combination back pain, anemia, renal dysfunction, elevated ESR. Cholesterol Emboli: acute renal failure, skin changes in lower extremities (bluish discoloration or livedo reticularis), GI symptoms, elevated eosinophils in blood/urine, decreased compliment levels. History of recent angiography. Can develop pancreatitis. Hepatojugular Reflex: useful tool to differentiate between heart and liver disease related cause of lower extremity edema. (+) = heart. (-) = liver. Tropical Sprue: malabsorption (B12, folate), history of living in endemic area for > 1 month, involves SI, characterized by blunted villi with infiltration of chronic inflammatory cells, lymphocytes, plasma cells, eosinophils. Hyperactive bowel sounds and borborygmi. Generaliziability: external validity. Pertains to the applicability of the results to the study of other populations. Restriction of the study to a certain population. Erysipelas: sudden onset of sharply demarcated, erythematous, edematous, tender skin lesions with raised borders. Most frequently implicated organism is group A beta hemolytic strep. Inflammation of the superficial dermis. Legs are most frequently involved. Pancreatic Cancer: RF are family history, chronic pancreatitis, smoking, diabetes, obesity, high fat diet. Alcoholism is not a risk factor. Higher in males and blacks. Jaundice and weight loss. Recent onset diabetes, thrombophlebitis, previous pancreatitis attacks. Hypocalcemia: can be due to low albumin. Always measure albumin in order to correct for it. Measured calcium + 0.8 (4 measured albumin). Every gm/dL decrease in albumin is 0.8 mg/dL decrease in calcium. Two Sampled T Test: statistical method that is commonly employed to compare means of two groups of subjects. Need two means, the sample variances, the sample size. If p < 0.05, reject the null hypothesis. Atrial Fibrillation: irregularly irregular R-R interval with absent P waves and narrow QRS complexes. In unstable patients, do immediate cardioversion. If stable who have been in atrial fibrillation < 48 hours, cardioversion is appropriate. > 48 hours, 3-4 weeks of rate control and anticoagulation before. Use beta blocker or CCB.

Hawthorne Effect: tendency of a study population to affect the outcome because these people are always aware that they are being studied. Try to keep subjects unaware that they are being studied. Pleural Effusion: CHF is the MCC. Pleural fluid will be consistent with transudate. Normal pleural fluid pH is 7.64. < 7.3 indicates pleural inflammation. 7.35 would be transudative. Glucose < 60 favors parapneumonic effusion, TB, or RA. Alports Syndrome: recurrent episodes of hematuria/proteinuria, sensorineural deafness with a family history of renal failure. EM shows alternating areas of thinned and thickened capillary loops with splitting of the GBM. Bacterial Overgrowth: a malabsorption syndrome associated with a history of abdominal surgery. Symptoms may be nonspecific and include abdominal pain, watery diarrhea, dyspepsia, weight loss. May have tetany (hypocalcemia due to Vitamin D deficiency), night blindness (Vit A deficiency), neuropathy (B12 deficiency), dermatitis, arthritis, hepatic injury. Abdominal distension with succussion splash (palpable, soft, fluid-filled loops of bowel). Can have macrocytic anemia. Breast Cancer: single most important RF is age. Women > 40-50 years of age need regular annual mammograms. Only 10% have family history. Rare before age 30. Acute Pyelonephritis: potentially results in G(-) sepsis. Urine and blood cultures before giving antibiotics. Give cipro or ceftriaxone. Hypotensive patients need fluids and maybe pressors. CT or US only if diagnosis is not clear or acute episode does not respond. Acanthosis Nigricans: thickening and hyperpigmentation of skin in flexural areas with velvety texture. Common in insulin resistant states (DM, acromegaly, obesity) and GI malgnancies (MCC is gastric adenocarcinoma). Celiac Disease: malabsorption and iron deficiency anemia. Bulky, foul smelling, floating stool. Bone pain (osteomalacia), pallor (anemia), easy bruising (vit K deficiency), hyperkeratosis (vit A deficiency). ELISA for IgA Ab to gliadin, TTG, and anti-endomysial antibodies. Renal Transplant Dysfunction: in early post operative period = ureteral obstruction, acute rejection, cyclosporine toxicity, vascular obstruction, ATN. Acute rejection is best treated with IV steroids. Can do radioisotype scanning, US, MRI, renal biopsy to diagnose. NPV: probability of being free of a disease if test is negative. NPV will vary with pretest probability. High probability = low NPV and vice versa. HUS: child who has recently recovered from diarrheal illness and presents with ARF, MAHA, fever, thrombocytopenia, schistocytes and giant platelets on peripheral smear. GI bleeding is common. Purpura and HTN. Elevated LDH and indirect BRN and reticulocyte. SCC: of the head and neck in alcoholic smoker who presents with palpable cervical LN. Panendoscopy (esophagoscopy, laryngoscopy, bronchoscopy) to find primary tumor. Anemia: if in CKD, due to erythropoietin deficiency (normocytic, normochromic). Be sure iron stores are adequate prior to erythropoietin replacement, otherwise can precipitate iron deficient state. In dialysis patients, give IV iron dextran. Toxic Megacolon: UC is MCC. Medical emergency. Give IV steroids, NG decompression, fluid management. Emergency surgery may be needed. Ischemic colitis, volvulus, diverticulitis, infection, obstructive colon cancer can also cause.

Dipstick: test for nitrites and esterase in suspected cases of UTI. (+) LE signifies significant pyuria and (+) nitrites indicate Enterobacteraceae. Diuretic Abuse: increased excretion of water and electrolytes by the kidneys. Dehydration, weight loss, orthostatic hypotension, hypokalemia, hyponatremia. High urine sodium and potassium. Common in eating disorders. Leydig Cell Tumor: estrogen production can be increased with secondary inhibition of LH and FSH. MC type of testicular sex cord stromal tumors. Principle source of testosterone and capable of estrogen production. MC presentation of gynecomastia or precocious puberty. PE: MC S&S are dyspnea, pleuritic CP, tachypnea, tachycardia. Helical CT angiogram is investigation of choice in patients with normal creatinine. V/Q scan for those with kidney problems or allergic to dye. GN after URI: IgA nephropathy is MCC of GN in adults. Recurrent episodes of gross hematuria several days after URI. Serum compliment is normal. PSGN is 10 days for pharyngitis, 21 days for impetigo. OA: predominantly involves DIP joints. Major radiographic features are joint space narrowing, subchondral sclerosis, osteophytes, subchondral cysts. COPD: inhaled muscarinic antagonists like ipratroprium are mainstay therapy. May be combined with short acting beta agonists. Gradual decreasing flow rates, increasing lung compliance and volumes. Smoking cessation, O2, lung reduction only for increased survival. Hyperparathyroidism: indications for surgery are serum calcium at least 1 mg/dL above upper limit of normal, 24 hour urinary calcium > 400 mg, < 50, BMD < -2.5, reduced renal function. Pleural Effusion: undiagnosed effusion is best evaluated with thoracocentesis except in patients with clear cut evidence of CHF. Can determine of transudate or exudate. Lung, breast, lymphoma cause 75% of malignant effusions (exudative). Huntingtons Chorea: present in 40s or 50s with chorea and/or behavioral disturbance. Atrophy of caudate nucleus is characteristic (enlargement of lateral ventricles). AD neurodegenerative disorder. Chorea is sudden jerky irregular movements. TSH Adenoma: excessive TSH levels -> hyperthyroid state. Elevated T3 and T4 levels with inappropriately elevated TSH levels. Usually macroadenomas. Do not have infiltrative ophthalmopathy or pretibial myxedema. Elevated alpha subunit. Ventricular Tachycardia: in presence of stable BP does not need cardioversion. Best treatment is amiodarone (DOC) or lidocaine. Bladder Cancer: screening is not recommended even in those who are at risk of developing the disease. 2nd MC urologic cancer. Men > women. Smoking and exposure to industrial chemicals are common causes. Inferior Wall MI: most likely cause is RCA occlusion (could be left circumflex). ST elevation in inferior leads (II, III, aVF). Bradycardia and hypotension suggesting SA node involvement. Cross Sectional Study: exposure and outcome are measured simultaneously at particular point in time (snapshot study). Temporal relationship is not always clear.

Acne: if patient has mild acne (non inflammatory comedones) use topical retinoids. Topical antibiotics are used if mild to moderate inflammation. Oral antibiotics are used if papular and inflammatory acne. Oral isotretinoin for nodulocystic or scarring. ITP: autoimmune platelet destruction is common cause of thrombocytopenia and suspect in patients with ecchymoses, petechiae, mucosal bleeding without S&S of TTP/HUS, pancytopenia, marrow failure, splenomegaly. Papillary Thyroid Carcinoma: MC thyroid malignancy. Slow infiltrative local spread and spreads to LN. Presence of psammoma bodies. Cells with ground glass cytoplasm with inclusion bodies and central grooving. Unencapsulated. Follicular Carcinoma: invasion of the capsule and blood vessels required for differentiating follicular carcinoma from adenoma. Tend to invade blood vessels and metastasize to different organs. MS: suspect in young female patient with bilateral trigeminal neuralgia. Presents in 3rd or 4th decade with recurrent focal neurological dysfunction. Acute Limb Ischemia: in a patient with an MI who develops a cold leg, one has to get an echo to rule out a thrombus in the LV. RA: patients with rheumatoid arthritis are at increased risk of developing osteoporosis and osteopenia. Likely due to combined effects of disease itself, steroid therapy, female sex, inability to perform weight bearing exercise. Erythema Nodosum: condition of painful, subcutaneous, pretibial nodules. Can be symptom of sarcoidosis, TB, histoplasmosis, streptococcal infection, IBD. Association is strong in AA women. Do CXR. Cough, arthritis, uveitis, hilar adenopathy are also common. Metoprolol: selective beta 1 antagonist that, in high doses, can block bronchodilatory beta 2 receptors and cause bronchoconstriction in susceptible individuals. History of intermittent dyspnea and coughing, possible history of eczema -> possible asthma. Alcoholic Liver Disease: fatty liver (steatosis), alcoholic hepatitis (Mallory bodies, infiltration by neutrophils, liver cell necrosis, perivenular inflammation distribution), early fibrosis can be reversible with cessation of alcohol intake. True cirrhosis is irreversible regardless of alcohol abstinence. Lacunar Stroke: can cause lesion in posterior limb of internal capsule characgterized by unilateral motor hemiparesis of the face, arm, leg without any higher cortical dysfunction or visual field abnormalities. Seborrheic Dermatitis: also called cradle cap. Papular scaly rash tends to affect eyebrows, nasolabial folds, and scalp. Treat with moisturizers, antifungals, topical steroids, antidandruff shampoo. Transparent yellow papules. Severe cases may be due to immunodeficiency. HIV and Dysphagia: give 1-2 weeks of fluconazle therapy since candidal esophagitis is most likely. If symptoms persist, do endoscopy. HSV ulcers are multiple, well circumscribed, volcano like (small and deep appearance) -> treat with acyclovir. CMV ulcers are large, shallow, superficial and intracytoplasmic/intranuclear inclusions -> treat with ganciclovir. Defibrillation: in VF and pulseless VT, it is of primary importance. Time to defibrillation is strongly correlated with survival. Complication of MI. 200-320 joules. If unwitnessed or > 5 minutes, do cycle of CPR before defibrillation.

Polycystic Kidney Disease: relatively common autosomal dominant disease. Presents with hematuria and HTN but can cause abdominal masses and pain. Associated with intracerebral aneurysms. Do abdominal US. Scabies: highly contagious disease with presents with generalized itching and pruritic papules over the penis and scrotum in males and on areolas and breasts in females. Treat with 5% permethrin cream which is applied from neck down and left overnight. Infectious Endocarditis: in high risk patients presenting with fever, chills, evidence of septic emboli or abscesses. Can have LUQ pain and splenic fluid collection. Left sided lesions -> brain, kidneys, liver, spleen septic emboli. Right sided lesions -> septic pulmonary emboli. Pernicious Anemia: MC megaloblastic anemia -> B12 deficiency due to decreased IF. Antibodies to parietal cells have been reported -> achlorhydria. Have low B12, positive IF Ab, and extremely elevated LDH. Anaphylactic Reactions: rare to occur to transfused blood products. More common in patients with IgA deficiency. Rapid onset of symptoms with associated bronchospasm and hypotension plus absensce of fever helps to distinguish from other types of transfusion reactions. Stop transfusion, start epinephrine, IV fluids, possibly pressors. Pronator Drift: relatively sensitive and specific for UMN damage affecting upper extremities. Supinators are naturally stronger but exaggerated with UMN lesion. When people are feigning, they will tend to drop the affected arm without pronating. PCKD: heritable form of renal disease with multiple renal cysts and intermittent flank pain, hematuria, UTI, and nephrolithiasis. Enlarged right kidney is easier to palpate than enlarged left because its lower. Liver might be enlarged due to cystic involvement. Healthcare HIV Exposure: whenever healthcare worker is exposed to HIV, do baseline HIV testing immediately. PEP with 2-3 antiretroviral drugs should be stated without delay. Repeat testing at 6 weeks, 3 months, 6 months. Use 2 NRTI and 1 protease if adding a third. Hypercapnea: if respiratory acidosis is compicating metabolic acidosis -> lethargy due to hypoventilation. Bronchiectasis: bronchial dilatation -> impaired clearance of secretions -> obstruction. Can be acquired due to Tb or pneumonia. Inherited can be due to CF. Cough, mucopurulent sputum, hemoptysis. CXR -> prominent bronchioles, peripheral opacities, linear atelectasis. High resolution CT scan is used for definitive diagnosis. Vetricular Aneurysm: late complication of MI, persistent ST elevations on EKG. CHF, arrhythmias, thrombus formation with mitral regurgitation. Echo can be used to diagnose. Zollinger Ellison Syndrome: MC cause is a gastrinoma in pancreas -> parietal cell hyperplasia -> increased stomach acid -> multiple duodenal ulcers, possible jejunal ulcers. Steatorrhea can develop due to inactivation of pancreatic enzymes by stomach acids. Normal Distribution: symmetric and bell shaped. All its measures of central tendency are equal, mean=median=mode. Skewed distributions do not have the same tendency. Turcots Syndome: AR, association between FAP/HNPCC and brain tumors (primary medulloblastomas and gliomas in FAP, high grade gliomas in HNPCC). Occurs in teens.

Gardners Syndrome: AD, colonic polyps with desmid tumors, sebaceous or epidermoid cysts, lipomas, osteomas (especially of the mandible), supernumery teeth, gastric polyps, juvenile nasopharyngeal angiofibromas. Cowden Syndrome: multiple hamartoma syndrome, GIT hamartomas with breast, thyroid cancer and nodular gingival hyperplasia. Cronkhite Canada Syndrome: juvenile type polyps and ectodermal abnormalities like alopecia, hyperpigmentation, nail loss (oncholysis). First Degree Heart Block: characterized by PR > 0.2 seconds. Completely benign and requires no treatment. Can be secondary to increased vagal tone or digoxin. BNP: measurement of serum BNP can help distinguish between CHF and other causes of dyspnea. Released from ventricles in response to volume overload. Usually levels > 100 for CHF. Fanconis Anemia: AR, congenital marrow failure, poor growth, other morphological abnormalities (microcephaly, abnormal thumbs, hypogonadism), areas of skin hypopigmentation. Anemia is usually macrocytic. Aplastic anemia (fatigue and pounding in ears). Treat aplastic anemia with BMT. Orbital Cellulitis: pain with eye movement, proptosis, decreased visual acuity. CT used to define extent or presence of abscess. Preseptal cellulitis presents similarly with swollen, painful eye and fever. Sinusitis can cause orbital. Treat with broad spectrum antibiotics. Anasarca: results from organ failure or hypoalbuminemia. With GN, is due to decreased GFR with some proteinuria and hypoalbuminemia in some cases. Will have RBCs, RBC casts, WBCs, protein in urine. Inflammatory Diarrhea: inflammatory changes in the blood (anemia, elevated ESR, elevated acute phase reactants, reactive thrombocytosis). Blood and leukocyte positive stool. Contrast: potential to cause nephropathy in patients with chronic renal insufficiency (Cr > 1.5) or diabetes. Non-ionic are better than hyperosmolar ionic agents. Also use hydration and acetylcysteine prior to giving. Consider alternative studies. Clubbing: new clubbing in patients with COPD can indicate cancer. NOT a feature of simple COPD. Thickening of the nail bed, loss of angle between nail bed and nail fold. Ehrlichiosis: history of tick bite, systemic symptoms (fever, malaise, myalgias, HA, nausea, vomiting), leukopenia/thrombocytopenia, elevated LFTs, endemic area (SE, SC, mid-atlantic, upper MW, California). No rash present. Treat with doxycycline without delay. Alcoholic Hepatitis: AST:ALT > 2, thought to be due to hepatic deficiency of pyridoxal-6phosphate (needed for ALT activity). Usually < 500. If higher, consider viral, shock liver, or Tylenol use. Nephrotic Syndrome: results in alterations in lipid metabolism. Dyslipidemia puts patients at increased risk of for accelerated atherosclerosis. Added to increased risk of thrombosis (usually venous, especially renal) -> risk for MI and stroke. Have high LDL and low HDL. Hypersensitivity Pneumonitis: inflammation of the lung parenchyma caused by antigen exposure. Cough, breathlessness, fever, malaise occurring within 4-6 hours of exposure. Chronic -> weight loss, honeycombing, clubbing. Avoid antigen. Can be bird fanciers lung or farmers lung.

Primary HIV Infection: present with mononucleosis type syndrome with fever, night sweats, LA, arthralgias, diarrhea. Make the diagnosis in an early stage. Usually 2-4 weeks after the exposure. Can have mucosal ulcerations and skin rash. Prolonged diarrhea and weight loss. Duodenal Ulcer: epigastric pain that improves with eating (otherwise unopposed acidic fluid goes into duodenum). 90% are due to H pylori. Use PPI and antibiotics as long term treatment (amoxicillin, clarithromycin, PPI). Parkinsonism: most effective symptomatic therapy is L-dopa, but does not stop progression. Greater risk of dyskinesia. SE are nausea, vomiting, hypotension. Better for older patients. Other medications are DA agonists, anticholinercics, amantadine. Young -> DA agonist. VIPoma: pancreatic cholera. Diarrhea, hypokalemia (leg cramps), achlorhydria. Women > men. Can become dehydrated, have abdominal pain, cramping, weight loss, flushing. Test for VIP in blood. CT or MRI to confirm. Pancreatic Cancer: enlarged, non tender gallbladder, evidence of biliary obstruction (elevated direct BRN and ALP). US can show dilated ducts. Abdominal CT to diagnose. Gout: cessation of alcohol and low purine diet are important measures to prevent future attacks. Ethanol -> lactate which competes with urate for excretion. Also avoid drugs like diuretics and pyrazinamide. Treat acute attack with colchicine, NSAIDs, or steroids. HOCM: heart murmur at LLSB that decreases with increased preload (standing to squatting) or intensifies with decreased preload (Valsalva). MC in AA. AD disease inheritance. Dermatitis Herpetiformis: presence of pruritic papules and vesicles over extensor surfaces and presence of anti-endomysial antibodies. Also have GI symptoms of malabsorption. Increased risk of GI lymphomas (reduced with gluten free diet). Choledochal Cysts: congenital abnormalities of the biliary tree characterized by dilatation of the intra and/or extra hepatic biliary tracts. Most cases related to anomalous pancreaticobiliary junction. Leads to weakness and dilatation of the biliary wall due to reflux of pancreatic secretions. Present with jaundice and passage of acholic stools. Abdominal pain, jaundice, attacks of acute pancreatitis (elevated amylase and lipase). Can degenerate into cholangiocarcinoma. Do US followed by CT/MRI. Bacillus Cereus: causes nausea and vomiting after eating rice. Symptom onset is 1-6 hours. Produces a heat stable toxin in inadequately refrigerated cooked rice. Chemical irritants also cause abrupt onset nausea and vomiting. Tetracyclines: important cause of phototoxic drug eruptions. Manifest as exaggerated sunburn reactions with erythema, edema, vesicles over sun-exposed areas. Consider in patient being treated for mild-moderate acne. Doxycycline is most photosensitizing. Produce reactive oxygen products with exposure to UV radiation. Jaundice:determine if conjugated or unconjugated. Dipstick with bilirubin suggests conjugated. Rotors syndrome is a possible cause (benign condition with defective hepatic storage of conjugated BRN -> leaking into plasma. LFTs are normal. No treatment necessary. SIADH: water restriction is first step in managing their hyponatremia. Can occur from lung cancer. If Na < 120 or if patient is having seizures, use 3% NaCl to raise to 125. If evidence of fluid overload, CHF, resistant to treatment, use loop diuretics. Lithium or demeclocycline for chronic treatment.

Gout: caused by overproduction or underexcretion. Chemotherapy -> rapid tumor cell lysis > uric acid release. Give allopurinol to prevent formatin of uric acid with chemotherapy. To prevent, use allopurinol or probenecid. To treat, use colchicine, NSAIDs, steroids. SLE: presence of antibodies to DS DNA is highly specific for and confirms diagnosis. Also have lack of or reduced suppressor T cell functions and hyperproduction of helper T cells. Concurrent B cell hyperactivity -> increased serum Ab and IgG -> immune complexes. De Quervains Tenosynovitis: classically affects new mothers that hold their infants with the thumb outstretched. Abductor pollicis longus and extesor pollicis brevis tendons affected. Tenderness to palpation of radial side of wrist. Finkelsteins test (passive stretch of tendons with thumb gripped inside fist and ulnar deviation). Warfarin: vitamin K antagonist used for anticoagulation. Foods with high vit K (dark green, vegetables) decrease efficacy while foods, supplements, medications such as alcohol, vitamin E, garlic, ginko biloba, ginseng, St Johns wort, antibiotics increase efficacy -> bleeding. Vitiligo: macular depigmentation that involves acral and peri-orificial areas. Caused by autoimmune destruction of melanocytes. Pale white macules with hyperpigmented borders. Isoniazid: 10-20% of patients develop mild aminotransferase elevation within first few weeks of treatment. Injury is self limited and resolves without intervention. LFTs usually < 100. Can continue taking it as long as LFTs are regularly monitored and remain mildly elevated. Unconjugated Hyperbilirubinemia: Gilberts, Crigler-Najjar Type 1 and 2 are causes. Gilberts Syndrome: familiar disorder of BRN glucuronidation, production of UDP glucuronyl transferase is reduced. Icterus secondary to mild unconjugated hyperbilirubinemia (< 3). Have malaise, fatigue, abdominal discomfort. Hemolysis, fasting, consuming fat free diet, physical exertion, febrile illness, stress or fatigue will precipitate. Crigler Najjar Type 1: AR with severe jaundice and neurological impairment due to kernicterus. 20-25, can be upto 50. LFT and histology are normal. Phenobarbital does not change BRN level. Phototherapy and plasmapheresis for short term, liver transplant for long term. Crigler Najjar Type 2: AR with milder jaundice (< 20). Survival into adulthood with no kernicterus or neurological impairment. LFT and histology are normal. Phenobarbital decreases BRN level. Periodic phenobarbital or clofibrate can be used if necessary. Mallory Weiss Tears: increased intragastric pressure during vomiting -> tears in cardial mucosa and sometimes esophagus. Account for upto 10% of GI bleeds. Usually spontaneously stops but can use vasopressin, endoscopic injection, electrocautery. Pseudotumor Cerebri: LP only after completely ruling out space occupying lesion with CT/MRI. Have pulsatile HA that awakens patient from sleep. Can have neck pain, double vision, visual loss, tinnitus. Can have papilledema or VI nerve palsy. Most patients have empty sella (caused by downward herniation of arachnocele due to high CSF pressure). LP has high opening pressure. Remove sufficiency CSF to decrease pressure to 150. Brain Hemorrhage: hypertension and atrial fibrillation on anticoagulation are major RF. Regularly assess general well being and current medication list in elderly patients. Hyperdense area on CT indicative of bleed. Stop anticoagulation and give FFP and Vit K.

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Coarctation: presents with rib notching on CXR. 3 sign is typically seen with coarctation of longer duration implying proximal aortic dilatation, constriction, descending aortic dilatation. MC location is at site of LA. HA, epistaxis, cold extremities. Radiofemoral delay. Upper extremity may be preferentially well developed. Hepatorenal Syndrome: complication of liver disease characterized by renal failure that does not respond to fluid resuscitation. Decreased GFR in absense of shock, proteinuria, other clear cause of dysfunction. Results from vasoconstricton due to decreased blood flow and low vasodilatory product production. Type 1 is rapid and patients die within 10 weeks. Type 2 is slower and survival is 3-6 months. MCC of death is hemorrhge or infection. Liver transplant is only treatment. Disseminated Histoplasmosis: occurs in patients with HIV. Treat with IV amphotericin B to decrease fungal load with lifelong itraconazole to prevent relapse. Pagets Disease: osteitis deformans. MCC of asymptomatic elevation of ALP in elderly. Dyslipidemia: first line treatment is statin therapy. Is increased to maximum dose as needed. With persistently low HDL, after max statin, start nicotinic acid. Usage usually limited by SE like flushing, pruritis, nausea, paresthesias. Use controlled form for decreased SE. Glucagonoma: patient with hyperglycemia, necrolytic migratory erythema, diarrhea. Triad of hyperglycemia, necrotizing dermatitis, weight loss. Usually malignant and metastasizes to the liver. Elevated glucagon in the blood. Pancreatic tumor on CT scan. Surgery to treat. Lactose Intolerance: positive hydrogen breath test, positive stool for reducing substances, low stool pH, increased stool osmotic gap. No steatorrea. Osmotic diarrhea, abdominal cramps, bloating, diarrhea. Breath test = positive hydrogen level after ingestion = bacterial metabolism. Cerebellar Hemorrhage: sudden onset vertigo, occipital headache, vomiting in hypertensive patient. Can have VI paralysis, conjugate deviation, blepharospasm, coma. Generally evolves over hours. Fever is common with any brain hemorrhage. Immediate evacuation needed. Pneumoconiosis: causes restrictive interstitial lung disease with normal or high FEV1/FVC and decreased DLCO (normal DLCO would be neuromuscular). Can result in fibrosis from occupational exposure. Asbesosis -> pleural calcifications (can be from hemorrhage or empyema). Hyperparathyroidism: uncommon cause of secondary HTN. Asymtomatic hypercalcemia in a hypertensive patient or presence of symptoms of hypercalcemia. Anterior Cerebral Artery Stroke: contralateral motor and sensory deficits which are more pronounced in the lower limb than the upper limb. May have urinary incontinence, gait apraxia, primitive reflexes, abulia, paratonic rigidity. Systolic Heart Failure: depressed CI (measure of cardiac output), increased TPR (due to sympathetic output and RAAS activation), increased LVEDV (may be normal in diastolic failure). Pica: appetite for non nutritive substances like ice, clay, dirt, paper products. Can be a cause of iron deficiency (suspect chronic bleeding), especially with ice. May also be a manifestation of psychiatric disease. Metastatic Prostate Cancer: radiation therapy is done in patients with prostate cancer who have undergone orchiectomy. Do focal external beam therapy.

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WPW: if develop atrial fibrillation with rapid ventricular rate treat with cardioversion or procainamide/quinidine. AV blockers like beta blockers, CCB, digoxin, adenosine should be avoided since it can increase conductance through accessory pathway. Iron Deficiency: low serum iron, ferritin, transferrin saturation, high TIBC. Have low MCV, MCH, reticulocyte count. Have anisocytosis, poikilocytosis, hypochromia, microcytosis on smear. Steroid Induced Myopathy: painless proximal muscle weakness that improves when medication was discontinued. Have normal ESR (unlike PMR). May have history of disease that was or should be treated with steroids. Syringomyelia: areflexic weakness of upper extremities and dissociated anesthesia in cape distribution. Presence of cord cavity is most characteristic feature. Caudal displacement of 4th ventricle, cerebellar tonsils, focal cord enlargement may occur. Mitral Stenosis: left atrial dilatation with risk of atrial fibrillation and cardiac emboli. Pressure is transmitted to pulmonary vasculature -> dyspnea, cough, hemoptysis. Can present with stroke. Patient may have history of rheumatic fever or be an immigrant. Multisystems Atrophy: Shy Drager Syndrome. Patient with Parkinsonism presents with orthostatic hypotension, impotence, incontinence, other autonomic symptoms. Also have widespread neurological symptoms. Can have accompanying bulbar dysfunction or laryngeal stridor. Treat with intravascular volume repletion, fludricortisone, salt, alpha agonists. Dilated Cardiomyopathy: can be secondary to alcoholism. Thrombocytopenia, macrocytosis, elevated transaminases suggest alcoholism. Total abstinence from alcohol may reverse condition if employed early in the disease. Macular Degeneration: usually seen in patients over 50 years old. Presents with bilateral progressive loss of central vision. Navigational and peripheral vision is preserved but may be complicated by cataracts. Degeneration of outer retina, pigment epithelium. Parapneumonic Effusion: when pH < 7.2, glucose < 60, probability is high that fluid needs to be drained. Drained via a chest tube (tube thoracostomy). Ischemic Strokes: fibrinolytic therapy improves outcomes if given within 3 to 4.5 hours of onset. Non contrast CT should be done prior to rule out hemorrhage and patient should be screened for other CI to therapy. Herpes Zoster: a painful reaction of the varicella zoster virus that causes vesicular rash in dermatomal distribution. Acyclovir and other antivirals are used to decrease duration and incidence of post herpetic neuralgia. Pain precedes rash by 48 hours. CMV Colitis: any HIV (+) patient with bloody diarrhea and normal stool examination should have colonoscopy to look for CMV colitis. Bloody diarrhea with abdominal pain. Colonoscopy shows multiple ulcerations and mucosal erosions. Biopsy has characteristic cytomegalic cells with intracytoplasmic and intranuclear inclusions. Aortic Regurgitation: wide pulse pressure, felt as water hammer pulse. Lying down and turning to the left brings the heart closer to the chest wall and makes the patient more aware of forceful heartbeat. Aortic root and bicuspid aortic valve are MCC. Rheumatic fever is CC. Adrenal Insufficiency: characterized by non specific symptoms like anorexia, fatigue, GI complaints, weight loss, hypotension, hyperpigmentation. Hyponatremia is MC electrolyte abnormality and hyperkalemia is common as well. Due to volume loss and low aldosterone.

PE: suspected in all patients at risk of DVT with acute onset tachypnea, dyspnea, chest pain. Can have exudative (MC) or transudative effusion. Diagnosed by helical CT of chest. Chi Square Test: used to compare proportions. A 2 by 2 table may be used to compare the observed values with expected values. Cholelithiasis: UDCA is a medication used to dissolve small radiolucent gallstones in patients with normal functional GB who are poor surgical candidates. Medication is very costly and associated with high risk of relapse. Also tell to avoid fatty foods. Factor V Leiden: MC inherited disorder causing hypercoagulability and predisposition to thromboses, especially DVT of lower extremities. Mutation -> resistance to deactivation by protein C. DVT: treated to prevent PE. CI to anticoagulation are recent surgery, hemorrhagic stroke, bleeding diathesis, active bleeding. HIT and developing DVT/PE even with anticoagulation are indications to put in an IVC filter. Acute Variceal Bleeding: first step is to establish vascular access with two large bore IV needles or central line. Protect airway and decompress stomach with NG to prevent aspiration. 50% stops spontaneously. Terlipression (analog of vasopressin), octreotide, somatostatin can be used. Rebleeding is common in 6 weeks following initial bleed. Sarcoidosis: most commonly affects young to middle aged AA females causing insidious onset dyspnea and dry cough in the absence of constitutional symptoms. Also affects skin (erythema nodosum, protean manifestations), and eyes (uveitis). Diffuse interstitial infiltrates on CXR. Loop Diuretics: cause hypokalemia and hypomagnesemia which can cause ventricular tachycardia and potentiate effects of digoxin. Order serum electrolytes and digoxin level. Vibrio Parahemolyticus: diarrhea usually transmitted by ingestion of seafood (shrimp, crab, raw oysters). Have fever, abdominal cramps, nausea after 4 hour to 4 day incubation period. Can be watery or bloody diarrhea. Tuberculosis: most cases occur in people who have immigrated to this country from endemic geographic regions. Have chronic low grade fever, sweats, weight loss, cough productive of blood tinged sputum. Chronic Liver Disease: hyperestrogenism as a result of decreased clearance of estrogen from blood by the liver due to increased portosystemic shunting. Decreased sex hormone binding globuin synthesis increases ability of estrogen to exert its biologic effects. Have telangiectasias, palmar erythema, testicular atrophy, gynecomastia, impotence. Can have hypothalamic-pituitary dysfunction as well -> secondary hypothyroidism. Seborrheic Dermatitis: characterized by waxy scales with underlying erythema on the scalp, central face, presternal region, interscapular areas, umbilicus, body folds. May be in association with Parkinsonism or HIV. Pityrosporum ovale plays role. Use antifungals. GBM: typical CT/MRI findings are heterogeneous and serpiginous contrast enhancement with classic butterfly pattern. Change in personality and strange behavior -> frontal lobe. Acute Prostatitis: presents similarly to UTI, addition of perineal pain and tender boggy prostate. Cystitis is uncommon in men. Vigorous prostatic massage should be avoided -> bacteremia. Obtain a mid stream urine sample to direct antibiotic therapy.

Radioactive Iodine: in hyperthyroid patients not initially treated with antithyroid medications, treatment with RI may initially cause exacerbations of thyrotoxic state. Especially in elderly patients with cardiovascular disease. Diffuse Esophageal Spasm: seen in young females, can present with intermittent episodes of chest pain and dysphagia. Barium swallow may reveal corkscrew esophagus. Have high amplitude peristaltic contractions. Treat with antispasmodics, diet changes, counseling. Exercise Induced Asthma: short acting beta agonists administered 20 minutes before exercise are first line treatment. Induced trigger is rapid ventilation of cold dry air. Atopic dermatitis and allergic rhinitis. Long acting beta agonists may be used in children and athletes. Optic Neuritis: central scotoma, afferent pupillary defect, changes in color perception, decreased visual acuity. Associated with MS. Presents in women 20-45 years old. Have pain with eye movement. Risk: probability of getting disease over a certain period of time. Divide number of diseased subjects by total number of subjects at risk. HIV Vaccinations: follow same immunization schedule as the general population for Td. Should get it every 10 years. Patients < 65 who have never had Tdap should get one dose. Get influenza, HBV, pneumococcus. HAV for MSM. Sickle Cell Trait: suspect in young black male who presents with painless hematuria. Thought to be due to papillary ischemia due to low local oxygen tension -> sickling. Unfractionated Heparin: thrombocytopenia and hypercoagulation within days of starting anticoagulation therapy. HIT -> abnormal intravascular thrombosis. Heparin induced release of platelet factor 4 -> immunogenic heparin-PF4 complexes. IgG Ab -> activation of platelets and endothelial cells and abnormal generation of intravascular thrombin. Elevated aPTT. Thrush: MC SE of inhaled steroid therapy. Cornerstone of asthma therapy. High doses for long period -> systemic symptoms of adrenal suppression, cataract formation, decreased growth in children, interference with bone metabolism, purpura. Ankylosing Spondylitis: seronegative spondyloarthropathy, HLA-B27 association. Young men with progressive inflammatory back pain and stiffness. Reduced lower back ROM and sacroiliitis. MC extraarticular manifestation is anterior uveitis (monocular pain, blurring, photophobia). Hereditary Spherocytosis: AD defect in spectrin. Anemia, spherocytosis, splenomegaly, increased osmotic fragility. May present with cholecystitis. Complicated by episodes of aplastic crisis. Life threatening, due to parvovirus infection. Should be on folate to prevent severe anemia. Smear -> spherocytes and polychromatophilia. MCV is normal. MCHC is elevated. Metaclopramide Induced Dystonia: DA antagonist and prokinetic agent used to treat nausea, vomiting, gastroparesis. Can cause agitation and loose stools as well. EPS occur less frequently. NMS may occur rarely. Treat with discontinuation and benztropine or Benadryl. Secondary Hyperparathyroidism: hypocalcemia and hyperphosphatemia with increased PTH, usually due to CRF. Almost university in ESRD. Phosphate retention -> hypocalcemia which stimulates PTH. High phosphate blocks calcium receptors on PTH gland. Low formation of Vit D3 -> no inhibitory effect on PTH. PTH resistance is similar but earlier.

HIT: first step in management is to stop all heparin including LMWH. HIT I is non immune -> direct heparin effect on platelets. HIT II is autoimmune, within 4-10 days. Give alternate anticoagulation like danaparoid and direct thrombin inhibitor (argatroban, lepirudin). Respiratory Alkalosis: kidney compensates by preferentially excreting bicarbonate -> alkalinized urine with high pH. PSVT: most commonly results in accessory conduction pathways through AV node. Vagal maneuvers (cold water dunking, valsalva, carotid massage) and medications (adenosine) resolve and decrease conduction through AV node. Staph Endocarditis: IVDA are at increased risk usually on tricuspid valve. Also those with skin infections, infected medical devices. Vegetations can embolize to the lungs causing nodular infiltrate with cavitation. Delerium: acute confusional state due to organic illness commonly superimposed on dementia in the elderly. Urosepsis and metabolic disturbances are common precipitants. Do UA and CMP initially. Are confused, disoriented, have hallucinations. MCC in hospitalized patients is withdrawl or substance abuse. SCC: firm solitary LN are highly suspicious for LN metastases, particularly in older patients with a significant smoking history. Non-tender solitary nodes in head and neck (submandibular and cervical) are concerning for SCC. Do prompt biopsy. Exertional Heat Stroke: occurs in otherwise healthy individuals undergoing conditioning in extreme heat and humidity due to thermoregulation failure. Temperature > 105 (can cause rhabdomyolysis -> large blood but no RBC in urine, organ system damage), altered mental status, dehydration, hypotension, tachycardia, tachypnea. Diverticulosis: if asymptomatic only needs dietary modification in the form of high fiber intake -> bulky stools -> increase width of colon -> decreased pressure. Causes constipation and abdominal pain in elderly patients. Coccidiomycosis: endemic in the southwestern US, as well as Central and South America. Primary pulmonary infection has non-specific features like fever, fatigue, dry cough, weight loss, pleuritic chest pain. Can have erythema multiforme, erythema nodosum, arthralgias. Actinic Keratosis: develop in predisposed individuals in chronically sun exposed individuals. Erythematous papules with central scale and sandpaper texture. 1% convert to SCC. Hyperkeratosis -> cutaneous horns. Skin Histology: acanthosis (thickening of epidermis), parakeratosis (retention of nuclei into stratum corneum), dyskeratosis (abnormal keratinization), hyperkeratosis (thickening of stratum corneum). All seen in AK. Ethylene Glycol Poisoning: hypocalcemia and calcium oxalate deposition in the kidneys. Flank pain, hematuria, oliguria, ARF, anion gap metabolic acidosis. Give fomepizole or ethanol to achieve alcohol dehydrogenase inhibition, bicarb to alleviate acidosis, dialysis for acidosis or organ damage. Coagulopathy: FFP contains all the clotting factors and first line treatment (esophageal variceal bleeding in patients with hepatic disease). Also has plasma proteins and fluid. Fluid resuscitation is more important that diagnosis in unstable patients.

Ectopic ACTH: lung cancer can cause. Important cause of Cushings. Sexual dysfunction can be presenting complaint. Can have hypokalemic acidosis. Also caused by adrenal neoplasia, pituitary adenoma, exogenous intake. Acromegaly: gold standard test is measurement of GH levels following oral glucose load. Patients are unable to suppress GH levels after glucose. IGF1 is a good screening tool. Have uncontrolled HTN, increase in ring size, doughy/sweaty hands, skin tags, CTS. Normal individuals suppress GH < 1 mcg/dl after 75g glucose, Porphyria Cutanea Tarda: painless blisters, hypertrichosis, hyperpigmentation. Associated with HCV infection. Triggered by ingestion of certain substances (ethanol, estrogen) which should be discontinued. Deficiency of uroporphyrinogen decarboxylase. Elevated urine porphyrin levels. Phlebotomy or hydroxycholoquine may provide relief. IFN-alpha for HCV. Hemochromatosis: increased intestinal iron absorption results in deposition of excessive amount of iron -> tissue damage and organ failure. Have > 45% transferrin saturation and > 1000 ferritin. HCC is the most serious complication and causes 30% of deaths. Aspiration Pneumonia: impaired consciousness, advanced dementia, other neurologic dysfunction due to impaired epiglottic function. Aerobic oral flora are usual pathogens like viridans strep. May be necrotic -> abscess. Acute Vertigo: sensation of spinning head, due to dysfunction of the labyrinth. BPPV have symptoms related to head position. Cerebral ischemia -> presyncome -> lightheadedness. 30% of cases can occur after trauma. Pseudomonas: common cause of severe, pulmonary infections in CF patients. Preferred therapy is aminoglycoside (tobramycin), and antipseudomonal PCN (piperacillin). Can use antipseudomonal cephalosporin (ceftazidime, cefepime), and aminoglycoside. Fluoroquinolone can be used in adults as AG alternative. Metastatic Breast Cancer: local therapy is rarely curative (resection of metastases, local radiation) but can be tried in patients with soliary focus without signs of metastatic involvement. Recurrent Pneumonia: in same anatomic location is red flag for cancer or some obstruction. Smoking is another RF for cancer. When suspected, do CT chest. Bronchoscopic of CT guided biopsy depending on location. Could be due to bronchiectasis, foreign body, bronchial stenosis. TCA OD: sodium bicarb (if QRS > 0.1 seconds) narrows QRS preventing development of arrythmia by alleviating cardio-depressent action on sodium channel. QRS prolongation -> ventricular arrhythmias. Vertebral Osteomyelitis: MRI of the spine is most sensitive indicator. It will reveal if there is an abscess or cord compression. Blood cultures are important for targeting antibiotic therapy. Usually hematogenous, and lower back. Low grade fever, ESR. Local tenderness to percussion and paraspinal spasm. Dementia vs Normal Aging: impairment in ADLs is essential for differentiating dementia from normal changes in aging. Patients with dementia have functional impairments. Buproprion: FDA approved for smoking cessation. Use in conjugation with counseling and nicotine replacement. TCAs like amytriptyline are also used but not FDA approved. Varenicline is a partial agonist of the nicotinic receptor and is somewhat more effective.

Subdural Hematoma: serious intracranial hemorrhages that occur due to tearing of bridging veins. Blunt trauma is the MCC and surgical evacuation is usually required. Develop more slowly than epidural. Have HA and LOC. Common in older patients. White cresecent on CT with possible midline shift. Respiratory Acidosis: can be due to chronic hypercapia from COPD. Body compensates by increasing HCO3 reabsorption from renal tubules. Can also be due to obesity hypoventilation, neuromuscular. Patients typically do not normalize or overcorrect pH. MS: suspect in female patient with multiple neurologic presentations interspaced between time periods. Optic neuritis can result in blurring of vision and is often associated with retrobulbar pain. Brainstem involvement -> diplopia, nystagmus, vertigo, facial weakness, hemispasm. HIV Ophthalmologic Disease: HSV and VZV can both cause severe, acute retinal necrosis associated with pain, keratitis, uveitis, peripheral pale lesions and central necrosis on fundoscopy. CMV retinitis is usually painless and not associated with keratitis or conjunctivitis. Hemorrhage and fluffy or granular lesions around retinal vessels. Acute Hepatitis B: testing for both HBsAg and anti HBc is best screening. ALT>AST. HBsAg is the first marker detected and is detectable during entire symptomatic phase. Anti-HBs is found after immunization or clearance of HBsAg, detectable for life. Indicator of noninfectivity and immunity. Window period between disappearance of HBsAg and antiHBs. HBcAg not usually detectable. Anti-HBc appears after HBsAg, IgM is indicative of acute disease and is present during window period, so is important between clearance of HBsAg and anti-HBs. HBeAg detectable shortly after HBsAg, indicates viral replication and infectivity. Cleared before HBsAg and followed by presence of anti-HBe. Anti-HBe suggests cessation of active replication and low infectivity. Overflow Incontinence: autonomic neuropathy may lead to denervated bladder -> overflow incontinence. Characterized by high PVR. Can be due to diabetes. Acute Hepatic Encephalopathy: lactulose and reduced protein diet. Increased levels of ammonia -> inhibitory neurotransmission via GABA. Non responders to lactulose, use ornithine-aspartate infusion, oral sodium benzoate. Neomycin also (long term -> ototoxicity and nephrotoxicity). CTS: most common mononeuropathy of upper extremity. Paresthesias of first 3 digits and occasionally thenar eminence atrophy. Empyema: infection of pleural space. Can occur from parapneumonic effusions. Common cause is hemothorax. Present with low grade fever and best diagnosed with CT. When localized, complex, thick rim, surgery is answer. CIN II/III: should have Pap smears with or without coloposcopy and ECC every 6 months until 3 (-) results. May resume standard screening after that (annual until 65 or 70). Can increase to every 2-3 years if 3 (-) results with same monogamous partner. Tumor Lysis Syndrome: hyperphosphatemia, hypocalcemia, hyperkalemia, hyperuricemia. Tumors with high cell turnover (poorly differentiated lymphomas and leukemias). Allopurinol can decrease incidence of acute urate nephropathy. Phosphate binds calcium and causes hypocalcemia. Testicular Mass: after diagnosis of solid testicular mass is made (painless hard mass in testicle + suggestive US), initial management is removal of the testis and cord. Transcrotal biopsy is CI due to risk of spillage of cancer cells -> spread through lymphatics and blood.

Nephrosclerosis: usually due to HTN. MC lesions are arteriosclerotic lesions of afferent and efferent renal arterioles and glomerular capillary tufts. As HTN progresses -> decreased blood flow and GFR -> glomerulosclerosis. Hematuria and proteinuria. Kidneys are small. Mitral Stenosis: due to rheumatic heart disease (MC valvular manifestation), especially in immigrants. 70% of patients develop atrial fibrillation due to LA dilation. Irregularly irregular with no p waves. Lack of atrial kick -> pulmonary congestion -> dyspnea. GBS: acute or subacute ascending paralysis. CSF has elevated protein with normal glucose, WBC, RBCs. Acute idiopathic polyneuropathy. Motor > sensory (can have distal parasthesias). Autonomic disturbances are rare & fatal. Treat with IVIG and plasmapheresis. Acute Otitis Media: consider in any patient with ear drainage and difficulty hearing. Ear pain is also common, but may be absent in young patients. Fever, irritability, diarrhea. Can have boggy nose and PND. Erythematous TM with decreased motion. Mitral Regurgitation: MC valvular abnormality observed in patients with endocarditis not related to IVDA. Subacute endocarditis affects previously damaged valuves (previous murmur). PAC: benign and to not require any follow up or treatment. P waves that are premature relative to the cardiac cycle and differ in morphology. Anxiety, CHF, hypoxia, caffeine, electrolyte abnormalities. Hypocalcemia: patients who receive multiple transfusions or PRBCs over 24 hours may develop elevated levels of citrate which chelates calcium (paresthesias) and magnesium. Usually in massive transfusions of > 1 blood volume over 24 hours. Toxic Epidermal Necrolysis: severe mucocutaneous exfoliative disease. Erythematous morbilliform eruption that rapidly evolves into exfoliation of the skin. (+) Nikolskys sign. Painful oral blisters. Reaction to drug (sulfonamides, barbiturates, phenytoin, NSAIDs). In the spectrum of SJ and SJ/TEN overlap. SJ < 10% of body. TEN > 30%. Hemochromatosis: causes a restrictive cardiomyopathy (diastolic dysfunction). Symmetric thickening. Signs of right heart failure and sometimes left heart failure. Can be reversed with early treatment (phlebotomy). AV Fistulas: cause high output cardiac failure -> increased cardiac preload. Can be due to trauma. Circulation cannot meet O2 demands of the body. Wide PP, brisk carotid upstroke, tachycardia. Flushed extremities, displaced PMI. Thyrotoxicosis, Pagets disease, anemia, thiamine deficiency also cause high output cardiac failure. MG: oral anticholinesterases are initial treatment of choice. Increase Ach at the synapse. Use pyridostigmine or neostigmine. SE are abdominal cramps, fasciculations, muscular weakness. Immunosuppression and thymectomy are also used to treat. Cellulitis: infection of the skin and subcutaneous tissue. Obseity, venous insufficiency, disruption of the cutaneous barrier, previous cellulitis are RF. Red, edematous skin that is hot to the touch is consistent. Fever, lymphangitis, LA (masses) are seen. GAS and Staph. Melanoma: excisional biopsy with narrow margins is preferred study. If depth < 1 mm, can be excised with 1 cm tumor free margin, with 99% 5 year survivial. > 1 mm depth should have sentinal node study. Excision allows multiple parameters to be determined. Do not excise with wider margins until diagnosis is made -> may disrupt lymph flow and ability to ID sentinal nodes.

MEN IIa: medullary carcinoma of the thyroid, hyperparathyroidism, pheochromocytoma. Serum calcitonin is elevated, use this to screen. CAH:21 hydroxylase deficiency is the MC form. Partial deficiency presents in adulthood with signs of hyperandrogenism. 17 alpha hydroxyprogesterone accumulates. Also have salt wasting due to aldosterone deficiency. 17 hydroxylasedeficiency -> delayed puberty and mineralocorticoid excess. 11 beta hydroxylasedeficiency -> androgen and mineralocorticoid excess. 3 beta hydroxysteroid dehydrogenase deficiency -> DHEA-S excess. Autoimmune Hemolytic Anemia: in patient with malignant lymphoproliferative disorder is likely due to anti-RBC IgG warm immunoglobulins. Treat with prednisone. If ineffective, splenectomy. May have enlarged LN. Have elevated BRN, LDH, low haptoglobin. Coombs (+). Hepatic Encephalopathy: alteration in CNS function due to decreased clearance of toxins. Typically clear precipitant and symptoms may range from mild confusion to coma. Treat with lactulose, neomycin or rifaximin, laxatives. Will have asterixis in exam. Strawberry Hemangiomas: benign vascular tumors of childhood. Appear during first few weeks of life, initially grow rapidly, regress by 5-8 years. Composed of capillaries separated by connective tissue. Can be found in deep tissues (liver). Endothelium rapidly proliferates. Transfusions: individuals who received transfusions before 1992 should be screened for HCV. Before 1986, HBV. UTI: common in diabetics, elderly, postoperative. Elderly may present with confusion and absence of GU complaints. UA will help diagnose. (+) nitrites, LE, bacteria, > 5 WBC. TMPSMX is appropriate treatment. HIV Pulmonary Cavitation: can be caused by Tb, atypical mycobacteria, Nocardia (weakly acid fast, branching, filamentous G(+) rod), G(-) rods, anaerobes. Nocardia is found in soil and water. Infects immunocompromised -> nodules, reticulonodular, diffuse infiltrates, abscess, cavity. Treat with TMP-SMX. Post Cholecystectomy Pain: MC occurs due to CBD stones, sphincter of Oddi dysfunction, or functional causes. Normal LFTs and no bile duct dilatation rule out first two causes. Treat symptomatically with analgesics and reassurance. Kaposi Sarcoma: caused by HHV-8. Asymptomatic, elliptical, linearly arranged papules -> plaques, nodules. Involve legs, face, oral cavity, genitalia. No necrosis of skin or underlying structure involvement. Cluster HA: acute severe retroorbital pain that wakes patient from sleep. Accompanied by redness of ipsilateral eye, tearing, redness, stuffed or runny nose, ipsilateral Horners syndrome. Occur in clusters, daily, for 6-8 weeks, followed by remission for a year. Acute attack: treat with 100% O2 and SQ sumatriptan. Iron Deficiency Anemia: decreased serum iron/percent saturation, elevated TIBC. Decreased MCV/MCH. MCC in infants is inadequate intake. In older children and adults, is chronic blood loss. Children with diet primarily of milk without iron supplemented foods in early years. Anemia: the most appropriate blood product is PRBCs. In patient with pre-existing heart disease, you want to keep Hgb > 10. Oxygenation can be maintained at Hgb > 7 in patients with normal cardiac function. Transfusion is often necessary with active bleeding.

Secondary Pneumothorax: suspect in patient with COPD presenting with catastrophic worsening of symptoms. Dilation of airspace, especially in apices -> present with acute chest pain and SOB. Worsening is slower in COPD exacerbation caused by infection. Subdural Hematoma: rupture of bridging veins. Can occur with severe trauma, or minor trauma when patient is anticoagulated, especially combination of ASA and warfarin. Semi lenticular hematoma on CT. More common in elderly and alcoholics with brain atrophy. Hashimotos Thyroiditis: anti-TPO are present in 90% of HT, tend to appear later in life, are higher in early stages of disease, decrease with time and treatment. Also have antithyroglobulin Ab. Rheumatic Fever: patient with previous attack should receive antibiotic prophylaxis with penicillin to prevent further attacks until 18. Due to untreated streotococcal pharyngitis. Jones criteria require evidence of GAS infection and evidence of 2 major, or 1 major/2 minor. o Major: carditis, polyarthritis, chorea, rash (erythema marginatum), SQ nodules o Minor: arthralgias, fever, elevated acute phase reactants, prolonged PR Metabolic Alkalosis: can be chloride sensitive (hypochloremic, saline responsive) or chloride resistant (normochloremic, saline unresponsive) based on urinary chloride levels and ECF volume status. Chloride sensitive associated with low urinary chloride excretion and volume contraction. Diuretics, loss of gastric secretions. Correct with saline. Chloride resistant has urinary chloride > 20 and volume expansion. Primary hyperaldosteronism, Bartter syndrome, Gitelmans syndrome, excessive black licorice. Not corrected by saline. Latex Allergy: anaphylactic reaction on exposure to things like surgical gloves and condoms. Common in patients with spina bifida. Back Pain: common symptom. Identify signs of serious etiology: pain not relieved by rest, night pain, constant or dull pain, lack of exacerbation with movement or palpation, presence of neurologic changes. Cancer pain often not tender to palpation. MC are lung, breast, prostate, renal, thyroid. In older man, get PSA. Bowel Ischemia: common cause of lactic acidosis (anion gap metabolic acidosis) in patients with severe atherosclerotic disease and atrial fibrillation without anticoagulation. Anemia: can be due to decreased RBC production, increased RBC destruction, frank blood loss. Anemia of lymphoproliferative disorders is due to marrow infiltration with cancerous cells (will have LA and splenomegaly). Treatment if malignancy may improve anemia. MEN IIa:AD, chromosome 10. Genetic testing has replaced serum calcitonin as recommended screening test. If (+) for RET proto-oncogene, total thyroidectomy is indicated. Fibrocystic Disease: treat with aspiration of the cyst which should yield clear fluid and result in disappearance of the mass. Afterwards patients are observed for 4-6 weeks. No cytology needed. Rubbery, firm, mobile, painful mass with more tenderness during menses. PJP: occurs when CD4 < 200. Fever, dry cough, exertional dyspnea. CXR shows diffuse bilateral interstitial infiltrates. Use TMP-SMX and prednisolone when PaO2 < 70. Insulinoma: elevated insulin, c-peptide, proinsulin levels > 5. In normal individuals, glucose < 60 results in near complete suppression of insulin. Hypoglycemia and elevated insulin indicates. Hypoglycemia in nondiabetics = insulinoma or insulin/sulfonylurea use. Atopic Dermatitis: in infancy, presents with pruritis, skin lesions typically distributed symmetrically over the face, scalp, chest, extensor surfaces of extremities. Diaper region is

usually spared. Erythematous excoriated papules that may weep. Decreased skin barrier function due to improper synthesis of components of epidermal cornified cell envelope. Allergens readily access deeper levels to generate immune response. y Pagets Disease of the Bone: characterized by increased bone remodeling and abnormal osteoid formation. May be asymptomatic or accompanied by pain and deafness. ALP elevation is only abnormality. Normal GGT. Treat with oral or IV bisphosphanates. Intermittent Catheterization: effective measure to reduce risk of UTI in patients with neurogenic bladder or spinal cord injuries. Better than indwelling catheters. Bacteria can form biofilm. Longer catheterization -> higher risk. Mumps: parotitis. Orchitis is one of the most frequent complications of mumps, 20% of cases. Common in 15-29. Rarely bilateral, rarely infertility results. Apply cold compresses to parotid and testes. Aseptic meningitis and encephalitis can be complications. Aortic Dissection: tearing chest pain radiating to the back. Cardiac tamponade, acute AR, stroke, renal failure can be complications. Tamponade -> hypotension, increased JVP, pulsus paradoxus, pericardial effusion. Difference in blood pressures between two arms. Chronic Pancreatitis: inflammatory condition characterized by chronic abdominal pain and pancreatic insufficiency (diarrhea). Fecal elastase is most sensitive and specific to diagnose pancreatic exocrine failure. Serum amylase and lipase are usually normal. Metabolic Syndrome: 3/5 (waist > 40 in men and > 35 women, fasting glucose > 100-110, BP > 130/80, TG > 150, HDL < 40 in men and < 50 women). Increased waist to hip ratio. Insulin resistance plays central role in pathogenesis. Cryptococcal Meningitis: IV amphoterocin plus flucytosine. Usually have underlying HIV infection. Encapsulated yeast that causes meningitis in HIV patients. Tb can also be a cause. Once there is clinical improvement, changed to oral fluconazole as maintenance. Homocysteine: vitamin B6, B12 and folate all play role in metabolism. B12 used by methionine synthetase to make methionine from folate and oxidize 5-MTHF -> THF which is reduced back to 5-MTHF by MTHFR. B6 used by cystathione B synthetase to convert homocysteine to cystathione to be converted into cysteine. B6 lowers homocysteine levels. B12 can be added if patient is deficient. Osteosarcoma: Codmans triangle and sunburst appearance are two classic radiologic features. MC malignant bone tumor of youth. Average 15 y/o. Usually boys > girl except early on when are they same. Occur in distal thigh, proximal leg, proximal humerus. MC initial symptom is pain. Surgery to treat, either limb saving or amputation. AS: echo is needed for definitive diagnosis. Symptomatic requires replacement. MCC of LV outflow obstruction. Angina, dyspnea, syncope are symptoms. Crescendo-decrescendo systolic murmur. Pulsus parvus et tardus, weak S2, S4. Porcelain GB: intramural deposition of calcium salts and diagnosed on abdominal x ray. Increased risk of carcinoma of the GB. Occurs in chronic cholecystitis. Needs cholecystectomy. Liver Metastases: MC site of colon cancer metastasis. RUQ pain, mildly elevated LFTs, firm hepatomegaly. Diagnosed by abdominal CT. Microcytic anemia and (+) FOBT indicate possible GI malingnancy.

DI: administration of DDAVP after water deprivation distinguishes between nephrogenic and central. Central DI will increase urine osmolarity by 50%. Peripheral will not. Treatment is intranasal DDAVP. Urine osmolarity will be less than plasma. Concentrated urine after water deprivation = psychogenic polydipsia. IBD: may occur in association with inflammatory arthritis, especially UC. AS and IBD are both associated with HLA B27. Both may be inherited with (+) p ANCA despite absence of vasculitits. Can have erythema nodosum, pyoderma gangrenosum, episcleritis, cholangitis. Seborrheic Keratosis: common benign overgrowths with warty or cerebriform, stuck on appearance. Typically pigmented but may lack pigment. Less common in dark skinned populations. Favor face and back. Slow enlargement with increasing thickness. Ewings Sarcoma: LE > UE. MC sites are metaphysis and diaphysis of femur, tibia, humerus. Metastasizes early to lungs and LN. White males in 1st or 2nd decade. Confused with osteomyelitis. Fevers, anemia, leukocytosis, elevated ESR. Lamellated onion skin appearance with moth eaten mottled appearance and extension into soft tissue. Acute Pancreatitis: hypotension indicates intravascular volume loss due to local and systemic vascular endothelial injury -> increases vascular permeability and transudation of plasma. Systemic vasodilation may occur. Several liters of IVF may be needed. PID: treat with appropriate antibiotics, council on safe sex practices, inform any partners of the past 60 days so they can be treated. Also screen for HIV, syphilis, HBV, cervical cancer (pap), HCV if have history of IVDA. Gonococcal Arthritis: MCC septic arthritis in young sexually active adults. Can present as asymmetric polyarthritis (with tenosynovitis and skin rash) or isolated purulent arthritis affecting one or a few joints. Diagnosis may be confirmed by gram stain of the synovial fluid, blood cultures, urethral cultures, skin cultures. Vaccinations: can decrease morbidity and mortality in certain patients. DM -> up to date on Td, pneumococcal, and influenza vaccines. Td should be given every 10 years after 18 and single Tdap between 19 and 64. Influenza to all adults 50 and older, all adults with chronic disease, healthcare workers, close contacts of children, nursing home workers. Healthy nonpregnant may get intranasal. PCV to all 65 and older and all with chronic disease. If before 65, need booster after 5 years. Cauda Equina Syndrome: acute compression presenting with acute motor and sensory loss, loss of rectal tone, urinary retention. Surgical emergency. MRI should be performed to determine location. May occur with metastatic prostate cancer. Crohns Disease: non-caseating granulomas are characteristic. GI Tb, sarcoidosis, Yersinia also cause GI granulomas. Shows transmural involvement, skip lesions, cobblestone appearance, creeping fatty appearance of the mesentery, fistulas, fissures, perianal disease. Amiodarone: class III antiarrhythmic that causes lung fibrosis (total cumulative dose). Thyroid dysfunction (85% hypothyroid), hepatotoxicity (stop only if > 2x normal), corneal deposits (benign), skin discoloration (blue gray discoloration of the face) are also causes. COPD: long term supplemental oxygen therapy has been shown to prolong survival. PaO2 < 55, SaO2 < 88, erythrocytosis (Hcrt > 55), evidence of cor pulmonale. Vomiting: gastric contents are rich in acid, chloride, potassium. Vomiting -> hypokalemic hypochloremic metabolic alkalosis. Bicarbonate levels rise due to loss of hydrogen and activation of RAAS. Give isotonic NaCl with K to correct.

Anion Gap Metabolic Acidosis: gap is increased by presence of non-chlorinated acids in the serum. Lactic acidosis, ketoacidosis, methanol/formaldehyde, ethylene glycol, salicylate poisoning, uremia. Intrahepatic Cholestasis of Pregnancy: functional disorder of bile formation in 2nd or 3rd TM. Intense pruritis, increased serum bile acid concentation. Significant itching on palms and soles, worse at night, skin excoriations, ALP and total/direct BRN increased, AST/ALT can be high. Treat with UDCA. PBC: autoimmune destruction of intrahepatic bile ducts and cholestasis. Anti-mitochondrial antibodies are seem. Nocturnal pruritis, fatigue, hepatosplenomegaly, xanthomas, elevated ALP, cholesterol, IgM. Treat with UDCA. Can use methotrexate or colchicine. Postoperative Endophthalmitis: MC form of endophthalmitis. Occurs within 6 weeks of surgery. Present with pain and decreased visual acuity. Swollen eyelids, conjunctiva, hypopyon, corneal edema, infection. Can do intravitreal antibiotic injection or vitrectomy. Amyloidosis: causes nephrotic syndrome. History of RA or other chronic inflammatory condition, enlarged kidneys, hepatomegaly. Have apple green birefringence under polarized light after staining with congo red. Extracellular amyloid fibrils on EM. Antiphospholipid Antibody Syndrome: false (+) VDRL, prolonged PTT, thrombocytopenia. Arterial and venous thromboses, tendency to spontaneous abortions. Prophylaxis with low dose ASA and LMWH during pregnancy. Angioedema: rapid onset non-inflammatory edema of the face, acral extremities, genitals, trachea, abdominal organs. Due to C1 esterase inhibitor deficiency which results in elevated edema producing factors of C2b and bradykinin. C1q levels are normal in hereditary and low in acquired. C4 is depressed. Episodes follow infection or trauma. Hepatorenal syndrome: severe liver disease -> systemic hypoperfusion and subsequent renal failure. Elevated Cr, low urine sodium (<10). Renal hypoperfusion is the cause. Can be secondary to generation of NO in splanchnic circulation due to portal HTN. Can use midodrine and octreotide. Pseudodementia: elderly patients with depression can present with memory loss. Can mimic other causes of dementia like Alzheimers. CT findings are usually normal and noncontributory. Dexamethasone suppression test abnormal in 50%. Vasovagal Syncope: MCC syncope. Frequently recurrent. Neurally mediated or neurocardiogenic syncope. Lightheaded, weak, blurry vision prodrome. Provoked by emotional stimulus with rapid recovery. Upright tilt table test to diagnose. SLE Nephropathy: minimal mesangial lupus nephritis -> advanced sclerosing lupus nephritis, graded I to VI. Treatment and outcomes are different. Must do kidney biopsy in all patients with new onset lupus nephritis. Immunosuppressive therapy given after grading. Breast Cancer: tumor burden is single most important prognostic consideration in the treatment of patients with breast cancer. Based on TNM staging. Stage IV is the worst. Decreasing significance: ER+ PR+ are good, over expression of Her-2/neu is bad, histological grade. Menieres Disease: disorder resulting from distention of the endolymph compartment of the inner ear. Vertigo that lasts from 20 minutes to 24 hours. Have ear fullness, tinnitus, hearing loss. First line therapy consists of environmental and dietary modification, including maintenance of low salt diet. Alcohol, caffeine, nicotine should also be avoided.

Hyperkalemia: ACE-I, NSAIDs, potassium sparing diuretics like spironolactone and amiloride. Leukamoid Reaction: marked increase in leukocytes due to severe infection or inflammation. Increase in LAP is typical. CML is indistinguishable on smear but LAP is usually low. Look for Philadelphia chromosome if unsure. SIADH: hypotonic hyponatremia with euvolemia. Low plasma osmolarity (<280), high urine osmolality (> 100-150) in suspected patients is diagnostic. NSAIDs potentiate action of ADH. Hypothyroidism and adrenal insufficiency should be ruled out. GERD: predisposes to Barretts esophagus, erosive esophagitis, peptic stricture formation. Strictures are symmetric narrowing of the involved esophagus and dysphagia to solids but no weight loss. Radiation, scleroderma, caustic ingestions also cause strictures. Adenocarcinoma occurs with long GERD, asymmetric narrowing, weight loss. Any case of stricture with Barretts should be biopsied. Internuclear Ophthalmoplegia: characteristic of MS due to demyelination of the MLF in the dorsta pontine tegument. Vetricular Fibrillation: a reentrant ventricular arrhythmia. MCC death in patients with acute MI. Caused by areas of partial block in conduction that predispose to reentrance. CML: increased number of mature granulocytic forms, segmented neutrophils, band forms. Hypercellular bone marrow with promininent granulocytic hyperplasia. Crisis phase can cause visual blurring and altered mental status. BMT after high dose chemotherapy and radation needed. Can also give imitinib, tyrosine kinase inhibitor. Prsbycusis: sensorineural hearing loss due to aging. Noticed in 6th decade with high frequency bilateral hearing loss. Difficulty hearing in crowded noisy environments. Medications, genetics, history of infection, exposure to loud noise can also cause. Hairy Cell Leukemia: type of B lymphocyte derived chronic leukemia. Fine hair like irregular projections from cells. Can have dry tap bone marrow aspirates due to fibrosis. TRAP staining (strong acid phosphatase reaction not inhibited by tartaric acid) and CD11c. Edema in CHF: due to both mechanical impedence to fluid removal and increased renal sodium retention. Renal hypoperfusion -> RAAS -> afferent and efferent vasoconstriction and sodium reabsorption. Elevate total body water volume further exacerbating CHF. Temporal Arteritis: suspected in patients > 50 with new onset temporal HA, jaw claudication, vision loss, symptoms of polymyalgia rheumatica. Immediate initiation of high dose steroids to prevent damage to the retinal artery and other vessels. ESR is elevated. Cat Scratch Disease: Bartonella henselae. May be transmitted by cat stratch, cat bite, flea bite. Localized cutaneous and LN disorder. Rare involvement of liver, spleen, eye, CNS. Rash goes vesicular -> erythematous -> papular phases. Localized tender/suppurative regional LA. Diagnose with (+) antibody, tissue with (+) Warthin Starry stain. Give 5 days azithromycin. Cardiogenic Pulmonary Edema: results from left heart failure and characterized by crackles on pulmonary exam. NO is the most rapidly acting medication to relieve symptoms of pulmonary edema. Works quicker than morphine or loop diuretics. Caution in hypotension. Acute Glaucoma: suspect with sudden onset of eye pain, photophobia, mid-dilated pupil, nausea, HA. Do ocular tonometry to diagnose. Damages the optic nerve. Drugs that dilate pupil can cause.

Hip Avascular Necrosis: can be corticosteroid induced. Progressive hip or groin pain without ROM restriction and normal radiograph early on. MRI is the golden standard for diagnosis. Can be traumatic or non traumatic. Alcoholism and hemoglobinopathies. MS: relapsing remitting form is well defined acute episodes with no significant disease progression between episodes. Interferon beta decreases the frequency of relapse and reduces disability in patients with this form. OSA: MC medical cause of daytime sleepiness in US. Due to poor oropharyngeal tone -> daytime sleepiness, morning HA, depression. Obesity, tonsillar hypertrophy, hypothyroidism are RF. Increased soft tissue in pharynx. Erythrocytosis. Can cause pulmonary HTN -> RVF. Trousseaus Syndrome: migratory thrombophlebitis. Usually have occult tumor, not always detectable at time of presentation. MC tumor is adenocarcinoma. Pancreatic, lung, prostate, stomach, acute leukemia, colon. Acute Epididymitis: fever, painful enlargement of the testis, irritative voiding symptoms. Sexually (adults, urethritis, urethral discharge, gonorrhea, chlamydia) or non sexually transmitted (associated with UTI, gram negative rods). ACE I: DOC for lowering BP to target levels in diabetics (<130/80). Tight BP control in diabetes delays cardiovascular disease and renal failure. ACE I have kidney protective effects and decrease proteinuria. Use for BP higher than target, diabetic nephropathy (> 30 alb/Cr). Mild Persistent Asthma: proper treatment includes PRN albuterol and inhalted corticosteroids. PSGN: 10-20 days after skin or throat infection. Periorbital swelling, hematuria, oliguria. May be hypertensive. UA will show hematuria with RBC casts and proteinuria. Serum C3 levels are low. Cysteinuria: inherited disease causing recurrent renal stone formation. Look for personal history of recurrent kidney stones from childhood and (+) family history. Hard and radioopaque. UA shows hexagonal crystals. Urine sodium nitroprusside test is widely used. Pancoast Syndrome: neoplasm in the pulmonary apex at the thoracic inlet can compress inferior portion of the brachial plexus resulting in shoulder pain radiating in the ulnar distribution. Causes Horners, hoarse voice, SVC syndrome. New Onset Seizures: CT scan of the head without contrast is the first diagnostic test when patients presents with new unprovoked seizures. Exclude intracranial hemorrhage. Reinfarction: CK MB is the most useful lab test in assessing for coronary reocclusion after an MI because it returns to normal in 1-2 days. Troponin T is better indicator, takes upto 10 days to return to normal. Also do repeat EKG. Temporal Arteritis: aortic aneurysms are a well known complication due to involvement of the branches of the aorta. Follow with serial CXR. Mucormycosis: requires aggressive surgical debridement plus early systemic chemotherapy with amphotericin B. Most often caused by fungus Rhizopus. Brain Abscess: isolated, round, smooth bordered, ring enhancing lesion on contrast CT in an immunocompetent patient with known extracranial bacterial infection (sinusitis). Aerobic and anaerobic streptococci and Bacteroides (anaerobic) are MC. HA, focal neurological signs.

Spinal Cord Compression: signs and symptoms of UMN (means CNS) distal to the site of compression. Weakness, hyperreflexia, extensor plantar response. Medical emergency needing MRI and surgery. Can be due to disc herniation, abscess (IVDA), trauma, malignancy. Dermatitis Herpetiformis: dapsone is an effective treatment. Occurs in association with celiac sprue. Nephrotic Syndrome: renal vein thrombosis is common complication (abdominal flank pain, fever, gross hematuria). MCC membranous GN in adults and most likely to cause RVT. Antithrombin III is lost in urine. Trichinellosis: GI complains followed by triad of periorbital edema, myositis, eosinophilia. Subungal splinter hemorrhage and conjunctival/retinal hemorrhage. Tension Pneumothorax: complication of high PEEP. Alveolar damage -> tension pneumothorax -> hypotension. Sudden onset SOB, hypotension, tachycardia, tracheal deviation, unilateral absence of breath sounds. ARDS is predisposed since tissue is already compromised. HOCM: murmur is located at LLSB and is worsened by maneuvers that decrease preload (Valsalva, standing). AD inheritance pattern. Pneumococcus: MC pathogen causing pneumonia in nursing homes. Pneumonia is the leading cause of death in nursing homes. Vaccinate with pneumovax. BPH: only required evaluation for BPH suggested by history and physical is UA to assess for UTI and hematuria. Measurement of PSA can be considered to help evaluate the likelihood of prostate cancer. Trachoma: presents with follicular conjunctivitis and pannus (neovascularization) formation in the cornea. Caused by Chlamydia trachomatis A-C. Concurrent nasopharyngeal infection > discharge. Diagnosed by Giemsa stain of conjunctival scraping. Topital tetracycline or azithromycin. Repeated infections are due to corneal scarring. MALT Lymphoma: antibiotic therapy is most accepted and recommended management for eradication of H pylori in MALT lymphoma without metastases. May regress after treatment. Treat with amoxicillin, clarithromycin, omeprazole. If not, use systemic chemotherapy. Methanol Intoxication: most severe consequences are vision loss and coma. Optic disc hyperemia. Labs show anion gap metabolic acidosis. Increased osmolar gap. COPD: reduced FEV1 compared to FVC, low FEV1/FVC ratio (normal in restrictive lung disease). DLCO is decreased in emphysema and normal in chronic bronchitis (productive cough for 3 months over 2 consecutive years. Prolonged exposure of tracheobronchial tree to irritants. Lacunar Stroke: if patient presents with limited neurological deficit. Pure motor (posterior limb of IC), pure sensory (VPL thalamus), ataxic hemiparesis (posterior limb of IC), dysarthria clumsy hand syndrome (basis pontis). Principle cause is HTN. CMV: consider in patients with mononucleosis symptoms, atypical lymphocytes, negative monospot. Sore throat and LA are uncommon in CMV. Atypical lymphocytes are large basophilic cells with vacuolated appearance. Warfarin: patients who develop serious bleeding due to excess anticoagulation with warfarin should be given FFP for rapid reversal. If INR is excessive but < 5 with no significant

bleeding, omit next dose. 5-9 with no significant bleeding, stop temporarily. > 9, stop warfarin and give vitamin K. y Achalasia: complaints of dysphagia for both liquids and solids as well as regurgitation. Pseudoachalasia secondary to a neoplasm at the GE junction can have similar presentation. Endoscopy is recommended for patients presenting with above symptoms > 60 and weight loss. Results from degeneration of the nerves in the esophagus. Can be due to Chagas disease, amyloidosis, sarcoidosis. Prinzmetals Angina: variant angina. Vasospastic disorder that typically occurs in young female smokers. Chest pain occurs in middle of the night and episodes have transient ST elevations in EKG. Associated with Raynauds and migraine HA. Precipitated by exercise, hyperventilation, emotional stress, cold, cocaine. Use CCB or nitrates. Lyme Disease: erythema migrans rash and facial nerve palsy. Can cause palsy of any CN but VII is MC. EM rash may be present on arms, abdomen, moist areas. Erythematous with central clearing or uniformly red. Constrictive Pericarditis:pericardial fibrosis and diastolic dysfunction. Signs of decreased cardiac output and venous overload. Common etiologies include viruses, radiation, idiopathic. In third world, TB is a common cause. Have fatigue, dyspnea, muscle wasting, elevated JVP, ascites, positive Kussmauls sign, pedal edema, sharp x y descents on central venous tracing. Zenkers Diverticulum: MC in elderly males and present with dysphagia, regurgitation, foul smelling breath secondary to pooling of material in the pouch. May be palpable. Contrast esophagram is diagnostic test of choice. Usually repaired surgically. Pregnancy Induced Respiratory Alkalosis: causes physiological compensated, chronic respiratory alkalosis due to stimulatory effect of progesterone on medullary respiratory center. Metabolic compensation occurs in later pregnancy. Cor Pulmonale: term for right sided heart failure MC due to pulmonary disease. Signs of right sided HF -> JVD, S3, RV heave, hepatomegaly, ascites, dependent edema. Acute Angle Closure Glaucoma: unilateral eye pain, redness, dilated pupil with poor light response, photophobia, halos around things. Distinguish from migraine, cluster headache, temporal arteritis, keratoconjunctivitis. Colon Cancer: RF for polyps turning into colon cancer are villous adenoma, sessile adenoma, size > 2.5 cm. Only adenomatous polyps are premalignant, but < 1% turn into cancer. Hyperplastic are non neoplastic and do not require further workup. Hamartomatous polyps are either juvenile or Peutz Jeghers. Malignant HTN: suspect in patients with very high BP (>200/140). Presence of papilledema confirms the diagnosis. End organ damange is due to fibrinoid necrosis of small arterioles. Renal failure occurs, but not necessary for diagnosis. Randomization: method to control confounders. Helps to control known risk factors as well as unknown and difficult to measure confounders. Relative Risk: used as a measure of association in cohort studies. Ratio of risk in exposed group vs. unexposed group. RR > 1 shows association, stronger as it goes larger.

Intracranial Hemorrhage: HTN is a common cause. MC locations are basal ganglia, cerebellum, thalamus, pons. If in cerebrum (basal ganglia), will have contralateral motor deficit and ipsilateral conjugate gaze. Splenectomy: risk for sepsis present for > 30 years. Patients should receive pneumococcal, meningococcal, Haemophilus vaccination several weeks before operation and daily oral PCN for 3-5 years. GBS: can cause respiratory muscle weakness -> failure. Best way to measure is through serial measurements of VC. Risk for failure greatly increases when VC < 15 mL/kg. Liver Metastases: MC malignant neoplasms of the liver. Second MC site of spread after LN. GIT, lung, breast, skin are MC. Do US, CT, or MRI. Multiple nodules can be seen. Biopsy confirms. HIV Vaccinations: influenza, HBV, pneumococcus. HAV for MSM. Should not receive live vacciation (BCG, varicella, anthrax, oral thyphoid, intranasal influenza, oral polio, yellow fever). One exception is MMR, used if no evidence of immunity and CD4 > 200 and no ADI. Malignant Melanoma: consider in patients with metastatic mass bleeding inside brain. Can go almost anywhere, lie dormant, and present much later. Non melanomatous skin, oropharyngeal, esophageal, prostate have never reported brain metastases. GERD: cough can be presenting symptom. 24 hour pH recording is most specific test. Used to diagnose cause of chest pain or supraesophageal esophageal complications in patients with negative endoscopy. Water brash (regurgitation of sour fluid into mouth) also present. Mohs Surgery: special surgery where microscopic shaving is done such that 1-2 mm of clear margins are excised. Highest cure rate for BCC. Indicated in patients with high risk features, lesions in functionally critical areas (face). Rhabdomyolysis: nearly 20% of cocaine ODs are complicated by this. Marked elevation in CPK (> 20,000 -> risk of ATN due to myoglobinuria). Prolonged immobilization can also cause this. Elevated K levels. Dipstick will be positive for blood, UA will have no RBCs. Use mannitol and alkalinization of urine. CML: low LAP with leukocytosis. Anemia, increased number of mature granulocytic forms, Seen after age 50. Night sweats and fever due to increased cell turnover. BM shows prominent granulocytic hyperplasia. Presence of Philadelphia chromosome. D Xylose Test: abnormal in bacterial overgrowth and celiac disease. Normalizes in bacterial overgrowth with antibiotic administration. Absorption only requires intact mucosa, no enzymes needed. Acute Erosive Gastritis: severe hemorrhagic erosive lesions after exposure of mucosa to injurious agents or decresed blood flow. ASA decreses PG production, ASA and alcohol both cause direct damage. Decreases normal protection -> acid leaks into LP -> vascular damage > hematemesis and abdominal pain. Amaurosis Fugax: visual loss that is usually monocular and trasient. Like a curtain falling down. Whitened edematous retina in distribution of arterioles. Retinal emboli from ipsilateral carotid. Do non invasive evaluation of carotid. Hashimotos Thyroiditis: increased risk of thyroid lymphoma. Rapid enlargement of the gland with pre-existing disease. Compressive symptoms are common. CT shows enlargement of the thyroid around the trachea (doughnut sign). Pseudocystic on US.

Opioid Withdrawal: nausea, vomiting, abdominal pain, diarrhea, restlessness, arthralgias, myalgias. Increased bowel sounds, mydriasis, piloerection. Does not cause seizures. Methadone is appropriate treatment. Congenital Long QT: syncopal episode, hearing impairment, normal physical exam, family history of sudden death. Predisposed to torsades -> syncope and sudden death. Beta blocker is MC used treatment modality. If patient is symptomatic, use beta blocker with DDD pacer. Giant Cell Bone Tumor: soap bubble appearance in epiphyseal end of long bone. 20-40 year old female with knee pain and some mass. Oval or spindle shaped cells with multinucleated giant cells. Benign but locally aggressive. Recurs even after local curettage. Refer to ortho. HTN: most patients will require pharmacotherapy but lifestyle changes can make a difference. Weight control is the most important, then physical activity, salt restriction, moderate alcohol consumption. Smoking decreases CV risk, but will not affect HTN. ARF: catheterization is most critical first step. Can resolve post renal obstructions in addition to monitoring urine output in pre-renal and intrinsic renal failure. Urinary retention common after lower abdominal/pelvic surgery. Dihydropyridine CCB: like nifedipine can worsen cardiac ischemia due to peripheral vasodilation and reflex tachycardia. CI in MI. Verapamil and diltiazem can be used after beta blockers are used but do not improve mortality. Gallbladder Carcinoma: rare malignancy that occurs in Hispanic and SW Native American females with history of gallstones. Diagnosed during or after cholecystectomy. Increases with age, history of gallstones, porcelain GB, salmonella typhi, anatomic variations, carcinogen exposure. Tends to be late presenting and has spread at time of diagnosis. Surgery to remove GB and the bed, pancreatic head, LN, portions of the liver/biliary tree. If confined to LP, simple cholecystectomy is all that is needed. Legionella Pneumonia: presents similarly to other pneumonias, but can cause GI symptoms (abdominal pain, diarrhea), hyponatremia, LFT abnormalities. Diagnose with urinary Ag. Treat with quinolone or macrolide. Cirrhosis: if signs of portal HTN are present, do endoscopy to look for varices. May be asymptomatic until they rupture. All patients with cirrhosis should be screened for varices. Primary prophylaxis is beta blockers. Proteus: most likely cause of UTI with alkaline urine. Produces urease. Common in patients of long term care facilities and chronic indwelling catheters. Candida, Pseudomonas, Klebsiella also cause alkaline urine. Digitalis Toxicity: increased ectopy in atria and increased vagal tone. Atrial tachycardia with AV block occurs from the combination of these two effects. Allergic Contact Dermatitis: type IV hypersensitivity inflammatory skin condition caused by poison sumac (encountered while cutting firewood), cosmetics, nickel. Days to weeks after exposure -> intensely pruritic erythematous rash with vesicles. Scratching -> secondary infection (impetiginized) by strep or staph suggested by pustules. Secondary Syphilis: diffuse maculopapular rash involving soles and palms. Accompanied by generalized LA, fever, arthritis, iritis, hepatitis, meningitis, osteitis. Serology will be positive.

MG: MC in women 18-25. Intermittent dysarthria, dysphagia, ptosis, diplopia. Generalized weakness often develops within a year of onset. Weakness gets worse as day progresses. Resolves with rest. Massive PE: likely in post operative patient with JVD, new onset RBBB. PE complicated by hypotension, right heart strain. Sycope occurs. Need respiratory and hemodynamic support, along with fibrinolysis. Surgery in past 10 days is CI to fibrinolytics. > 50% die in 1 hour. Restless Leg Syndrome: potentially debilitating condition characterized by uncomfortable desire to move ones legs at night or at rest. Treat with DA agonists (abnormalities in DA system may be cause). Sensation is better with massage/warming. Common in middle aged to older, especially with CKD, iron deficiency. Cat Bites: should be treated prophylactically with 5 day course of amoxicillin/clavulanate. Can cause deep wounds, and can be infected with Pasturella -> pain, erythema, swelling. Localized cellulitis and LA. Acute Aortic Dissection: chest pain that is sudden, tearing, radiating to the back. HTN is MC predisposing factor. Decrescendo diastolic murmur suggests AR. Wide mediastinum. Acute DVT: treat with combination warfarin and heparin for 5 days. After 5 days heparin can be discontinued if INR is therapeutic. Warfarin should stay on for 6 months for first clot. Progressing clot with subtherapeutic INR needs bridging heparin until INR is therapeutic. Reyes Syndrome: found in children given ASA for viral induced fever. Can cause fulminent hepatic failure. Elevation of ammonia levels, transaminases, vomiting, mental status changes are common manifestations. Diffuse mitochondrial disease -> extensive fatty vacuolization of liver. Treat with glucose with FFP and mannitol to decrease cerebral edema. SVT: if hemodynamically stable, treat with vagal maneuvers followed by adenosine and AV nodal blockers. Unstable patients should be cardioverted. Tachycardia with narrow QRS. Carotid Artery Stenosis: aymptomatic patients with stenoses of 60-99% are considered to have proven indication for CEA. Complete occlusion is a CI to surgery. Pemphigus Vulgaris: mucocutaneous blistering disease characterized by flaccid bullae and intracellular IgG deposits in epidermis. Autoantibodies against desmoglein, an adhesion molecule. Start in oral mucosa. (+) Nikolsky sign. Treat with steroids. Azathioprine and methotrexate can be used. Scalded Skin Syndrome: disease of children. Sudden diffuse erythema, skin tenderness, fever, flaccid bullae, facial edema, perioral crusting. Caused by toxins produced by phage group 2 Staph aureus. Replace fluids, topical wound care (similar to burns), antibiotics against staph. Have (+) Nikolsky sign. COPD: recommended therapy for acute COPD exacerbation is supplemental O2 (caution, can suppress hypoxia fueled respiratory drive), inhaled bronchodilators (B2 agonists, anticholinergics), antibiotics, two week steroid taper (decreases inflammation, edema in bronchial mucosa), smoking cessation. RAS: common cause of resistant HTN in patient with advanced atherosclerosis (CAD, claudication, difference in BP between arms, risk factors). Auscultate periumbilical area to reveal continuous murmur.

Warfarin: anticoagulant that functions by inhibition of synthesis of vitamin K dependent factors II, VII, IX, X, protein C and protein S. Can cause false positive deficiency in any of these factors. Methotrexate: DMARD. Inhibits DHFR. Macrocytic anemia is a common SE. Also causes nausea, stomatitis, rash, hepatotoxicity, interstitial lung disease, alopecia, fever. May cause pancytopenia. Supplement with folic acid. Acute COPD Exacerbation: inhaled/nebulized bronchodilators, systemic steroids (usually methylprednisolone). Platelet Dysfunction:MCC of abnormal hemostasis in patients with CRF. PT, PTT, platelet count is normal. BT is prolonged. DDAVP is usual treatment (increases release of VIII:vWF multimers). Platelet transfusion will not work. Caused by uremic toxins (guanidinosuccinic acid). Cholecystitis: abdominal ultrasound is the best tool for initial investigation of GB pathology. Asymptomatic patients do not need treatment. Laproscopic cholecystectomy is the treatment of choice for those with symptomatic disease. Pagets Disease: asymptomatic patients rarely need treatment. Symptomatic patients are best treated with oral bisphosphanates. If there is bone pain, hypercalcemia, neurological deficit, high output cardiac failure, preparation for surgery, involvement of weight bearing bones, then treat. Full extent determined by bone scan, followed by x ray. Osteomyelitis: staph aureus is MCC osteomyelitis in both infants and children. GBS and E coli in infants and strep pyogenes in children. Allergic Rhinitis: nasal eosinophilia is characteristic for allergic rhinitis, but not specific. Absent in patients with infectious (neutrophils) or vasomotor rhinitis (non allergic). Nasal polyposis (including ASA sensitivity) and non-allergic rhinitis with eosinophilia. Chlamydia Screening: USPSTF recommends routine screenining for chlamydial infection in all sexually active women 24 years and younger and in asymptomatic women at increased risk for this infection (other STDs, multiple partners). HIV Screening: ELISA is the preferred screening test. Western blot is confirmatory. CF Vaccinations: should adhere to regular schedule with some additions. Yearly influenza is needed and may need pneumococcal booster shots (between 4 and 6). Egg allergies -> do not give influenza, yellow fever, caution with MMR. Children 6-59 months should get influenza. HHNK: very high blood glucose, plasma hyperosmolarity, normal anion gap, (-) ketones. Can get very dehydrated -> poor perfusion -> lactic acidosis. T2DM. Enough endogenous insulin to suppress ketosis but not hyperglycemia. Serum osmolarity is 2(Na)+(Glc/18)+(BUN/2.8). Cushings Syndrome: central obesity, limb wasting, purple striae, excess bruising, HTN. Have high 24-hour urine cortisol. Will have low low-dose dexamethasone suppression test. ACTH will be high in Cushings disease and ectopic production. High-dose dexamethasone suppression test is used. If fails to suppress by > 50% = ectopic. Confounding: matching is frequently used in case-control studies to control confounding. Match variables that could be confounders. Cases and controls are then selected based on matching variables so that both groups have similar distribution.

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Acute Pancreatitis: gallstones and alcoholism are the two MCC in US. Do US to search for gallstones in all patients experiencing first attack. CT is used to confirm the diagnosis and ID complications. Diabetic Neuropathy: presents with alterations in sensation, including loss of proprioception. Motor findings are late. Can have tingling and imbalance. Hyperactive reflexes and upgoing plantar response are suggestive of UMN lesion, not compatible with diabetes -> do spinal MRI. Mitral Regurgitation: holosystolic murmur heard best at the apex with radiation to the axilla. Exertional dyspnea, fatigue, atrial fibrillation, signs of heart failure. Could be due to rheumatic heart disease, IE, trauma, ischemia, HOCM. Vaccinations: all adults should have Td every 10 years. Adults with close contact with children 0-59 months should have influenza vaccine. HTN: lifestyle modification should be first line intervention for newly diagnosed Stage 1 HTN. Reduction of alcohol/sodium intake, weight loss, aerobic exercise. For men, should be < 2 drinks per day, for women, should be < 1. SAAG: serum ascites albumin gradient. Used to distinguish between different causes of ascites. 1.1 g/dL or greater is consistent with portal HTN. Ascites can be due to trauma, infection, pancreatitis, malignancy. Hyperestrogenism: in cirrhosis -> gynecomastia, testicular atrophy, decreased body hair, spider angiomas, palmar erythema. Liver Functions: can be synthetic (clotting factors, cholesterol, protein), metabolic (drugs, steroids, detoxification), excretory (bile excretion). Germ Cell Tumors: typically affect young patients and display aggressive biologic behavior. Nonseminomatous germ cell tumors produce both AFP and HCG. Can occur in mediastinum. HCG is elevated in both seminomatous and non. Pure seminomas do not produce AFP. Pseudogout: cannot be reliably distinguished from gout and septic arthritis based on history and physical alone. Rhomboid, (+) birefringent crystals, chondrocalcinosis (calcified articular cartilage). Crystals are calcium pyrophosphate. Pain, swelling redness of the joint. Vaccinations: all adults should get Td booster every 10 years. 50 and older as well as younger with certain comorbidities should get annual influenza. Pneumococcal for those over 65 or those at risk for pneumococcal disease (chronic illness, immunosuppression, smokers). Meningococcal Meningitis: CSF with elevated white count, elevated protein, decreased glucose = bacterial meningitis. Petechiae and purpura. Myalgias are common and can be severe like in flu. Develops very rapidly. RMSF does not cause meningitis. Pneumococcal meningitis is similar but no skin rash. DKA: managed by restoring intravascular volume with normal saline, correction of hyperglycemia, electrolytes (potassium), acidosis, treatment of precipitating cause (usually antibiotics). Give IV normal saline and regular insulin. Massive PE: can cause RV dilatation and failure that results in hypotension, tachycardia, syncope, SOB. Hemodynamic compromise is an absolute indication, and RV strain is a relative indication, for thrombolytics. Have history of DVT sometimes.

Ischemic Stroke: if patient presents within 4.5 hours, thrombolytic therapy with tPA (after CT scan to rule out hemorrhage) should be started. Improved neurological outcomes. Cardiogenic Shock: depressed CO (normal is 5L/min for male, 4.5L/min for female) and elevated PCWP (>18, indicator of LAP and usually LVEDP). SVR will be elevated as result of neurohumoral activation (sympathetic, RAAS) to preserve CO and maintain tissue perfusion. CHF: hyponatremia is a bad prognostic factor. Indicates presence of severe heart failure and high level of neurohumoral activation (water retention). Associated with high aldosterone, vasopressin, NE. Survivcal is significantly reduced if sodium < 137. Hypo and hyperkalemia may reflect the activity of the RAAS or may be due to different drugs. Decrease water intake to help with electrolyte abnormalities. Acromegaly: MCC death is cardiovascular (38-62% of death). High GH -> high IGF-1 -> excessive growth of bone and soft tissue. Increased CAD, cardiomyopathy, arrhythmias, LVH, diastolic dysfunction. Respiratory (0-25%) and malignancy (9-25%). HTN is common but not only cause of CV disease. Can have strokes, colon cancer, renal failure (HTN, hyperglycemia), adrenal failure. Hypoxemia: 1) Hypoventilation, 2) Decreased FiO2, 3) Shunting, 4) V/Q mismatch. Look at ABG, A-a gradient, if 100% O2 improves picture. PAO2 = FiO2(760-47) PaCO2/0.8 o Hypoventilation: elevated PaCO2 with normal A-a gradient o Decreased FiO2: normal PaCO2 with normal A-a gradient o Shunting: normal PaCO2 with elevated A-a gradient (O2 does not help) o V/Q Mismatch: normal PaCO2 with elevated A-a gradient (O2 does help) Ankylosing Spondylitis: seronegative spondyloarthropathy presenting with progressive inflammatory back pain and stiffness. In setting of suggestive H&P, AS is confirmed by plain film x-ray demonstrating fused SI joints and/or bamboo spine. Any young patient with low back pain and spinal stiffness > 3 months should be investigated. PJP: non productive cough, exertional dyspnea, fever, severe hypoxia, bilateral interstitial infiltrates on CXR, normal white count. CD4 < 200. TMP-SMX is DOC. Steroids decrease mortality. Indications for steroids are PaO2 < 70, A-a gradient > 35. Esophageal Cancer: heart burn, significant weight loss, fatigue, smoking history. Barium swallow, EGD & biopsy, PET scan (useful to determine the stage or whether surgery is possible). When localized, surgery is treatment. Chemotherapy and radiation may be used in conjunction. Acute Abdominal Pain: one of the differential diagnoses is MI and should be ruled out first before GI workup in patients with RF. Vertebral Osteomyelitis: focal pain, fever, chills, elevated ESR. Common in IVDA (as is all osteomyelitis). SCA and immusuppressed are also at risk for OM. Staph aureus is MCC, other G(-) as well. MRI is most sensitive study. Treatment is long term IV antibiotics with or without surgery. Herpes Simplex Keratitis: characterized by corneal vesicles and dendritic ulcers. Frequent cause or corneal blindness in the US. Pain, photophobia, blurred vision, tearing, redness. Recurrences precipitated by excessive sun exposure, outdoor occupation, fever, immunodeficiency. Scrapings show multinucleated giant cells. Topical or oral antivirals. Primary Hyperaldosteronism: suspect in young person with HTN, muscle weakness, numbness (potassium depletion). Most specific lab is high aldosterone/renin ratio.

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Selection Bias: loss to follow up in prospective studies causes selection bias. Warfarin Induced Skin Necrosis:pain -> bullae formation -> skin necrosis. Breast, buttocks, thighs, abdomen are commonly involved. Protein C deficiency is commonly associated. Females are MC affected. Occurs within weeks. Vit K should be given initially and warfarin discontinued if progresses. Heparin should be used until heals. Stroke: do CT scan without contrast to determine ischemic or hemorrhagic. If there is evidence of ischemic stroke, carotid dopper and TEE are done to look for possible sources of emboli. Esophageal Cancer: may mimic achalasia radiographically and manometrically (called pseudoachalasia). Older age, shorter history, rapid weight loss, inability of esophagoscope to pass through LES. CT can show asymmetric thickening. Tick Borne Paralysis: rapidly ascending paralysis, absence of a fever, absence of sensory abnormalities, normal CSF. Search and removal of a tick usually results in improvement within an hour and complete recovery in several days. UC: patients with UC and pancolitis should begin surveillance colonoscopy after 8 years of having the disease. 4 biopsies should be taken every 10 cm from cecum to rectum. Any suspicious lesions or masses should be biopsied. Should be done every 1-3 years. Bakers Cyst: excessive fluid production by inflamed synovium as occurs in RA, OA, cartilage tears. Excess fluid accumulates in popliteal fossa -> tender mass. Occasionally burst and release contents and present similarly to a DVT. Waldenstroms Macroglobulinemia: hyperviscosity of blood owing to excess production of IgM. Need IgM spike on electrophoresis and hyperviscosity. Rare chronic plasma cell neoplasm. Mitral Valve Prolapse: mid systolic click over the apex, with short systolic murmur after the click. Squatting decreases the murmur. Associated with chest pain, anxiety, palpitations, hyperventilation. HTN in Diabetes: better to keep systolic < 130 to prevent slow end organ damage in diabetes and CRF. Want to keep diastolic < 80. Vitamin K Deficiency: seen in patients who are NPO for a long time and receiving broad spectrum antibiotics. Labs show prolonged PT and then PTT. PT elevated more than PTT. Fat soluble vitamin that serves as a cofactor for enzymatic carboxylation of glutamic acid residues on prothrombin complex proteins. FFP is used in acute hemorrhage. Complex Partial Seizure: brief episodes of impaired consciousness, failure to respond to various stimuli during the episode, staring spells, automatisms, post-ictal confusion. EEG is usually normal or has brief discharges. Hyperventilating does not cause seizure (differs from absence). Atheroembolism: dislodgement of cholesterol plaques from the aortic root. Blue toe syndrome in which emboli to the pedal circulation cause cyanotic and painful toes with intact pulses, is one common presentation of catheter induced atheroembolism. Also cause ARF. Orthostatic Hypotension: characterized by a drop in blood pressure after standing and is typically preceded by a lightheaded or presyncopal sensation. Defined as a drop in systolic >

20 mmHg. Common in elderly, hypovolemic, autonomic neuropathy. Diuretics, vasodilators, adrenergic blocking agents. y Renal Stones: decrease protein (causes calcium stones) and oxalate in diet, decrease sodium intake, increase fluid intake, increase dietary calcium. CT scan is done to diagnose. Dyspepsia: epigastric pain, bloating, nausea not secondary to biliary or pancreatic disease. May be nothing, could be PUD or gastritis. Recommended screen is H pylori serology. > 55, weight loss, dysphagia, persistent vomiting would warrant endoscopy. Melanoma: one of the most practical methods of primary prevention is wearing protective outer clothing. Little to no protection from sunscreen lotions SPF 15-30 but can protect against SCC. S3: low frequency diastolic sound heard just after S2 that is associated with LVF. IV diuretics provide symptomatic benefits to patients with decompensated HF. Can be normal in younger individuals and athletes. Thyroid Nodule: MC a colloid nodules which are benign. Eczema Herpeticum: form of primary HSV associated with atopic dermatitis. Numerous umbilicated vesicles over area of atopic dermatitis as its healing. Can be life threatening in children. Treat promptly with acyclovir. Accompanied by fever and adeopathy. Amiodarone: effective antiarrhythmic but its use is associated with several potential side effects. Can cause pulmonary fibrosis, hepatotoxicity, thyroid. PFT, LFT, TFT should be monitored. Difficulty concentrating, fatigue, dry skin, weight gain while receiving treatment for HTN and atrial fibrillation. Pneumatocele: Staph aureus can cause secondary pneumonia complicating a viral URI. Can cause necrotizing bronchopneumonia resulting in pneumatoceles (blood streaked sputum and mupltiple midfield lung cavities). Pneumococcus and H flu both cause secondary pneumonia. Odansetron: drug of choice for chemotherapy induced emesis. 5-HT3 antagonist. Small frequent meals, avoiding bland food, attractive food presentation, giving patient his/her preferred meals. Transplant Patients: should be given oral TMP-SMX for prophylaxis against PJP. Can prevent toxoplasmosis, nocardiosis, UTI, pneumonia. Vaccinate against influenza, pneumococcus, HBV. Gancyclovir or valgancyclovir can be used to prevent CMV infections. Zenkers Diverticulum: pharyngoesophageal. Develops immediately about the UES by herniating through the fibers of the cricopharyngeal muscle. Motor dysfunction and incoordination are responsible. Surgical treatment is cricopharyngeal myotomy. > 50 with oropharyngeal dysphagia and neck mass. Babesiosis: patient from endemic area (NE US) who presents with tick bite especially if there is evidence of hemolysis and patient is splenectomized. Rash is not a feature (unless thrombocytopenia is present). Jaundice, hemoglobinuria, renal failure, death. Giemsa stained thick and thin blood smear. Use quinine-clindamycin or atovaquone-azithromycin. COPD: all patients with PaO2 < 55 or SaO2 < 88 are candidates for long term O2 therapy. Signs of pulmonary HTN or hematocrit > 55, start on home O2 when PaO2 < 60. If become hypoxic during exercise or sleep can use O2.

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MG: pathology lies at NMJ. Mediated by autoantibodies against the Ach receptor. Pupils are always spared (as opposed to botulism). Bulbar muscle involvement -> myasthenia snarl, nasal speech, difficulty in chewing or swallowing. Sympathetic Ophthalmia: characterized by damage of one eye (the sympathetic eye) after a penetrating injury to the other eye due to uncovering of hidden antigens. Can have anterior or panuveitis, papillary edema, blindness. Can involve auto antibodies and cell mediated. Cocaine Abuse: papillary dilatation and blood at the external nares in a patient with chest pain can be a clue to cocaine induced vasospasm. STEMI can occur as a consequence. Inhibits catecholamine reuptake in synapses. Give ASA and nitrates but not beta blockers. CCB and alpha blockers. SVT: suspected on an EKG with a regular, narrow QRS complex tachycardia without definite P waves. Adenosine is initial treatment of choice. Terminates the arrhythmia and diagnoses and treats. Caused by AVRT or AVNRT. If does not work, try CCB, beta blocker, CV. Increasing Prevalence: but stable incidence can be attributed to factors which prolong the duration of disease (improved quality of care). Molluscum Contagiosum: firm, flesh-colored, dome-shaped, umbilicated papules. Cellular immunodeficiency, steroid use, chemotherapy predispose. Common in HIV patients. On trunk, limbs, anogenital regions. Can be due to sexual contact. Senile Purpura: characterized by ecchymoses that occur on elderly patients extensor surfaces due to perivascular connective tissue atrophy. Develop rapidly and resolve over several days leaving brownish discoloration due to hemosideran deposition. CHF: elevated BNP and S3 are both signs of increased cardiac filling pressures. Acute Cholangitis: provision of supportive care and broad spectrum antibiotics. If they do not respond, they should undergo biliary drainage, stone removal/stenting with ERCP. Charcots triad: fever, jaundice, RUQ pain. Hypotension and mental status change -> Reynolds pentad. Usually secondary to infection or obstruction. US is first study to do. Latent Period: exposure must be continuously present for a certain period of time (latent period) to influence the outcome. Iron Deficiency Anemia: bone marrow iron stains is the most definitive way to diagnose iron deficiency anemia. MS: focal neurological deficits in young adult with asymmetric periventricular white matter signal changes on MRI. Glatiramer acetate is a long term disease modifying treatment for MS that works by modulating T cell mediated autoimmunity to MBP. HCC: have either chronic viral hepatitis or cirrhosis, but otherwise asymptomatic. Weight loss, abdominal pain, palpable mass, worsening signs of portal HTN. AFP measurement is first reasonable step. Diastolic Dysfunction: impaired ventricular filling due to poor myocardial relaxation or diminished ventricular compliance. Usually due to HTN, treated with diuretics and antihypertensives. Can cause decompensated HF. Melanoma: MCC fatal malignancy in young adults. Recently changed mole is strongest RF for malignancy, with RR of at least 10.

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Cerebral Emboli: most dreaded consequences of endocarditis. Pieces of infected valve vegetations break off and enter CNS circulation. Can affect lung, kidney, intestines, extremities. IVDA with chills, evidence of cardiac disease on EKG. Treat with antibiotics. PMR: pain and stiffness in the neck, shoulders, pelvic girdle in patient > 50 with elevated ESR and morning stiffness > 1 hour. Treatment when not associated with GCA is low dose steroids. If GCA is coming along with it, treat with high dose prednisone. Alcohol Abuse: MCC of nutritional folate deficiency -> megaloblastic anemia. Impairs enterohepatic cycle and inhibits absorption. Can have microcytic anemia due to chronic blood loss, anemia of chronic disease, thrombocytopenia, macrocytosis. Heat Stroke: temperature is usually > 105. Results from inefficiency cooling mechanisms. Treatment involves induction of evaporative cooling to reverse hyperthermia. Dunking in cold water may work but difficult to monitor the patient. Effect Modification: present when the effect of the main exposure on the outcome is modified by the level of another variable. Not a type of bias! Bells Palsy: peripheral lesion. Absence of forehead furrows indicates peripheral lesion. Central lesions still have forehead furrows because contralateral motor innervation of the forehead remains intact. HIV Therapy: didanosine (induced pancreatitis), abacavir (related hypersensitivity syndrome), lactic acidosis (any of NRTIs), Stevens-Johnson (any of the NNRTIs), nevirapine (liver failure), indinavir (protease inhibitor -> crystal induced nephropathy). Acute Acalculous Cholecystitis: acute inflammation of the GBin the absence of gallstones most commonly seen in hospitalized/severely ill patients -> burns, trauma, prolonged TPN, prolonged fasting, mechanical ventilation. Multiple Myeloma: increased risk of infection due to total decrease in functional antibodies and leukopenia that develops as bone marrow is filled with malignant plasma cells. CRAB (calciu, renal, anemia, bones). Paraprotein gap = protein albumin. Uric Acid: highly soluble in alkaline urine -> oral potassium bicarbonate or potassium citrate to get urine > 6.5. Radiolucent stones. Usually due to acidic urine. Also hydrate, try low purine diet. Primary Hyperaldosteronism: PA to PRA is used as initial screening test. > 30 suggests diagnosis. No suppression of aldosterone after saline or oral salt loading. Abdominal CT to confirm. Withdraw drugs that may suppress RAAS 2-4 weeks prior. Hypokalemia should be corrected since this can suppress aldosterone. Digoxin: cardiac glycoside whose SE are nausea, vomiting, diarrhea, vision changes (blurry yellow), arrhythmias. Treatment for atrial fibrillation and heart failure. Scooped ST, prolonged PR, short QT, T wave inversion. Renal failure and hypokalemia exacerbate. Sporotrichosis: gardners disease. Initial lesion is reddish nodule that later ulcerates, appears at the site of thorn prick or other skin injury. Spreads along lymphatics forming SQ nodules and ulcers. Adenopathy and systemic signs usually absent. Travelers Diarrhea: ETEC is MCC. Abdominal cramps, diarrhea, malaise.

Aortic Dissection: sudden tearing chest pain that radiates to the back. Mediastinal widening is sometimes present. Leg weakness can occur if dissection progresses to involves arteries of spinal cord. Severe HTN is a RF. Can have pleural effusion. Do contrast CT or TEE. Primary HIV: manifests similarly to IM. Rash and diarrhea are LESS common in IM, tonsillar exudate is not common in HIV. Splenomegaly with splenic rupture is worrisome. Heterophile Ab can distinguish. Arise within 1 week and can persist upto a year. Anti-EBV Ab as well. Hyperkalemia: membrane stabilization with calcium, shift potassium intracellularly, decreasing total body potassium. Insulin/glucose administration is the quickest way to decrease serum potassium. Shifts are only transient and must try to decrease potassium. Hematuria: bladder tumors are the MCC of painless hematuria in adults. Could be a kidney or ureter malignancy as well. Do contrast CT or IVP as well as cystoscopy of bladder/urethra. Infections, trauma, nephrolithiasis, GN, prostatic disease are MCC of hematuria in US. Myoglobinuria, porphyria, eating beets, rifampin can cause hematuria like picture. CMV Retinitis: when CD4 < 50. Patients may be asymptomatic. Yellow white patches of retinal opacifiation and hemorrhage are diagnostic. Initially eye is usually white and quiet. Treatment is ganciclovir or foscarnet. HAV: MC vaccine preventable disease in travelers. Consider in patients traveling to developing countries. North Africa will also need HBV, thyphoid, polio booster. Single dose can be enough for young adult, second dose for long term immunity. ALS: riluzone is a glutamate inhibitor approved for use in ALS. Prolongs survival and time to tracheostomy. Dizziness, nausea, weight loss, elevated liver enzymes, and skeletal weakness. Goodpastures Disease: affects lungs (cough, dyspnea, hemoptysis), kidney (nephritis, ARF, dysplastic RBCs, casts). No systemic symptoms. Renal biopsy shows linear immunofluorsence of IgG Ab along GBM (to alpha-3 chain of type IV collagen). TTP: requires emergency treatment with plasmapheresis (plasma exchange). Rates of recovery (usually defined as normalization of platelets and LDH level) are high if started soon. Renal impairment and schistocytes may persist for several weeks. Deficiency or autoantibody against vWF cleaving protease. Lidocaine: not used prophylactically in ACS. Decreases risk of ventricular fibrillation but increases risk of asystole. Little effect on myocardial contractility. Hepatic Encephalopathy: CNS complication of liver failure secondary to accumulation of ammonia in blood due to livers inability to detoxify ammonia to urea. Reversal of sleep cycle, asterixis, progressive coma, delta waves on EEG. SBE: one the causative agent is identified, the antibiotics can be narrowed from empiric to specific. Strep viridans is highly susceptible to IV PCN G and IV ceftriaxone. Progressive fatigue and waxing waning low grade fever. Lead Poisoning: MCC in adults is work exposure. GI complaints, poor concentration, anemia. Treat with exposure reduction and lead chelator such as EDTA or succimer. Neuropathy is common. Diagnose with blood lead levels. Basophilic stippling. Shock Liver: occurs in the setting of hypotension. Acute massive increases in ALT/AST with milder increases in total BRN and ALP. Typically return to normal in a couple weeks.

PBC: xanthalesma are cholesterol plaques on the medial aspects of the eyelids. Upper and lower eyelids may be affected. Can occur in PBC but MC idiopathic. Pruritis, jaundice, hepatomegaly, increased ALP. Ascites: treat with sodium/water restriction, spironolactone, loop diuretic (not more than 1L/day), then frequent abdominal paracentesis (2-4 liters/day as long as kidneys work). Upper Thoracic Spinal Cord Lesion: paraplegia, bladder and rectal incontinence, absent sensation from nipple downward. Impetigo: presents as erythematous macule which rapidly evolves into vesicles and pustules that rupture and leave honey colored crusted exudates. Caused by staph or strep. Parkinsons Disease: suspected in patients with 4-6 Hz tremor that is asymmetric and associated with rigidity. Tremor is often presenting symptom. Trihexylphenidyl is an anticholinergic medicaton used in younger individuals where tremor is presenting symptom. Nitroglycerin: main mechanism for pain relief in patients with anginal pain is dilitaiton of veins (capacitance) and decreased ventricular preload. This decreases myocardial oxygen demand. Blastomycosis: pulmonary fungal infection endemic to Great Lakes, Mississippi and Ohio river basins. Wisconsin has highest rate. May cause ulcerated skin and lytic bone lesions. Broad based budding yeast grown from the sputum. Itraconazole or amphotericin B may be used to treat systemic disease. NF1: caf au lait spots, macrocephaly, feeding problems, short stature, learning disabilities. Later develop fibromas, neurofibromas, different tumors. COPD: causes airflow limitations and increased lung volumes. Latter results in diaphragmatic flattening, evident on CXR, which exacerbates patients dyspnea and work of breathing. Difficult to decrease intrathoracic pressure enough. Hemochromatosis: AR disorder, increased skin pigmentation, diabetes, cirrhosis, arthralgias. Mutation on chromosome 6. Avoid iron containing foods, weekly phlebotomy for 2-3 years. Deferoxamine is second line treatment for those who cannot undergo phlebotomy. Metabolic Acidosis: observed during DKA and is typically accompanied by hyperkalemia which is paradoxical. Extracellular shift of potassium in exchange for H+ ions. Impaired insulin dependent cell entry of the potassium ion. Should get potassium once dips below 4.5. HBV Exposure: reassurance is the most appropriate course of action for a patient with known immunity to HBV who is exposed. HBIG and HBV vaccination should be given to patients with unknown immunity. Elevated Aminotransferases: if patient is asymptomatic, first step is to take thorough history to rule out more common hepatitis risk factors (alcohol, drugs, travel, blood transfusions, high risk sexual practices). Also medications (statins, antiepileptics, anti TB, herbals). If transaminases persist, test for HBV, HCV, hemochromatosis, fatty liver. Then polymyositis and thyroid. HIT: immune mediated process that causes thrombocytopenia several days after heparin therapy is started. Highly thrombogenic and can cause A or V thromboses.

Lyme Disease: erythema chronicum migrans in a patient with a history of a tick bite warrents immediate treatment with doxycycline. Serologic testing is not needed if patient presents with classic EM (usually in moist areas, bulls eye, asymptomatic). Avascular Hip Necrosis: chronic corticosteroid use and chronic excessive alcohol ingestion account for > 90% of cases of avascular necrosis. Present with slowly progressive anterior hip pain with limited ROM. Unable to remodel -> trabecular thinning occurs. Pain is worse with activity. X rays fail to show in first few months. MRI is most sensitive. Trauma and antiphospholipid syndrome can be causes. EHEC: bloody diarrhea. Presence of abdominal pain with lack of fever in a patient without travel. Most cases due to ingestion of undercooked beef. Shigella, salmonella, campylobacter also cause bloody diarrhea but have fever. TTP-HUS can also result. Stool culture. Septic Shock: most important steps in management of lactic acidosis from septic shock are IV NS with or without pressors to maintain volume and antibiotics to correct underlying condition. Attributable Risk Percent: represents the excess risk in exposed populations that can be attributed to RF. ARP = (RR-1)/RR or (risk in exposed risk in unexposed)/risk in exposed. Retinal Detachment: sudden onset of photopsia (flashes of light) and floaters. Described as curtain coming down over eyes. Myopia or trauma can cause breaks -> allows fluid to seep in and separates the retinal layers. Can occur after surgery. Gray elevated retina. Laser and cryotherapy are done to create permanent adhesions. Pericardial Effusion: electrical alternans when QRS varies from beat to beat and is specific. Enlargement of cardiac silhouette. Echo will more definitively diagnose. Recent URI usually precedes. Digoxin: medication with narrow therapeutic window. Verapamil increases digoxin levels and predisposes to toxicity. MC SE is GI (anorexia, nausea, vomiting). Bidirectional ventricular tachycardia and accelerated junctional rhythms are relatively specific. Expressive Aphasia: lesions in dominant frontal lobe. Also contains motor cortex whose damage -> contralateral hemiparesis. Absence Seizures: ethosuximide is treatment along with valproic acid. Works against calcium channels. Drowsiness, nausea, vomiting, hyperactivity, sleep disturbance. Not useful for generalized tonic clonic and partial epilepsy. SLE: autoimmune disease MC affecting AA women 20-40 years old. Fatigue, fever, weight loss, non-deforming arthritis, oral ulcers, serositis, hematologic abnormalities, proteinuria, rash. > 90% have arthritis usually of MCP and PIP. Similar to RA. Glycosylated Hgb: excellent way to measure chronic glycemic control. Measurement of average glucose readings for 100-120 days. Formed by non enzymatic glycosylation of Hgb. 1% increase -> blood glucose of 35. Inflammatory Myopathy: polymyositis and dermatomyositis. Both present with proximal muscle weakness. Supported by elevated ESR and CPK. Confirmed with muscle biopsy. 40-50 years. Women > men. Drug induced, hypothyroid, muscular dystrophy, MG present similarly. Treat with high dose corticosteroids.

PE: when occurs with hemodynamic compromise, best treatment is fibrinolysis. If patient has CI (previous surgery, bleed), an embolectomy is treatment of choice. Will still need to be on warfarin for a few months. SLE: joint pain is common but not deforming. MC in hands or knees. Migratory arthritis. Pain > physical findings. Lower incidence of joint erosion, synovial abnormality, permanent joint deformity than RA. Retropharyngeal Abscess: most feared complication is spread of the infection to the mediastinum -> acute necrotizing mediastinitis. Partiularly the anterior and posterior portions. Spinal Stenosis: MC caused by DJD. Neuropathic claudication. Exacerbation of symptoms with walking. Symptoms are positional and remain while standing still. Pain relieved by flexion of spine. Diagnosis made on history and MRI of spine -> bony abnormality, neural structures, soft tissue seen well. Brain Death: clinical diagnosis. Absent cortical and brainstem functions and proven irreversibility. Spinal cord may still be functioning -> DTRs may be present. EEG can be used to confirm but not necessary. Some tools can demonstrate cerebral blood flow cessation. Epidural Abscess: consider in patients with fever and back pain. Espeically those who are immunosuppressed or use injectable drugs. MRI is diagnostic test of choice. Treat with antibiotics and surgical decompression. Can cause direct compression -> cessation of blood flow. Draw blood cultures to determine sensitivity. Hepatic Hydrothorax: cause of transudative pleural effusions with no underlying cardiac/pulmonary abnormalities. Usually right sided. Treat with salt restriction and diuretics. TIPS is done if refractory. Small defects in diaphragm allow fluid to flow into pleural space. Ethylene Glycol Poisoning: calcium oxalate crystals (rectangular envelope shaped crystals) are seen. Causes metabolic acidosis with anion and osmolar gap (as so methanol and ethanol). MAC Prophylaxis: HIV patients with CD4 < 50 require azithromycin or clarithromycin. Asymptomatic Gallstones: should not be treated. Laproscopic cholecystectomy is only for symptomatic disease unless have high risk of GB carcinoma or gallstone complications. 20% of these patients will develop symptoms in 15 years. Pancreatic Cancer: no serologic or radiologic test has been proven effective in screening in adults. Absence Seizures: suspect in a 4-8 year old with frequent daydreaming episodes, brief staring spells, decline in school performance, no post ictal phase. Treatment is ethosuxamide or valproic acid. Classic EEG is 3 Hz spike and wave activity. Observer Bias: when investigators decision is adversely affected by knowledge of exposure status. AR: early diastolic murmur. Can also have hyperdynamic pulse (bounding, water hammer, peripheral pulses).

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Fibromyalgia: pain worse with exercise. Fatigue, IBS, depression are common. Inflammation, joint swelling, muscle weakness are absent. No abnormal studies. Women from 20-55. Disorder of pain regulation. Cystic Fibrosis: affects a variety of organ systems including respiratory tract, sinuses, pancreas, intestines, reproductive systems secondary to abnormal secretions. Recurrent pulmonary infections and bronchiectasis. Decreased exocrine gland function of the pancreas -> fat malabsorption. Fulminent Hepatic Failure: hepatic encephalopathy that develops within 8 weeks of acute onset liver failure. Heavy users of Tylenol, alcohol, methamphetamines, co-infection with HBV and HDV. High priority on liver transplant and only effective mode of treatment. Dresslers Syndrome: present weeks after MI with chest pain improved by leaning forward. NSAIDs are the treatment of choice. Avoid anticoagulation to prevent hemorrhagic pericardial effusion. Malaise, fever, elevated ESR. Likely immunologic phenomenon. Urine Sediment: muddy brown granular = ATN, RBC = GN, WBC = interstitial cystitis and pyelonephritis, fatty = nephrotic, broad waxy = CRF. Prolonged hypotension -> ATN. Also have urine osm 300-350, urine Na > 20, FENA > 2%. Lewy Body Dementia: 10-20% of dementia in US. Alterations in consciousness, disorganized speech, hallucinations, EPS, early compromise of executive functions. Eosinophilic intracytoplastic inclusions = accumulations of alpha-synuclein. Treat with AchE inhibitors, atypical antipsychotics. Lewy bodies found in Parkinsons. Hepatic Adenoma: benign tumor most often seen in young and middle aged women who are taking OCP. Severe intra-tumor hemorrhage and malignant transformation are dreaded complications. Sheets of enlarged adenoma cells that contain glycocen and lipid. Acute MR: occurs due to papillary muscle dysfunction in patients with acute MI. Causes rise in LAP without significant increased LA size, LV size, or LV EF. Also have pulmonary edema. PCWP shows increased pressure in LA. MEN 2b: AD disorder. Medullary carcinoma of the thyroid, pheochromocytoma, mucosal neuromas (most distinguishing feature), marfanoid habitus. MEN 2a has medullary carcinoma and pheochromocytoma but has primary parathyroid hyperplasia, not adenoma. HOCM: first line of treatment is beta blockers or cardiac acting CCB such as diltiazem since they promote myocardial relaxation. Beta blockers also prevent anginal pain. AR: diastolic decrescendo murmur at left 3rd ICS. Medical therapy is afterload reduction with CCB or ACE-I. Handgrip increases vascular resistance -> increased regurgitation. Regurgitant blood flow causes dilation of the LV. Bacterial Pneumonia: all patients should have CXR done as first step and then administer antibiotics without waiting for sputum gram stain or cultures. Cervicofacial Actinomycosis: classically presents as slowly progressive, non-tender, indurated mass, which evolves into abscesses, fistulae, draining sinus tracts with sulfur granules, which appear yellow. High dose PCN for 6-12 weeks. Anaerobic G(+) branching bacteria. DJD: OA, or wear and tear arthritis. Presents indolently in patients over 40 years with progressive anterior hip pain exacerbated by walking and relieved by rest. Morning stiffness

or stiffness after prolonged resting, usually < 30 to 60 years. No tenderness to palpation or systemic signs. Predisposing factors are advanced age and obesity. y Angle Closure Glaucoma: predominantly in people aged 55-70 years. Presents with acute onset severe eye pain and blurred vision associated with nausea and vomiting. Examination reveals red eye with steamy cornea, moderate pupil dilation not responsive to light. Results form pre existing narrow anterior chamber angle. Anterior chamber is shallow with inflammatory changes. Tonometry reveals increased IOP. Do laser peripheral iridotomy. Toxin Induced GE: caused by staph aureus. Because illness is due to preformed toxin, emesis is predominant feature and starts in < 6 hours. Mayonnaise containing salads are often implicated in staph food poisoning. No P2P transmission. Legionella: intracellular G(-) organism commonly spread by cooling towers and water supplies. Travel associated infection. Cough, fever > 39, GI symptoms, confusion. Diagnosis confirmed by urine antigen or culture on charcoal agar. Treat with azithromycin and levofloxacin. Stains poorly. Sputum will have neutrophils with no organisms. Fibromyalgia: amitriptyline and cyclobenzaprine have been shown to be effective in the treatment of fibromyalgia. Increase amount of restorative phase 4 sleep. One possible etiology is lack of phase 4 sleep. In patients with co-existing depression, add SSRIs. Benign Intracranial HTN: acetazolamide is first line medical treatment (reduces choroid plexus bicarbonate production). Can use steroids, or treat underlying disorder. Then can do repeated lumbar punctures. Leukoplakia: hard to remove white patches in the oral mucosa and may lead to SCC. Only associated with tobacco. Caused by chronic irritation to the mucosa due to tobacco, alcohol, poorly fitting dentures. Risk of transformation to SCC. Acetaminophen Overdose: first data point occurs at 4 hours when decision to give antidote can be made based on levels. Get level at that time. As long as given within 8 hours, will not have adverse outcome. Give activated charcoal within 4 hours while waiting for level. Retropharyngeal Abscess: patients have sore throat, fever, difficulty swallowing, pain with certain neck movements, especially extension. Initiate treatment rapidly to prevent spread of infection to mediastinum. Give antibiotics and drain. Symptomatic Hypernatremia: medical emergency requiring prompt increase in sodium levels. Cells have not had time to adjust -> acutely symptomatic. Give 3% saline. Chronic hyponatremia can be slowly corrected because cells have had time to adjust and rapid increases in sodium -> CPM. Multiple Myeloma: any elderly patient with bone pain, renal failure, hypercalcemia. 50% of patients develop some kind of renal insufficiency. Likely due to obstruction of distal collecting tubules by large laminated casts of Bence-Jones proteins. Theophylline: usually manifests as CNS stimulation (headache, insomnia), GI disturbances (nausea, vomiting), cardiac toxicity (arrhythmia). PDE inhibition, adenosine antagonism, stimulation of epinephrine relase. Ciprofloxacin and erythromycin decrease clearance and raise plasma concentration. Hemochromatosis: patient with new onset diabetes, arthropathy, hepatomegaly. AR. Iron absorption is increased. Cirrhosis -> possible hepatoma. Do serum iron studies. Liver biopsy confirms.

Trigeminal Nerve: contains motor and sensory fibers. First branch carries sensory fibers to the scalp, forehead, upper eyelid, conjunctiva, cornea, nose, frontal sinuses. Damage to V1 -> corneal anesthesia and lesions on the eye may not be noticed. Hairy Cell Leukemia: leukemic reticuloendotheliosis. Characterized by lymphocytes with fine hair like projections with TRAP stain. Bone marrow -> fibrotic -> dry taps. Cladribine is DOC for hairy cell leukemia. Toxic to bone marrow. Has neurological and kidney damage. Stable Angina: with HTN, treat with beta blocker. Decreases threshold for anginal episode and controls HTN. Also are cardioprotective and can potentially reduce the risk of major CV events by decreasing sympathetic output to the heart. RA: morning stiffness presents with inability to do things in the morning but fine by afternoon time. Affects MCP, PIP, wrist. Disease of systemic inflammation. ESR will be high. Mostly peripheral joints. If affects axial -> cervical spine -> C1-C2 instability -> subluxation. Hemochromatosis: cirrhosis, pancreatic fibrosis (diabetes), increased skin pigmentation, and abnormalities of cardiac conduction. Can have hypogonadism, arthropathy, dilated or restrictive cardiomyopathy. Can deposit in pituitary and cause hypogonadotropic hypogonadism. Pancreatitis: nausea, vomiting, epigastric pain that radiates to the back. Low grade fever also common. History, physical, elevated amylase and lipase. Gallstones and alcohol are MCC. Hypertriglyceridemia, anatomic abnormalities, infection, medications also cause. Can have left sided pleural effusions when amylase is high, abdominal compartment syndrome, intraabdominal hemorrhage, shock, diabetes, pseudocyst formation, abdominal pseudoaneurysm. Reactivation TB: