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UWorld Notes: Step 2 CK

malingering: intentional production of false

physical symptoms for secondary gain
factitious disorder: intentional production of
false physical or psychological signs or symptoms
to assume a sick role; no secondary gain
hypochondriasis: fear of disease &
preoccupation with the body, manifests as
multiple somatic complaints; at least 6 months
o prominent during psychological stress
o inquire about current emotional stressors
o Rx: refer for brief psychotherapy
conversion disorder: unexplained neuro symptoms
preceded by an obvious emotional trigger; symptoms
are not artificially produced, unexplained by any
medical condition; cause social & functional
impairment (la belle indifference)
--------------------------------------------------------------- conduct disorder: middle childhood/adolescent
o Dx: at least 3 symptoms from the following
categories: (1) aggression towards people or
animals, (2) destruction of property, theft,
deceitfulness, or (3) serious violation of rules
oppositional defiant disorder: pattern of angry,
irritable mood & argumentative toward authority
o children; less severe vs. conduct disorder
antisocial personality disorder: age 18 yrs or
older; evidence of conduct disorder as minors
--------------------------------------------------------------- borderline personality disorder show a pattern
of unstable relationships, impulsivity, reckless;
identity disturbance, suicidal or self-mutilating
behavior, feelings of emptiness; splitting
histrionic personality disorder: excessively
labile emotions & attention seeking behavior;
uses physical appearance to draw attention
paranoid personality disorder: suspiciousness
& distrust; negatively interpret actions, words &
intentions of others; holds grudges
dependent personality disorder: submissive &
clingy; fear of separation, indecisive, does not
take initiative; difficulty expressing disagreement

avoidant personality disorder: shyness, feelings

of inferiority with a desire for friends, but intense
fear of embarrassment or rejection; low self-esteem
--------------------------------------------------------------- prolonged hypotension from any cause can lead
to acute tubular necrosis
o U/A: muddy brown granular casts consist of
renal tubular epithelial cells
o serum BUN:Cr ratio < 20:1
o urine osmolality 300 - 350 mOsm/L
o urine Na+ > 20 mEq/L, FENa > 2%
--------------------------------------------------------------- broad casts: a/w chronic renal failure
o arise in dilated tubules of enlarged nephrons
that undergone compensatory hypertrophy in
response to the reduced renal mass
waxy casts: chronic renal disease
o shiny & translucent
RBC casts: glomerulonephritis or vasculitis;
o Wegeners, SLE, Henoch-Schonlein
WBC casts: interstitial nephritis & pyelonephritis
o WBCs that originate in kidneys
fatty casts: nephrotic syndrome
hyaline casts: asymptomatics & prerenal azotemia
o proteins that pass unchanged along urinary tract
---------------------------------------------------------------Neonatal conjunctivitis etiologies
mild conjunctival
eye lubricant
& tearing after
silver nitrate
Gonococcal 2 - 5
eyelid swelling,
IV or IM
purulent exudate, ceftriaxone or
corneal ulceration cefotaxime
Chlamydia 5 - 14 eyelid swelling;
chemosis; watery erythromycin
or mucopurulent

best way to prevent neonatal chlamydial &

gonococcal conjunctivitis: screen, Dx, Rx pregos
screen for chlamydia @ 1st & 3rd prenatal visit

maternal infection may be asymptomatic

--------------------------------------------------------------- ceftriaxone should be avoided in infants with
hyperbilirubinemia displacement of bilirubin
from albumin-binding sites, risk of kernicterus
oral erythromycin: Rx chlamydial conjunctivitis
& pneumonia
o risk of infantile hypertrophic pyloric stenosis
topical erythromycin: prophylaxis for neonatal
gonococcal conjunctivitis; regardless of screening
topical silver nitrate: prophylaxis against
penicillinase-producing strains of N. gonorrhea
(not available in the US)
nasolacrimal duct obstruction (dacryostenosis):
unilateral chronic tearing & minimal conjunctival
injection; Rx massage nasolacrimal ducts
--------------------------------------------------------------- neonatal gonococcal conjunctivitis: acquired
through infected genital secretions
prophylaxis: erythromycin ophthalmic ointment
Rx: IV or IM ceftriaxone or cefotaxime
complications: corneal ulcers, scarring, blindness
--------------------------------------------------------------- meniscal & ligamentous tears can both be a/w a
popping sensation following precipitating injury
meniscal injury: gradual joint swelling, 12 24 hr
ligamentous injury (ACL): rapid joint swelling
& effusion due to hemarthrosis (ligaments have
greater vascular supply than menisci, which rely
on diffusion for nourishment)
definitive Dx: MRI
--------------------------------------------------------------- Ulcerative colitis: MC in females, Ashkenazi Jew,
peak @ age 15 - 25
MC site: rectum, confined to mucosal layer
bloody diarrhea, tenesmus, pseudopolyps
severe disease: weight loss, fever, or anemia
confirm Dx: friable mucosa on colonoscopy &
biopsy with mucosal inflammation
extraintestinal: erythema nodosum, uveitis,
sclerosing cholangitis, spondyloarthropathy
complications: toxic megacolon & colorectal ca
surveillance: annual colonoscopies beginning at
8 - 10 yrs after Dx for colon cancer detection

colonic dysplasia is a/w progression to

adenocarcinoma; Rx: total colectomy
--------------------------------------------------------------- young patient, aphthous ulcer, chronic diarrhea,
abdominal pain, weight loss: Crohns
non-caseating granulomas, cobblestone,
transmural inflammation, skip lesions, creeping fat,
non-lymphoid aggregates
MC site: terminal ileum; rectum is spared
--------------------------------------------------------------- primary features of Chagas disease: recent
immigrant from Latin America with chronic
megacolon/megaesophagus & cardiac disease
(CHF: pedal edema, JVD, S3, cardiomegaly)
systolic & diastolic heart failure, RBBB
Rx: benznidazole or nifurtimox
--------------------------------------------------------------- adjustment disorder: emotional or behavioral
symptoms within 3 months of identifiable stressor;
rarely > 6 months after the stressor ends
marked distress in excess of expected from exposure
to the stressor, with significant impairment
Rx: cognitive or psychodynamic psychotherapy
to develop coping mechanisms, response to &
attitude about stressful situations
SSRIs can be an adjunct for depressive symptoms
--------------------------------------------------------------- generalized anxiety disorder: excessive worry
over many aspects of life, at least 6 months
acute stress disorder: PTSD-like symptoms
develop within 4 wks, last > 3 days, but < 1 month
PTSD: anxiety symptoms > 1 month
OCD: recognizes unreasonable nature of behavior
o ego-dystonic beliefs
OCPD: preoccupied with orderliness & perfection;
does not see the behavior as a problem
o ego-syntonic beliefs
--------------------------------------------------------------- altered levels of serotonin involved in OCD
Rx: SSRI or clomipramine (TCA)
--------------------------------------------------------------- weight loss = most effective lifestyle intervention
to reduce BP

DASH diet is the next most effective approach

in prevent & treat HTN especially non-obese;
then exercise, dietary sodium, alcohol intake
smoking causes a transient rise in BP
--------------------------------------------------------------- HPV vaccine for all girls/women age 9 26
(except pregos) regardless of HPV status or
sexual activity (also immunocompromised)
all boys/men age 9 - 21
routine HPV screening (Pap) should not begin
prior to age 21, regardless of sexual activity
**sexually active women age < 21 can be
HPV+ & develop cervical dysplasia that is
transient with regression within 2 yrs
o thus no Pap smear
age 21 29: cytology every 3 years
routine HPV testing not for women age < 30
o HPV in most young women is transient,
clearing within 2 years
o age 30 65: cytology every 3 yrs, OR
cytology + HPV testing every 5 yrs
Routine cervical cancer screening
Immunocompromised screen at onset of
(HIV, SLE, organ
transplant patients)
6 months x2 then annual
Age 21
No screening**
21 to 29
Pap (cytology) every 3 years
cytology every 3 years
30 to 65
OR cytology + HPV test
every 5 years
no screening if negative
prior screens & not high-risk
no screening if no Hx of
high-grade lesions, cervical
without cervix
cancer, or exposure to DES
--------------------------------------------------------------- atypical squamous cells of undetermined significance
(ASC-US) is MC cervical cytological abnormality,
but risk of invasive cervical cancer is low
atypical squamous cells, cannot rule out high-grade
squamous epithelial lesion (ASC-H) is a/w
premalignant lesions
ASC-US/LSIL in age 21 24: repeat pap in 1 yr

HPV infection is transient & malignant

transformation is rare
colposcopy only if ASC in 3 consecutive paps
or ASC-H, atypical glandular cells, or HSIL
ASC-US in age 25: HPV testing
o HPV positive colposcopy
o HPV negative repeat pap & HPV in 3 yrs
---------------------------------------------------------------High-grade squamous intraepithelial lesion (HSIL)
age 21 24: colposcopy
o if no CIN 2,3 repeat colposcopy & cytology
@ 6-month intervals for 2 yrs
age 25: LEEP (except postmenopause & pregos)
pregos with HGSIL colposcopy
o if colposcopy is negative repeat cytology
& colposcopy @ 6 wks after delivery
o 50% of HGSIL & CIN 2 or 3 regress
spontaneously during pregnancy
o no cervical biopsy or LEEP during pregnancy,
unless colposcopy suggests invasive cancer
--------------------------------------------------------------- cephalohematoma: subperiosteal hemorrhage,
does not cross suture lines; presents several
hours after birth; resolves spontaneously
Caput Succedaneum: diffuse, ecchymotic
swelling of the scalp that Crosses Suture lines
--------------------------------------------------------------- Rheumatoid arthritis
o morning stiff >30 min, improves with activity
o tenosynovitis of palms (trigger finger)
o cervical joint involvement can lead to spinal
subluxation cervical cord compression
o positive anti-cyclic citrullinated peptide
o CRP & ESR correlates with disease
o XR: soft-tissue swelling, bony erosions,
joint space narrowing
greatest risk for osteoporosis
Rx: physical activity, optimize Ca++ & Vit D
intake, minimize corticosteroids, bisphosphonates
--------------------------------------------------------------- Pagets disease of bone = osteitis deformans; due
to osteoclast overactivity, leads to replacement of
lamellar bone with abnormal woven bone

Osteitis fibrosa cystica (Von Recklinghausen

disease of bone): due to hyperparathyroidism 2/2
parathyroid carcinoma
excessive osteoclastic resorption, leads to
replacement with fibrous tissue & bony pain
XR: subperiosteal bone resorption, salt-&-pepper
appearance of skull, bone cysts, & brown tumors
of long bones
--------------------------------------------------------------- Bronchiolitis: MCC is RSV
older children self-limited, mild URI
age < 2 yrs involves lower respiratory tract
o wheezing/crackles & respiratory distress
with waxing/waning; peaks @ days 5-7
Rx: supportive care
prophylaxis: Palivizumab for high risk cases
complications: apnea & respiratory failure;
develops recurrent wheezing through childhood
o increased risk of acute otitis media; but
rarely bacterial pneumonia or sepsis
---------------------------------------------------------------Caustic ingestion
chemical burn or liquefaction necrosis
results in:
laryngeal damage: hoarseness,
stridor, orofacial inflammation
esophageal damage: dysphagia,
gastric damage: epigastric pain,
GI bleeding
remove contaminated clothing,
irrigate exposed skin
upper GI XR with water-soluble
contrast for suspected perforation
CXR if respiratory symptoms
upper endoscopy within 24 hr
barium contrast (2 3 wks)
complications esophageal strictures
pyloric stenosis
ulcers, perforation

avoid interventions that provoke vomiting

(activated charcoal, milk, vinegar, NG lavage)
in absence of perforation, upper endoscopy within
12 24 hr to assess damage & guide therapy
--------------------------------------------------------------- chronic GERD with new dysphagia & symmetric
LES narrowing: esophageal stricture
bodys reparative response to chronic acid exposure
other causes: radiation, systemic sclerosis, caustic
Dx: endoscopic biopsy to r/o adenocarcinoma
DDx: adenocarcinoma (asymmetric narrowing),
hiatal hernia, achalasia (aperistalsis)
--------------------------------------------------------------- early-onset HTN, progressive renal insufficiency,
gross hematuria, flank pain, B/L abdominal masses


clinical signs


most are asymptomatic
flank pain (due to renal calculi, cyst
rupture, hemorrhage, or upper UTI)
early onset HTN
B/L upper abdominal masses
mild proteinuria, CKD
cerebral aneurysm
hepatic/pancreatic cysts
cardiac valves (MVP, AR)
ventral/inguinal hernias
abdominal USS
monitor BP, renal Fx, & potassium
control cardiovascular risk factors
ACE-inhibitors for HTN
ESRD: dialysis, renal transplant

central obesity, facial plethora, proximal weakness,
abdominal striae, ecchymosis: Cushings
headaches, palpitations, diaphoresis a/w
paroxysmal BP elevations: pheochromocytoma
o urinary vanillylmandelic acid, & metanephrines
--------------------------------------------------------------- alpha-1-antitrypsin: protease inhibitor that protects
from neutrophil elastase, which breaks down elastin
AAT deficiency: uninhibited elastase cause bullous,
panacinar emphysema of lower lobes

(smoking-induced emphysema is centrilobular)

also causes liver disease: cirrhosis, or HCC
liver Bx: hepatocyte inclusion stain +PAS &
resists digestion by diastase
Rx: purified human AAT
--------------------------------------------------------------- chemotherapy-induced peripheral neuropathy
from vincristine (also cisplatin, paclitaxel)
begins after several weeks
symmetric paresthesia in fingers/toes, spreads
proximally in stocking-glove pattern
loss of ankle jerk reflexes, pain/temp sensation,
occasional motor neuropathy (B/L foot drop)
--------------------------------------------------------------- Pinworm infection: erythematous vulvovaginitis in
prepubertal females; absence of vaginal discharge
recurrent episodes of nocturnal itching should be
examined with Scotch tape test
empiric Rx: mebendazole
--------------------------------------------------------------- early Lyme disease: erythema chronicum migrans
also a/w headache, malaise, fatigue, fever
unilateral Bells palsy
early Dx is based on trademark rash & recent travel
MCC: B. burgdorferi (spirochete)
Rx: oral doxycycline (age > 8)
Rx: oral amoxicillin (age < 8, pregos, or lactating)
or cefuroxime
--------------------------------------------------------------- doxycycline A/E: permanent tooth discoloration
& skeletal retardation in children & fetuses
--------------------------------------------------------------- avascular necrosis is a/w heavy alcohol use, SLE,
chronic systemic corticosteroids, sickle cell disease
--------------------------------------------------------------- sudden onset C/L lower extremity motor & sensory
deficits with UMN signs, urinary incontinence:
anterior cerebral artery (ACA) occlusion
MCC: ischemic stroke
---------------------------------------------------------------Spinal cord compression
spinal injury (MVA), disk herniation,
malignancy (lung, breast, prostate, MM),
infection (epidural abscess)
features gradual, severe focal back pain;

pain worse when recumbent & at night

early: B/L LE weakness, absent DTRs,
flaccid paraplegia
late: B/L +Babinski, absent rectal tone,
paraparesis with DTRs, sensory loss,
bowel/bladder dysfunction,
urinary retention
manage high-dose IV glucocorticoids,
emergency spinal MRI,
radiation-oncology, neurosurgery consult
pain worse on recumbent due to distension of
epidural venous plexus
--------------------------------------------------------------- anterior spinal cord infarct: abrupt onset
flaccid paralysis, loss of pain & temp sensation
(anterior spinal artery), & autonomic dysfunction
--------------------------------------------------------------- recurrent pneumonia in the same anatomic region
o bronchial obstruction or recurrent aspiration
bronchogenic carcinoma obstruction is most
concerning with a smoking history
chest CT is indicated initially
o central masses or negative CT: bronchoscopy
o peripheral lesions: CT-guided biopsy
recurrent aspiration, same lung region
o seizures
o ethanol/drug use
o GERD, dysphagia, achalasia
recurrent pneumonia in different regions
o sinopulmonary disease (CF, immotile cilia)
o immunodeficiency (HIV, leukemia)
o vasculitis, bronchiolitis obliterans
--------------------------------------------------------------- painless vesiculopustular rash, tenosynovitis, &
migratory polyarthralgia: disseminated
gonococcal infection
2 - 10 skin lesions similar to furuncles or pimples
Hx of recent unprotected sex with a new partner
all patients should undergo HIV screening
--------------------------------------------------------------- hypotension, tachycardia, poor skin turgor, lethargy,
confusion: hypovolemic hypernatremia
o Rx: IV normal saline (0.9%) until
euvolemic, then 5% dextrose

serum Na+ should be corrected by 0.5 mEq/dL/hr,

as cerebral edema can result if too rapid
--------------------------------------------------------------- high serum & low urine osmolality due to
inadequate ADH response is most likely due to
lithium-induced nephrogenic DI
Lithium induces ADH resistance, resulting in
acute-onset nocturia, polyuria, & polydipsia
hypovolemic hypernatremia
Rx: discontinue lithium; salt restriction & diuretics
(amiloride: K+ sparing diuretic)
Rx: hemodialysis for lithium level 4 mEq/L or
2.5 mEq/L + signs of toxicity or renal disease
--------------------------------------------------------------- normal aging: stage 4 sleep (deep sleep)
becomes shorter & eventually disappear
--------------------------------------------------------------- increased contractility & reflex tachycardia
are secondary effects provoked by nitroglycerin
due to changes in baroreceptor activity in
response to decrease BP from venodilation
--------------------------------------------------------------- fever, headache, N/V, petechial rash, stiffness, &
photophobia: meningococcemia
fever, arthralgia, sore throat, lymphadenopathy,
mucocutaneous lesions, diarrhea, weight loss:
acute HIV infection
migratory arthritis of large joints, carditis,
erythema marginatum (raised ring-shaped lesions
over trunk & extremities), subcutaneous nodules,
Sydenham chorea: acute rheumatic fever
o pharyngitis precedes onset by 2 - 4 wks
--------------------------------------------------------------- best method of reducing maternal-fetal transmission
of HIV infection: triple HAART therapy for the
mother throughout pregnancy
HAART: dual NRTI + NNRTI or protease inhibitor
test viral load monthly until undetectable, then
every 3 months; CD4 cell count every 3 months
avoid amniocentesis until viral load undetectable
mothers with undetectable viral loads at delivery
have 1% risk for transmission
intrapartum mother not on HAART: Zidovudine
intrapartum viral load > 1000 copies/mL:
Zidovudine + C-section

infants: Zidovudine for 6 wks & serial HIV

PCR testing
---------------------------------------------------------------PDA-dependent congenital heart disease
aortic coarctation
transposition of great vessels
hypoplastic left lung syndrome
total anomalous pulmonary venous connection
tricuspid atresia
normal ductus arteriosus constricts ~day 3 of life
prostaglandin E1 keep ductus arteriosus open
inspired O2 stimulates PDA constriction
indomethacin is a potent prostaglandin inhibitor,
stimulates PDA closure
---------------------------------------------------------------Common complications after acute MI
hours 2 days reinfarction
hours 7 days ventricular septal rupture
days 2 wks LV free wall rupture
hours 1 month post-infarct angina
1 3 days acute pericarditis
2 7 days papillary muscle rupture
5 days 3 months LV aneurysm
weeks months Dresslers pericarditis
--------------------------------------------------------------- acute pericarditis occur 1 - 3 days post-MI
o pericardial friction rub with/without chest pain
o self-limited, resolves with supportive care
posted-MI pericarditis occurring wks to months
after an MI: Dressler syndrome
o immune-mediated pericarditis
o Rx: NSAIDs
--------------------------------------------------------------- MCC blunt abdominal trauma: MVAs
MC injured: liver & spleen
o free peritoneal fluid should raise suspicion
for liver or splenic laceration
hemodynamically unstable & free intraperitoneal
fluid on USS emergency laparotomy
hemodynamically stable splenic lacerations &
no evidence of other intra-abdominal injuries
non-operative management
--------------------------------------------------------------- ventricular septum rupture: 3 to 5 days post-MI

sudden onset hypotension, holosystolic murmur

--------------------------------------------------------------- papillary muscle rupture: 3 to 5 days post-MI
hypotension 2/2 severe acute mitral regurgitation,
holosystolic murmur & pulmonary edema
-------------------------------------------------------------- ventricular free wall rupture: mechanical
complication 5 days 2 wks post- MI (anterior)
hemopericardium & cardiac tamponade
acute onset chest pain & profound shock, JVD,
with rapid progression to PEA & death
LV free wall rupture should be suspected in
patients with PEA after a recent first MI & no
signs of heart failure
--------------------------------------------------------------- ventricular aneurysm: late complication of
acute STEMI (5 days to 3 months)
MC complication of anterior MI
scarred or fibrotic myocardial wall resulting
from healed transmural MI
decompensated CHF, refractory angina,
ventricular arrhythmias, or mural thrombus
EKG: persistent STEMI with deep Q waves
unchanged from discharge after recent MI
Dx: echo shows dyskinetic LV wall motion
--------------------------------------------------------------- LV free wall rupture: hemopericardium &
cardiac tamponade PEA death
--------------------------------------------------------------- hypotension or shock, JVD, clear lungs,
Kussmaul sign: RV infarct
o Kussmaul sign: JVD with inspiration
EKG: inferior MI &/or ST elevation in V4R V6R
Rx: IV fluid bolus to improve RV preload
nitro, diuretics, opioids may worsen hypotension
---------------------------------------------------------------Mechanical complications of acute MI
artery features
RV failure Acute
clear lungs,
Kussmal sign
Acute, RCA
acute, severe
severe MR
with flail
edema; new

IV septum Acute, LAD
shock &
chest pain,
shunt VSD
apical holosystolic
free wall
5 days LAD
shock &
rupture of - 2 wks
chest pain,
JVD, distant
heart sounds, tamponade
large pericardial effusion presenting as cardiac
tamponade post-MI: LV free wall rupture
o dyspnea, hypotension, pulsus paradoxus, JVD
o EKG: low voltage QRS, electrical alternans
--------------------------------------------------------------- Sarcoidosis: no definitive diagnostic test
CXR: hilar adenopathy, reticulonodular infiltrates
Bx: noncaseating granulomas; serum ACE
erythema nodosum, acute polyarthritis, cough,
anterior uveitis, dyspnea
asymptomatics Rx: followed without treatment
due to high rate of spontaneous remission
symptomatic Rx: systemic glucocorticoid
--------------------------------------------------------------- sudden onset abdominal pain a/w vaginal bleed,
fetal distress, loss of fetal station in active labor:
uterine rupture
o risk factors: pre-existing uterine scar,
abdominal trauma, macrosomia
o prior low transverse c-section: < 1% risk
o prior vertical c-section: as high as 9%
HTN & cocaine use: risk for placental abruption
sinusoidal fetal HR tracing: vasa previa
fever, tender uterus, foul-smelling lochia,
progression to sepsis: endometritis
o polymicrobial infection
o Rx: IV clindamycin & gentamicin
clindamycin for Gram+ & anaerobes
gentamicin for Gram-negatives

strabismus after age 4 months is abnormal &

requires Rx to prevent amblyopia (vision loss
from disuse of deviated eye)
intermittent strabismus can be expected in
infants < 4 months due to immaturity of
extraocular muscles; reassurance & observation
new onset strabismus can be a sign of
retinoblastoma if accompanied by white reflex
acute onset strabismus can result from
intracranial hemorrhage, brain abscess, or
--------------------------------------------------------------- first 5 years of life are critical to development of
visual acuity, a time of visual cortex maturity
esotropia beyond infancy must be treated to
prevent amblyopia
deviated eye can be strengthened by patching the
normal eye (occlusion therapy) or blurring the
normal eye with cycloplegic drops (penalization)
--------------------------------------------------------------- Rx for SLE, malaria prophylaxis, acute malaria,
rheumatoid arthritis: hydroxychloroquine
Rx for Crohns, ankylosing spondylitis, RA,
psoriasis: infliximab (TNF--blocker)
Rx for histoplasmosis: itraconazole
Rx SLE with renal involvement: cyclophosphamide
--------------------------------------------------------------- encephalopathy, ocular dysfunction, gait ataxia:
Wernicke encephalopathy
giving IV fluids containing glucose prior to
thiamine can precipitate or worsen WE
thiamine is given along with or before glucose
--------------------------------------------------------------- acute onset back pain after physical exertion,
paravertebral tenderness, absence of radiation,
negative straight leg raise test, normal neuro
exam: lumbosacral strain
o Rx: NSAIDs, early mobilization
--------------------------------------------------------------- acute back pain, local spinal tenderness, &
decreased spinal mobility after minimal trauma,
coughing, lifting: vertebral compression fracture
worse with standing, walking, laying on back
point tenderness, but normal neuro exam
risk factors: postmenopausal or senile osteoporosis

also: steroid Rx, osteomalacia, osteomyelitis,

trauma, bone mets, hyper-PTH, Pagets
complications: risk of future fractures,
hyperkyphosis ( respiratory capacity, risk of
atelectasis, early satiety, weight loss)
--------------------------------------------------------------- Eikenella corrodens: G-negative anaerobe part
of normal oral flora
o infective endocarditis due to E. corrodens is
seen in poor dentition, periodontal infection,
or manipulative dental procedures
o E. corrodens belongs to the HACEK group
congenital heart lesions (bicuspid aortic valve,
PDA, ToF, VSD) predisposes to risk of IE
ulcerative colon lesions due to colonic neoplasia
or inflammatory bowel disease predisposes to IE
due to Strep gallolyticus (S. bovis type I)
S. aureus is the MCC of IE among IVDA
Enterococci (E. faecalis) MC endocarditis a/w
nosocomial UTIs
--------------------------------------------------------------- flumazenil: GABA/benzodiazepine Rc antagonist
o Rx benzodiazepine overdose (slurred speech,
ataxia, hypotension, depressed mental status)
labetalol: Rx hypertensive encephalopathy
(BP 180/120 mmHg, headache, N/V, confusion)
nitroprusside: hypertensive emergency
(BP > 220/120 with evidence of organ damage)
---------------------------------------------------------------Cryptococcal meningoencephalitis
Features develops over 2 weeks (subacute)
headache, fever, malaise, vomiting,
altered mental status, B/L papilledema
more acute & severe in HIV (CD4 100)
CSF features
high opening pressure
low glucose, high protein
WBC 50/L
(mononuclear predominance)
cryptococcal antigen positive
transparent capsule on India ink
culture on Sabouraud agar
initial: amphotericin B with flucytosine
maintenance: fluconazole

serial LPs may be required to reduce ICP

antiretroviral therapy should be deferred at least
2 weeks after completing induction antifungal
therapy for cryptococcal meningitis
o initiating retroviral therapy with acute infection
risk of immune reconstitution syndrome
itraconazole does not cross the BBB
--------------------------------------------------------------- sulfadiazinepyrimethamine: Rx cerebral toxo
(headache, focal neurologic deficits, seizures);
multiple ring-enhancing lesions with edema
--------------------------------------------------------------- prostaglandin-only oral contraceptives are
preferred for hormonal contraception for
lactating mothers
o does not affect volume or composition of
milk produced, or risk of venous thrombosis
a/w combination OCPs
lactation causes anovulation, thus some degree
of contraception due to high prolactin levels
which inhibit GnRH release, but not reliable
--------------------------------------------------------------- CMV retinitis: MC when CD4 < 50
o yellow/white patches of retinal opacification
& hemorrhages
o Rx: ganciclovir or foscarnet
HSV encephalitis: cognitive & personality changes,
focal neurologic deficits; temporal lobe hemorrhage
PML: JC virus detected on PCR of CSF, patchy
areas of white matter due to demyelination
o focal neurologic deficits; no mass effect
o hemiparesis; speech, vision, & gait dysFx
o no cure; 6 month survival
--------------------------------------------------------------- mononucleosis-like symptoms, atypical lymphocytes,
negative Monospot: CMV mono
absence of pharyngitis & lymphadenopathy
large basophilic lymphocytes with a vacuolated
--------------------------------------------------------------- +HIV, bloody diarrhea, normal stool: CMV colitis
typically CD4 < 50 cells/L
Dx: colonoscopy multiple ulcers, mucosal erosions
biopsy: large cells with eosinophilic intranuclear
& basophilic intracytoplasmic inclusions

Rx: ganciclovir (or Foscarnet)

complications: toxic megacolon
--------------------------------------------------------------- bone marrow transplant recipient with lung &
interstitial involvement: CMV pneumonitis
develops 2 wks 4 months post-transplant
CXR: multi-focal, diffuse patchy infiltrates
high-resolution CT: parenchymal opacification
or multiple small nodules
Dx: bronchoalveolar lavage
--------------------------------------------------------------- dizziness, spinning sensation with nausea:
vertigo classification: central or peripheral
o peripheral vertigo has a shorter interval
o ear fullness suggests peripheral vertigo
o CN VIII lesions lead to central vertigo
vertigo with a sensation of ear fullness suggests
Menieres disease, from abnormal accumulation
of endolymph in the inner ear
tinnitus, vertigo, sensorineural hearing loss
--------------------------------------------------------------- Baker cysts: excess fluid produced by an inflamed
synovium accumulates in popliteal bursa, results in
a tender mass; a/w RA, osteoarthritis, cartilage tears
Baker cyst rupture presents similar to DVT
o cystic fluid leaks down the inner leg, results
in a hematoma over medial malleolus
(crescent sign)
DDx: subcutaneous abscess, lymphedema
--------------------------------------------------------------- ARDS: non-cardiogenic pulmonary edema
caused by leaky alveolar capillaries
mechanical vent.: FiO2 improves oxygenation,
PEEP prevents alveolar collapse
arterial pO2 measures oxygenation influenced
by FiO2 & PEEP
arterial pCO2 measures ventilation affected
by respiratory rate & tidal volume
initial ventilator management is decrease FiO2
to non-toxic values (< 60%); goal = paO2 60
PEEP can be increased to maintain oxygenation
o decreasing PEEP lowers oxygenation by
decreasing availability of alveoli

hypoxemia is best treated by increasing PEEP

PEEP complications: barotrauma, tension
pneumoTx (resulting hypotension)
--------------------------------------------------------------- ARDS can develop in the setting of sepsis,
severe bleeding, severe infection, toxic ingestion,
burns, or acute pancreatitis
inflammatory mediators are released locally or to
distant tissues, damage the alveoli
alveolar capillary permeability allows fluid to
leak into alveoli, resulting in pulmonary edema
excessive IV fluids hydrostatic pressure, thus
can worsen pulmonary edema
Rx: mechanical ventilation with low tidal volumes
& PEEP to work of breathing & oxygenation
--------------------------------------------------------------- ventilation = product of RR & tidal volume
mechanically ventilated patients with respiratory
alkalosis in the setting of appropriate tidal volume
RR should be lowered
o reducing tidal volume can trigger an RR
worsens alkalosis
o increasing tidal volume would ventilation
worsens alkalosis
--------------------------------------------------------------- hypotension, tachycardia, flat neck veins,
confusion, & cold extremities despite IV fluid
resuscitation: hypovolemic/hemorrhagic shock
cardiogenic shock: decreased C.O. causes SVR,
PCWP, venous filling pressures & JVD
loss of vascular tone occurs in septic & neurogenic
shock with compensatory C.O./index
o less blood return: PCWP & SVR
---------------------------------------------------------------Hemodynamic measurements in shock
Normal Hypovole Cardiogen Septic
mic shock ic shock





intravascular volume loss leads to LV preload

C.O. & systemic BP HR & SVR
o pulmonary capillary wedge pressure
(PCWP) measures of LA & LVED pressure
cardiogenic shock leads to C.O. & BP
o PCWP due to heart failure
o HR & SVR maintains organ perfusion
C.O. decreases tissue perfusion, thus
signals tissues to extract more O2
vasodilatory/distributive shock, MC due to
sepsis, anaphylaxis, SIRS, or CNS injury
o peripheral vasodilation SVR & BP, with
compensatory HR & C.O.
o hyperdynamic circulation, which decreases
organ perfusion venous O2 saturation
o as sepsis progresses vasoconstriction is
a/w SVR & C.O.
--------------------------------------------------------------- acute massive PE can present as hypotension &
syncope, leading to PEA in some patients
PE occluding part of pulmonary artery results in
RA, RV, & pulmonary artery pressure
compensatory hyperdynamic LV function: early
cardiac index, but no effect on PCWP or SVR
--------------------------------------------------------------- RV infarct: RA & RA pressures
PCWP & cardiac index 2/2 reduced preload
--------------------------------------------------------------- exertional dyspnea, syncope, angina: aortic stenosis
o systolic murmur, radiates to apex & carotids
o peripheral pulse: pulsus parvus et tardus
(decreased amplitude & delayed upstroke)
hypotension, tachycardia, distended neck veins,
electrical alternans, pulsus paradoxus,
(exaggerated decrease (> 10 mmHg) in systemic
arterial BP with inspiration): cardiac tamponade

pulmonary edema, a-fib, late diastolic murmur

with opening snap: mitral stenosis
--------------------------------------------------------------- sudden severe chest pain radiating to back,
severe HTN, decrescendo diastolic murmur of
aortic regurgitation: acute aortic dissection
o systolic BP > 20 mmHg difference between
arms, & weak/absent peripheral pulses
o heard @ right sternal border
CXR & EKG to exclude other Dx
serum creatinine, contrast allergy?
Dx: transesophageal echo (TEE) is preferred
over chest CT with contrast in patients with
kidney disease or contrast-induced nephropathy
Rx: IV labetalol
o patients should not receive antiplatelets
(ASA, clopidogrel) or anticoagulation
without first excluding aortic dissection
o nifedipine is a vasodilator that can induce
reflex tachycardia & aortic shear stress
complications: Horners, LE weakness/ischemia,
hemothorax, abdominal pain
DDx: acute pericarditis, acute pancreatitis, PE,
MI, angina, mediastinal tumor, pleuritis
--------------------------------------------------------------- aortic dissection can extend to aortic valve,
carotids, renal arteries, or pericardium, leading to
aortic regurgitation, stroke, ARF, or tamponade
--------------------------------------------------------------- blunt abdominal trauma can cause splenic injury
delayed onset hypotension, LUQ pain radiating to
left shoulder 2/2 diaphragmatic irritation (Kehr sign)
Dx: abdominal CT with contrast if
hemodynamically stable
hemodynamic instability despite IV fluids
requires laparotomy
--------------------------------------------------------------- bipolar disorder is an episodic illness; periods of
severe irritability during discrete mood episodes
strong genetic component
bipolar I: manic episodes with/without Hx of
major depressive episodes
o Dx can be made with a first manic episode
bipolar II:, hypomanic episodes (less severe, less
functional impairment, no psychotic symptoms)

o Hx of 1 depressive episodes required

o never met criteria for a past manic episode
cyclothymic disorder: 2 years of fluctuating,
mild hypomania & mild depressive symptoms
that do not meet criteria for hypomanic episodes
nor major depressive episodes

Manic episode
Hypomanic episode
Symptoms more severe, Symptoms less severe,
one week (unless
4 consecutive days
symptoms not severe
marked impairment in enough to cause marked
social or occupational
impairment or necessitate
psychotic features
no psychotic features
--------------------------------------------------------------- bipolar disorder is at high risk of relapse after
remission from an acute episode
#1 maintenance Rx: atypical + lithium or valproate
Guidelines for maintenance Rx of bipolar disorder
first episode maintenance at least 1 yr
2 episodes long-term maintenance (years) if
episodes were severe or +family Hx
3 relapses lifetime maintenance
--------------------------------------------------------------- sunscreen: 30 min before exposure
reapply every 2 hrs
avoid sunscreen in infants < 6 months
--------------------------------------------------------------- long-acting injectable antipsychotics (depot)
Rx chronic noncompliance, who previously
responded to oral antipsychotics
o must assess tolerability of oral medication
o 1st & 2nd generations available as depot
o given as IM every 2 4 wks
Rx-resistant schizophrenia: clozapine
o fail to respond to 2 antipsychotics
o risk of agranulocytosis
o requires routine monitoring: CBC
---------------------------------------------------------------Lithium therapy
Indications mania due to bipolar
chronic kidney disease
cardiovascular disease
hyponatremia or diuretic use



BUN/creatinine, U/A
Thyroid function
EKG if coronary risk factors
tremor, ataxia, weakness
polyuria, polydipsia
vomiting, diarrhea, weight gain
cognitive impairment
nephrogenic DI
thyroid dysfunction
hyperPTH with hyperCa++

Lithium has a narrow therapeutic window, thus

monitor every 6 12 months or 5 7 days after
dose changes or drug interactions (diuretics, SSRIs,
NSAIDs, ACE-I, phenytoin, carbamazepine)
pregnancy: Ebsteins anomaly, polyhydramnios,
nephrogenic DI, floppy infant syndrome
no effect on liver function, lipids, or glucose
--------------------------------------------------------------- complications following rhinoplasty:
dissatisfaction, nasal obstruction, epistaxis
nasal septum has poor blood supply &
regenerating capacity, thus trauma or surgery
may result in septal perforation
presents as a whistling during respiration due to
a septal hematoma following rhinoplasty
--------------------------------------------------------------- > 2 weeks of persistent, high-volume, non-bloody
watery diarrhea after recent travel; no fever,
tenesmus or vomiting: Cryptosporidium parvum
travel-associated diarrhea > 2 weeks; parasitic
o cryptosporidium cystoisospora,
microsporidia, Giardia
diarrhea < 1 week: viral or bacterial
o rotavirus/norovirus: vomiting
o ETEC/EPEC: contaminated food/water
o Campylobacter: abdo pain, bloody diarrhea,
o Salmonella: frequent fever
o Shigella: fever, bloody diarrhea, abd pain

Entamoeba histolytica causes amebiasis,

resulting in abdo pain & bloody diarrhea
--------------------------------------------------------------- constrictive pericarditis is a complication of
mediastinal irradiation (Hodgkin lymphoma), TB,
& cause of right heart failure (hepatomegaly,
progressive peripheral edema, JVD, ascites)
can present 10 20 yrs after irradiation or
anthracycline therapy
scarring & inelastic pericardium results in
diastolic dysfunction
CXR: pericardial calcifications
confirm Dx: echo show pericardial thickening,
abnormal septal motion, bi-atrial enlargement
Rx: diuretics for temporary relief;
pericardiectomy for refractory symptoms

Constrictive pericarditis
idiopathic or viral, cardiac surgery,
radiation therapy (Hodgkins),
TB (developing countries)
fatigue, dyspnea on exertion,
right heart failure (peripheral edema,
ascites, JVD, Kussmaul sign )
hepatojugular reflux
pericardial knock (mid-diastolic sound)
pulsus paradoxus
complication: cardiac cirrhosis
EKG: a-fib, or low voltage QRS
pericardial calcifications & thickening
prominent x & y descents
NSAIDs, diuretics, pericardiectomy
--------------------------------------------------------------- spontaneous esophageal rupture after severe
retching/vomiting: Boerhaaves
CXR: left-sided pleural effusion with/without
pneumothorax, subcutaneous emphysema, &
widened mediastinum
exudative pleural fluid: low pH, high amylase
(>2500 IU)
Dx: CT or contrast esophagogram w/ Gastrografin
(water-soluble contrast)
mucosal tear
transmural tear 2/2
forceful retching;




forceful retching;
arterial or venule
plexus bleeding
epigastric pain
EGD endoscopy

pleural fluid shows elevated WBCs, protein,

& LDH, but not amylase
--------------------------------------------------------------- RA, moderate anemia, low serum iron, low TIBC,
transferrin: anemia of chronic disease
a/w chronic inflammatory diseases (RA)
iron trapping within macrophages, leads to poor
iron availability for Hb synthesis
low reticulocyte count
Rx underlying cause can improve anemia
--------------------------------------------------------------- stress fractures: MC in anterior middle third of the
tibia in jumping sports & posteromedial distal third
of the tibia in runners
microfractures within cortical bone that coalesce
risk factor: female athlete triad ( caloric intake,
oligo-/amenorrhea, osteoporosis)
MC site: 2nd metatarsal
XR is normal initially, 6 wks
Dx: MRI or bone scan
Rx: rest & analgesia
Rx: surgery for displaced fx or 5th metatarsal fx
--------------------------------------------------------------- child with severe headache of gradual onset a/w
N/V, photophobia, visual aura: migraine
most common form of headache < age 20
migraines in children are often bifrontal &
shorter duration than adult migraines
Rx in < age 12: supportive (dark, quiet room, &
cool cloth on forehead), acetaminophen or
NSAID (ibuprofen)
alternative Rx: triptans
--------------------------------------------------------------- indications for neuroimaging in a child with
headache: Hx of coordination difficulties, tingling,
numbness, focal neurologic signs; headache that
awakens from sleep, headache frequency
--------------------------------------------------------------- obese boy with a limp, knee pain, decreased ROM,
pain with hip internal rotation: slipped capital
femoral epiphysis (SCFE)
MC in obese boys, age 10 16 yrs
insidious onset dull hip or referred knee pain,
altered gait with no preceding trauma
affected hip is held in passive external rotation

esophageal perforation
with air/fluid leakage
vomiting, retching,
retrosternal pain, WBC
odynophagia, fever,
dyspnea, or septic shock
subcutaneous emphysema
CT or contrast
esophagography with
pneumomediastinum &
exudative pleural effusion
(low pH, high amylase)
cervical perforations:
conservative measures
thoracic perforations:

endoscopic Rx
as needed
(clipping or
--------------------------------------------------------------- allergic rhinitis: rhinorrhea, nasal pruritus, cough;
nasal mucosa is edematous & pale; polyps?
nasal furunculosis: 2/2 staphylococcal folliculitis
due to nose-picking or hair plucking
o pain, tenderness, erythema in nasal vestibule
o life-threatening if spreads to cavernous sinus
--------------------------------------------------------------- fetal distress (repetitive late decelerations) is an
indication for emergent c-section
--------------------------------------------------------------- chronic ankylosing spondylitis (> 20 yrs) are at
risk for vertebral fractures with minimal trauma
DDx: spinal root compression, bone mets
--------------------------------------------------------------- acute pancreatitis can cause unilateral, left-sided
pleural effusion with high amylase concentration,
but not widened mediastinum
cocaine use predisposes to aortic dissection with
wide mediastinum & unilateral pleural effusion,
but not high amylase content
aspiration pneumonia is MC in right lower lobe
& unilateral pleural effusion due to
parapneumonic effusion or empyema

a/w children with endocrinopathies

(hypothyroidism, growth hormone deficiency)
have B/L disease & present at an earlier age
Dx: XR in frog-leg lateral view
Rx: surgical screw fixation at current slippage
complication: avascular necrosis
--------------------------------------------------------------- Legg-Calve-Perthes: idiopathic avascular necrosis
of femoral capital epiphysis
MC in boys, age 5 7 yrs
insidious hip, groin, or knee pain & antalgic gait
(indication of pain with weight bearing)
limited internal rotation & hip abduction
Dx: high suspicion; early XR may be negative
Rx: observation & bracing; surgery if severe
DDx: SCFE, transient synovitis
--------------------------------------------------------------- MCC of hip pain in children: transient synovitis
boys age 3 10 yrs; after viral infection or trauma
well-appearing, able to bear weight
affected hip is flexed, slightly abducted &
externally rotated which maximizes joint space
Dx: XR to exclude bone lesions, fx, Legg-Calve
Rx: ibuprofen & rest, F/U in 1 wk
o recovery within 1 4 wks; no complications
--------------------------------------------------------------- amenorrhea > 3 months, hypoestrogenism, FSH,
age < 40: premature ovarian failure
may be secondary to accelerated follicle atresia
or low number of primordial follicles
MC is idiopathic; or a/w mumps, oophoritis,
irradiation, chemotherapy, autoimmunity
(Hashimotos, Addisons, DM Type I, pernicious
Dx: FSH/LH, hypoestrogen
o do not wait for 1 yr of amenorrhea for Dx
early Dx prevents osteoporosis
Rx: in vitro fertilization with donor oocytes
--------------------------------------------------------------- pulsatile GnRH agonists: induces ovulation
progesterone: corrects luteal phase defect (failure
of corpus luteum to produce progesterone to
maintain the endometrium for implantation)

exertional dyspnea, fatigue, pale conjunctiva

iron deficiency is MCC of microcytic anemia
iron studies confirm Dx
Microcytic/Hypochromic anemias
Iron-def anemia ferritin, TIBC
normal/ serum iron & ferritin
Anemia of
ferritin & transferrin,
chronic disease
normal/ iron & ferritin,

iron deficiency: 2/2 intake or blood loss

o RDW, reticulocyte count
thalassemia or hemaglobinopathies: globin
production & elevated HbA2
o reticulocyte count & total bilirubin 2/2
anemia of chronic disease: defective utilization of
storage iron, due to suppression of RBC production
by inflammatory cytokines
o ferritin = ongoing inflammation
lead poisoning or sideroblastic anemia:
reduced heme synthesis
hemochromatosis: intestinal iron absorption
& deposition
o iron, ferritin, & transferrin, TIBC
--------------------------------------------------------------- child with a painful, solitary, lytic long bone lesion
with overlying tender swelling & hypercalcemia:
Langerhans histiocytosis
locally destructive, but resolves spontaneously
benign, Rx conservative
--------------------------------------------------------------- thin vaginal discharge, erythematous mucosa, motile
pear-shaped organisms: trachomonal vaginitis
Rx: metronidazole
alcohol intake with metronidazole is a/w
disulfiram-like reaction; acetaldehyde
accumulates, causes flushing, N/V, hypotension
--------------------------------------------------------------- chronic inflammatory diarrhea (< 4 wks): anemia,
weight loss, ESR, acute phase reactants, reactive
thrombocytosis, +occult blood/leukocyte stool

infant with failure to thrive, B/L cataracts, jaundice,

hypoglycemia: galactosemia
galactose-1-phosphate uridyl transferase deficiency
also vomiting, hepatomegaly, convulsions
risk for E.coli neonatal sepsis
early Dx & Rx: eliminating galactose from diet
o breastfeeding is C/I
complications: cirrhosis, mental retardation
--------------------------------------------------------------- galactokinase deficiency: cataracts only
--------------------------------------------------------------- Dx for PCOS ( 2 criteria)
o androgen excess (hirsutism, acne, alopecia)
o olio- or anovulation
o polycystic ovaries on USS
o exclusion of other hyperandrogenic states
Rx for PCOS
weight loss
combined OCPs: Rx hyperandrogenism &
menstrual dysfunction, progestin risk of
endometrial hyperplasia
o clomiphene citrate: estrogen analog; induces
ovulation with some ovulatory reserve
o Metformin: promotes ovulation in PCOS
prevented by insulin resistance; also for
prevention or coexisting DM Type II
Comorbidities of PCOS
o obesity
o insulin resistance/glucose intolerance/DM
o dyslipidemia
o endometrial ca risk 2/2 chronic anovulation
--------------------------------------------------------------- DM screening: sustained BP > 135/80 mmHg
OGTT is preferred to screen glucose intolerance
& DM Type II
Dx: Type II DM
2 hr OGTT 200 mg/dL
o fasting blood glucose > 126
o HbA1c 6.5%
o random plasma glucose 200
--------------------------------------------------------------- age > 60, dysphagia, regurgitation, halitosis, cough,
variable neck mass: Zenker diverticulum

most important pathogenic factor in development

of Zenker: motor dysfunction
develops above the upper esophageal sphincter,
with posterior herniation between
cricopharyngeal muscle fibers
risk for aspiration pneumonia
Dx: barium esophagram
Rx: excision, cricopharyngeal myotomy
--------------------------------------------------------------- battery ingestion requires an XR
batteries in the esophagus should be removed
under endoscopic guidance to prevent mucosal
damage & esophageal ulceration
batteries distal to the esophagus need
observation with stool exam or follow-up XR
do not use NG tube or induce vomiting
--------------------------------------------------------------- aortic dissection is the most dangerous
complication of Marfan
o aortic regurgitation is a complication
o autosomal dominant; fibrilin-1 mutation
all Marfan patients with chest pain require
evaluation for aortic dissection
aortic regurgitation: early decrescendo diastolic
murmur along the LSB, 3rd/4th IC space, sitting
upright, leaning forward, after full expiration

Clinical features of Marfan syndrome

upper:lower body segment ratio
arm:height ratio
pectus deformity, scoliosis/kyphosis
joint hypermobility
ectopia lentis (lens subluxation)
aortic dilation, regurgitation, dissection
spontaneous pneumothorax due to
apical blebs
--------------------------------------------------------------- aortic dissection risk factors
o HTN (most significant)
o Marfan
o cocaine use

office-based anoscopy/proctoscopy is the initial

procedure for age < 50 with minimal bright red
blood per rectum & no colon cancer risk factors
o blood intermixed with stool is not included
MCC: hemorrhoids, anal fissure, polyps,
proctitis, rectal ulcers, cancer
anoscopy has higher sensitivity for hemorrhoids
than flexible endoscopy
colonoscopy/sigmoidoscopy for age > 50 or
other risk factors for colon cancer
--------------------------------------------------------------- DNA testing for RET proto-oncogene germline
mutation is screening test for suspected MEN 2
o no further monitoring for a negative result
o total thyroidectomy for a positive test result;
risk of invasive MTC is 100%

Multiple endocrine neoplasia classification

Type I
o Pituitary tumors
o Primary hyperPTH (90%)
o Pancreatic/GI tumors (gastrinoma)
Type 2A
o Medullary thyroid cancer (MTC)
(Sipples) o Pheochromocytoma
o Parathyroid hyperplasia
Type 2B
o Pheochromocytoma
o Mucosal neuromas
o marfanoid habitus
MEN1 pancreatic tumors: gastrinoma, insulinoma,
glucagonoma, VIPoma
o gastrinoma causes recurrent peptic ulcers
--------------------------------------------------------------- firm, flesh-colored, umbilicated, dome-shape plaques
on trunk, limbs, anogenital areas; spares palms/soles:
molluscum contagiosum (poxvirus)
MCC due to sexual contact MC occur on genitalia,
lower abdomen, inner thighs
transmitted: skin-skin or fomites
self-limited, localized infection
linear pattern due to spread 2/2 scratching
MC a/w cellular immunodeficiency (HIV),
corticosteroid use, chemotherapy

DDx: HSV-1 (vesicular eruption), HPV

(verrucous papules), Staph (furuncles, carbuncles)
--------------------------------------------------------------- Staph aureus is MCC of healthcare-associated
infective endocarditis (S. epidermidis)
o prosthetic valves, indwelling catheters, IVDA,
implanted devices (pacemakers, defibrillators)
Streptococci is MCC of community-acquired IE
o viridans strep: S. sanguinis, S. mutans
o after dental procedures or procedures
involving incision/biopsy of respiratory tract
Enterococci: E. faecalis: a/w nosocomial UTIs
Strep bovis: S. gallolyticus
o colon cancer & inflammatory bowel disease
---------------------------------------------------------------Endocarditis overview
poor dentition, congenital heart disease,
valve abnormalities (MVP, MR), IVDA,
intravascular catheters
features subungal hemorrhages, petechiae,
Janeway lesions, Oslers nodes,
Roth spots, splenomegaly,
mitral valve disease (MVP, MR)
positive blood cultures, WBCs,
glomerulonephritis, septic emboli
vancomycin (initially), based on cultures
Janeway lesions: macular, erythematous,
nontender lesions of palms/soles
Oslers nodes: painful, violaceous nodules on
Roth spots: edematous, hemorrhagic retinal lesions
--------------------------------------------------------------- blood cultures from 2 separate venipuncture sites
for suspected IE prior to initiating ABX

Duke Criteria for Infective Endocarditis

Major Criteria
Minor Criteria
2 positive blood culture Vascular phenomena:
for typical IE organisms
systemic arterial emboli,
(strep viridans or bovis,
pulmonary infarcts, mycotic
S. aureus, enterococcus
aneurysms, Janeway
lesions, conjunctival
Echocardiogram with
Immunologic phenomena:
oscillating intracardiac

mass on valve

rheumatoid factor,
Osler nodes, Roth spots
Dx : 2 Major, 0 Minor
predisposing heart condition
Dx : 1 Major, 3 Minor
Dx : 0 Major, 5 Minor
fever: > 38.0 C (100.4)
---------------------------------------------------------------Acute rheumatic fever
epidemiology MC in females, age 5 15 yrs
MCC: group A Strep pharyngitis
precedes onset of ARF by 2 4 wks
o Joints (migratory arthritis)
o (carditis, mitral stenosis)
o Nodules (subcutaneous)
o Erythema marginatum
o Sydenham chorea
fever, arthralgias, elevated ESR/CRP
prolonged PR interval
late features
mitral regurgitation/stenosis
PCN (regardless of +/- pharyngitis)

Dx: 2 major, or 1 major + 2 minor criteria

supportive findings: ASO titer, Strep antigen test
DDx: SLE, Henoch-Schonlein, Juvenile arthritis

Hx of rheumatic fever increases risk of recurrence

& progression of rheumatic heart disease
Dx: continuous ABX prophylaxis to prevent
recurrent group A Strep pharyngitis

ABX prophylaxis for rheumatic fever (RF)

IM benzathine PCN G every 4 wks
RF without carditis
5 yrs or until age 21
RF with carditis, but no
10 yrs or until age 21
heart or valvular disease
RF with carditis &
10 yrs or until age 40
persistent or valve dz
--------------------------------------------------------------- sore throat, skin infection, generalized edema,
dark urine, HTN: post-strep glomerulonephritis
recurrent high fevers, rash, arthritis: Adult Stills
o maculopapular, non-pruritic rash on the
trunk & extremities during febrile episodes
hypotension, hyperpigmentation, hyponatremia:
adrenal insufficiency (Addisons)

cutaneous Kaposi sarcoma appear as violaceous

papules due to increased vascularity
MC on face, oral mucosa, genitalia, lower extremity
Dx is clinical, but may need biopsy to exclude
bacillary angiomatosis 2/2 Bartonella
--------------------------------------------------------------- condyloma acuminata (anogenital warts) is due
to HPV; appear as skin-colored, white or gray
verrucous & papilliform lesions
HPV 16, 18 a/w risk of SCC
Rx: HIV screening
Rx: self-limited; trichloroacetic acid, podophylin
--------------------------------------------------------------- 20 syphilis: condyloma lata, flat pink/gray
velvety papules
o MC at mucous membranes & moist genital
skin, perineum, mouth
30 syphilis: ascending aortitis, tabes dorsalis,
psychosis, tumors (gumma) of skin, bone, liver
o brief stabbing pains, Argyll-Robertson pupils
(accommodate but do not react)
---------------------------------------------------------------Neurofibromatosis Type I
AD inheritance; neurocutaneous syndrome
caf-au-lait spots, Lisch nodules, neurofibromas
(benign peripheral nerve sheath tumors), short stature
risk of intracranial neoplasms: optic glioma
(chronic headache, early morning vomiting, HTN,
progressive unilateral vision loss, dyschromatopsia
(disorder of color vision))
o Dx: MRI brain & orbits
---------------------------------------------------------------Neurofibromatosis Type II
B/L acoustic neuromas (vestibular schwannoma)
cause sensorineural hearing loss
screening: audiometry; Dx: MRI with gadolinium
--------------------------------------------------------------- tuberous sclerosis: neurocutaneous genetic
syndrome 2/2 intracranial tumors
ash leaf spots, facial angiofibromas, cardiac
rhabdomyomas, renal agnioleiomyomas
--------------------------------------------------------------- allergic reaction with stridor: laryngeal edema,
results in respiratory acidosis (CO2 retention)

asthma exacerbation leads to acute respiratory

alkalosis due to tachypnea
persistent vomiting & excessive diuresis causes
volume contraction with increased HCO3 &
metabolic alkalosis
persistent vomiting results in hypochloremic
metabolic alkalosis from gastric H+ losses
--------------------------------------------------------------- primary respiratory alkalosis decreases arterial
PaCO2, leading to metabolic compensation that
serum HCO3 by 2 mEq/L for every 10 mmHg
decrease in PaCO2
acute respiratory acidosis leads to metabolic
compensation that serum HCO3 by 1 mEq/L
for every 10 mmHg increase in PaCO2
--------------------------------------------------------------- ASA toxicity causes mixed respiratory alkalosis
(low PaCO2) & metabolic acidosis (low HCO3)
respiratory alkalosis is due to direct stimulation of
medullary respiratory center causing tachypnea
metabolic acidosis is due to the production &
renal elimination of lactic acids & ketoacids
--------------------------------------------------------------- A-A women age 20 40 are at great risk for SLE
arthritis in 90%, may be a presenting symptom,
non-deforming arthritis affects MCP & PIP
fatigue, low-grade fever, painless oral ulcers,
malar/discoid rash, weight loss, serositis (pleuritis),
proteinuria (RBC casts)
hematologic abnormalities: anemia, leukopenia,
--------------------------------------------------------------- joint space erosion, articular demineralization,
soft tissue swelling: rheumatoid arthritis
osteophytes, narrowed joint spaces, subchondral
sclerosis & subchondral cysts: osteoarthritis
arthropathy of MCP joints, hepatomegaly, diabetes,
bronze skin, erectile dysfunction, hypogonadism,
dilated cardiomyopathy: hemochromatosis
dactylitis (sausage digits), DIP joints, nail pitting,
psoriatic plaques: psoriatic arthritis
o can occur without skin changes
--------------------------------------------------------------- pancytopenia following drug intake, exposure to
toxins, radiation, or viral infection: aplastic anemia

pallor, fatigue, weakness, anorexia, easy bruising,

petechiae, mucosal hemorrhage, fever
bone marrow Bx: hypocellularity & fatty infiltration
--------------------------------------------------------------- pallor & poor feeding in first 3 months of life,
normocytic anemia with reticulocytopenia:
Diamond-Blackfan anemia (aka congenital
pure red cell aplasia)
--------------------------------------------------------------- short stature, caf-au-lait spots, pancytopenia,
congenital abnormalities, hyperpigmentation on
trunk, neck & intertriginous areas, hypogonadism,
renal malformations: Fanconis anemia
initial manifestation: thrombocytopenia
neutropenia anemia
--------------------------------------------------------------- recent ABX use, watery bowel movements, mild
abdominal tenderness: C. difficle colitis
unexplained leukocytosis in hospitalized patients
should raise suspicion, even without diarrhea
complications: toxic megacolon, severe ileus
Dx: stool studies for C. difficle toxin
Rx mild/moderate: empiric oral metronidazole
Rx severe: oral vancomycin (+ IV metronidazole
if ileus is present)
o fidoxomicin: Rx recurrent colitis or severe
colitis who cannot tolerate oral vancomycin
surgical consult for acute peritoneal signs or
severe C. difficile colitis (toxic megacolon, ileus,
WBC > 20,000/L): subtotal colectomy
--------------------------------------------------------------- Gentamicin: Rx resistant G-negative bacteria
IV vancomycin: empiric Rx for bacteremia
secondary to a cutaneous source (central line) or
infection (pneumonia) due to resistant G-positive
o not excreted into the colon, thus not
effective against C. difficile colitis
--------------------------------------------------------------- solitary pulmonary nodule: coin-shaped lesion,
3 cm or less surrounded by normal parenchyma;
evidence of calcification is considered benign
low-risk patients (age < 40, non-smoker):
compare with old XR; F/U CXR every 3 months
for 12 month
high-risk patients: chest CT & FNA

bronchoscopy cannot reach peripheral lesions

--------------------------------------------------------------- headache, jaw claudication, proximal muscle
weakness, temporal area tenderness, ESR:
giant cell arteritis
Dx: temporal artery biopsy
complication: blindness, aortic aneurysms
o F/U: serial CXR
--------------------------------------------------------------- asymptomatic carotid artery stenosis (CAS)
can progress to TIA or embolic stroke
symptomatic CAS: sudden onset focal neurologic
symptoms within 6 months
indications for carotid endarterectomy (CEA)
o asymptomatic carotid stenosis, men: > 60%
o symptomatic carotid stenosis: > 70%
< 50% stenosis: Duplex USS annually, &
medical management alone
patients with CVD should start on ASA & statins
--------------------------------------------------------------- emphysematous cholecystitis is a common form
of acute cholecystitis in elderly diabetic males
(age 50 70)
gallbladder infection with gas-forming bacteria
(Clostridium, Escherichia, Strep, Staph,
Pseudomonas, Klebsiella)
RUQ pain, N/V, fever, abdo pain & crepitus
complications: gangrene, perforation
Dx: abdominal XR shows air fluid levels in the
gallbladder; USS shows curvilinear gas shadows
Rx: cholecystectomy within 72 hrs, IV ABX
--------------------------------------------------------------- beta-cell tumor (insulinoma): hypoglycemia
with insulin, c-peptide, & pro-insulin
non-beta cell tumor: large mesenchymal tumors
that produce IGF-II with insulinomimetic action
after binding insulin receptors
o insulin & c-peptide are suppressed
sulfonylureas output of endogenous insulin
from beta cells; insulin & c-peptide
o confirm Dx with plasma sulfonylurea level
glucagonoma causes necrotic migratory erythema

pelvic exam is contraindicated in a patient with

antepartum hemorrhage until placenta previa is
ruled out by transvaginal USS
management depends on gestational age &
severity of bleeding
stable mother, fetus at term: scheduled c-section
stable mother, fetus not at term: expectant
management; amniocentesis @ 36 wks to assess
lung maturity
extended/massive bleeding, regardless of gestation:
emergency c-section
--------------------------------------------------------------- polymyositis & dermatomyositis are
inflammatory myopathies; ESR & CK
confirm Dx: muscle biopsy
Rx: high-dose corticosteroids
proximal, symmetric extensor
muscle weakness; UE = LE
Grottons papules, heliotrope rash
extramuscular interstitial lung disease,
dysphagia, myocarditis
CPK, aldolase, LDH
anti-RNP, anti-Jo-1, anti-Mi2
equivocal: EMG, muscle biopsy
high-dose glucocorticoids PLUS
glucocorticoid-sparing agent,
screen for malignancy
--------------------------------------------------------------- Riluzole slows progression of ALS
TCAs decrease the pain of fibromyalgia
--------------------------------------------------------------- Herpes zoster is a reactivation of VZV due to
decreased cell-mediated immunity
pain precedes onset of vesicular rash by 48 hr
Rx: valacyclovir, or oral acyclovir (cheaper);
reduces incidence of post-herpetic neuralgia
TCAs can also prevent/Rx post-herpetic neuralgia
--------------------------------------------------------------- hyposthenuria: inability to concentrate the urine
nocturia & polyuria
MC a/w sickle cell disease & trait
RBC sickling in the vasa rectae impairs
countercurrent exchange & free water absorption

--------------------------------------------------------------- negative D-dimer (fibrin split product) best

excludes pulmonary VTE in low-risk patients
(negative predictive value > 95%)
positive D-dimer requires further studies with
CT angiography
--------------------------------------------------------------- brain death: irreversible loss of function of the
whole brain & brainstem; legal definition of death
no further steps are legally required to remove a
patient from artificial life support
--------------------------------------------------------------- clingy & submissive, crave protection & care,
avoids taking initiative due to feeling inadequate,
indecisive: dependent personality disorder
hypersensitive to criticism, social inhibition,
desire friendships, but fear embarrassment or
ridicule: avoidant personality disorder
restricted range of emotions, social detachment,
do not enjoy close relationships, aloof, indifferent
to praise/criticism: schizoid personality disorder
odd & eccentric behavior, magical thinking,
clairvoyant, capacity for close relationships:
schizotypal personality disorder
--------------------------------------------------------------- schizoaffective disorder: lifetime Hx of delusions
& hallucinations co-occurring with depressive or
manic episodes & Hx of at least 2 weeks of
psychotic symptoms without mood episodes
mood symptoms are present for majority of illness
--------------------------------------------------------------- dysphagia, Raynauds, extensive skin thickening:
diffuse systemic sclerosis
pulmonary complication are MCC of death
o MC is interstitial fibrosis
--------------------------------------------------------------- chronic cough after a recent URI, primarily at night,
no expectoration: postnasal drip
cough is caused by mechanical stimulation of the
afferent limb of cough reflex in upper airway
Rx: empiric 1st-generation antihistamine or
combined antihistamine-decongestant
Dx: elimination of nasal discharge & cough
with empiric H1-antagonisists
no response after 2 - 3 wks require investigation

--------------------------------------------------------------- upper airway cough syndrome (postnasal drip),

GERD, asthma: > 90 % of chronic cough (> 8 wks)
in non-smokers without pulmonary disease
o postnasal drip 1st-generation H1 blocker
o on ACE inhibitors stop ACE inhibitors
o asthma PFTs, inhaled corticosteroids
o GERD empiric PPI
CXR if no improvement after these interventions
--------------------------------------------------------------- CXR is indicated in those with no clear etiology
or possible parenchymal disease, purulent sputum,
immunocompromised, or smoking Hx
Common etiologies of chronic cough
postnasal drip
ACE inhibitors
asthma & cough-variant asthma
GERD or laryngopharyngeal reflux
o post respiratory tract infection
o chronic bronchitis or sinusitis
o bronchiectasis
o lung cancer
o non-asthmatic eosinophilic bronchitis
--------------------------------------------------------------- anemia of prematurity is the most common
anemia in premature & low birth weight infants
due to diminished RBC production, shorter RBC
lifespan in neonates, & fetoplactental transfusion
(baby held above placenta after delivery)
poor weight gain, poor feeding, pallor, lethargy,
tachypnea, tachycardia
labs: normocytic/normochromic anemia, low
reticulocyte count, normal WBC & total bilirubin
Rx: iron supplementation; but does not prevent
falling Hb levels; iron deficiency is not the cause
--------------------------------------------------------------- hemolytic disease of the newborn is due to Rh or
ABO incompatibility
jaundice, hepatosplenomegaly, pallor, & hydrops
fetalis in severe cases
Type II hypersensitivity
reticulocyte count due to hemolysis

EOM weakness (diplopia, proptosis) with

symmetrical proximal muscle weakness (upper
more than lower), neck, bulbar muscles
(dysarthria, dysphagia): myasthenia gravis
neurodegenerative disease, men age 40 to 60;
asymmetric muscle atrophy, muscle weakness
(distal more than proximal), hyperreflexia,
spasticity, fasciculations: ALS
DDx: electrolyte disturbance, fibromyalgia,
polymyositis, multiple sclerosis, Guillain-Barr,
thyroid-related myopathy
--------------------------------------------------------------- sickle cell anemia presents after the first 6 months
of life, due to presence of Hb F
dactylitis may be the initial presentation that
warrants further workup
--------------------------------------------------------------- hypothyroidism can cause reversible changes in
memory & mentation; accompanied by systemic
changes such as weight gain, fatigue, constipation
Rx: levothyroxine will improve cognitive symptoms
--------------------------------------------------------------- best indicator of dementia: functional impairment
of ADLs (hygiene, dressing, self-medicating)
occasional forgetfulness, word finding aphasia, &
insomnia can occur with normal aging
---------------------------------------------------------------DDx of dementia subtypes
Alzheimer early: insidious anterograde memory loss,
visuospatial & language deficits,
word finding difficulty
late: personality changes, hallucinations,
dyspraxia, urinary incontinence
stepwise decline, cerebral infarction,
early executive dysfunction (ADLs),
focal neuro deficits (+pronator drift,
+Romberg, unsteady gait)
early personality changes,
apathy, disinhibition, compulsive,
+primitive reflexes, +family Hx
late: memory deficits
Lewy body fluctuating cognition, altered alertness,
visual hallucinations, parkinsonism
late: memory deficits
dementia, gait ataxia, urinary incontinence


MRI: enlarged ventricles

rapidly progressive behavior changes,
myoclonus, akinetic mutism
choreoathetosis, behavioral disturbances,
insidious decrease in consciousness,
headache, cognitive & memory deficits,
aphasia, or motor deficits
dementia with megaloblastic anemia,
posterior spinal column deficits

ataxia, ophthalmoplegia, confusion (Wernicke);

with confabulation & amnesia (Korsakoff)
--------------------------------------------------------------- fluctuating cognition, insomnia, decreased alertness,
visual hallucinations, Parkinsonism, repeated falls:
Lewy body dementia
Lewy bodies: eosinophilic intracytoplasmic
inclusions due to alpha-synuclein accumulation
early appearance of dementia
Dx: progressive, cognitive decline, interferes
with social & occupational functions
DDx: Parkinsons (motor symptoms present early),
Alzheimers (early anterograde memory loss),
lacunar strokes (patchy neurologic findings), NPH
--------------------------------------------------------------- NPH: urinary incontinence, dementia, abnormal gait
dementia is characterized by memory loss, but
no focal neurologic changes
broad-based, shuffling gait
transient increase in intracranial pressure or due
to decreased CSF absorption causing
permanent ventricular enlargement
Dx: LP, enlarged ventricles on CT or MRI
Rx: serial large volume LPs, with subsequent
ventriculoperitoneal shunt
--------------------------------------------------------------- insidious decreased consciousness, headache,
cognitive & memory deficits, frequent falls, aphasia,
motor deficits: chronic subdural hematoma
MC in elderly & alcoholics
Dx: noncontrast CT shows a white crescent
with or without midline shift

dietary modification & exercise is the first step

in treating GDM
if nutritional therapy fails, insulin or oral agents
(metformin, glyburide)
insulin does not cross the placenta
--------------------------------------------------------------- GDM screening @ 24 - 28 wks gestation
GDM target blood glucose levels
o fasting 95 mg/dL
o 1-hour postprandial 140 mg/dL
o 2-hour postprandial 120 mg/dL
GDM is at increased risk for gestational HTN,
preeclampsia, & fetal macrosomia
GDM resolves after childbirth, 50% develop
Type 2 DM
--------------------------------------------------------------- uncontrolled maternal hyperglycemia causes
fetal hyperglycemia fetal hyperinsulinemia
1st trimester: spontaneous abortion, congenital
malformations (small left colon syndrome), NTDs
2nd/3rd trimester complications
o macrosomia (shoulder dystocia)
o neonatal hypoglycemia
o polycythemia
o organomegaly (heart, liver)
since the fetus is in constant anabolism, placenta
may not be able to meet metabolic demands,
leading to fetal hypoxemia; erythropoietin
production causes polycythemia
--------------------------------------------------------------- small left colon syndrome: transient inability to
pass meconium; resolves spontaneously
risk: infants of GDM mothers
--------------------------------------------------------------- prego with HTN, proteinuria & edema: preeclampsia
o ANA may be weakly positive in pregnancy
HTN in a prego with massive proteinuria, malar
rash, & strongly positive ANA titer: SLE
signs that favor lupus as the origin of proteinuria
include rapid aggravation of proteinuria, clinical
signs of active SLE, & RBC casts indicates
nephritis rather than simple protein loss
Dx: renal biopsy after delivery

physiologic jaundice of the newborn is common

on days 2 4, benign, resolves by age 1 2 wks
indirect hyperbilirubinemia is due to
physiologic differences in bilirubin metabolism
o bilirubin production: elevated RBC
concentration & shorter RBC life span
o bilirubin clearance: immature hepatic UGT
levels (especially Asians)
o enterohepatic recycling: sterile newborn gut
cannot break down bilirubin to urobilinogen for
fecal excretion; bilirubin is resorbed/recycled
encourage frequent feedings to promote gut
colonization & fecal excretion
Rx: phototherapy for rapidly rising
hyperbilirubinemia to prevent kernicterus;
exchange transfusion for severe cases
--------------------------------------------------------------- newborns of mothers with Rh-negative or Oblood group are at risk for hemolytic anemia &
severe hyperbilirubinemia
neonatal sepsis can cause hemolysis &
exacerbate hyperbilirubinemia
o fever & risk factors for neonatal sepsis
(PROM, +GBS screen)
--------------------------------------------------------------- -thalassemia can cause hemolysis &
unconjugated hyperbilirubinemia
newborns are asymptomatic due to fetal Hb =
alpha + gamma globin chains
hemolytic anemia symptoms after age 6 months
as gamma chains replaced with beta chains
--------------------------------------------------------------- sellar mass
o visual defect (diplopia, vision loss,
bitemporal hemianopsia)
o headache
o symptoms of pituitary hormonal deficiency
(decreased libido, amenorrhea)
benign causes
o pituitary adenoma (most common)
o craniopharyngioma (common in children)
o meningioma
Dx: CT scan or MRI

bitemporal hemianopia: pressure on optic chiasm

exerted by a pituitary tumor, craniopharyngioma,
or anterior communicating artery aneurysm
--------------------------------------------------------------- progressively worsening headache, focal motor
weakness, visual disturbance, cognitive deficits:
glioblastoma multiforme
acute/subacute painful vision loss with abnormal
pupillary response to light in the affected eye:
optic neuritis a/w multiple sclerosis
headache, transient visual symptoms, tinnitus:
idiopathic intracranial HTN
o papilledema, visual field loss, 6th nerve palsy
homonymous superior quadrantanopsia (pie in
the sky): temporal lobe stroke affecting the
inferior optic radiations in the Myers loop
--------------------------------------------------------------- vision assessment should be performed at every
well-child visit
evaluate infants by observing fixation & tracking
cover-uncover test for older infants/children to
assess for strabismus
visual acuity begins at age 3 with Snellen or
tumbling E chart
--------------------------------------------------------------- dyslipidemia universal screening: age 9 11 &
again @ 17 21
o lipid levels are stable prior to & after puberty
also if high risk for CVD (obesity, DM, tobacco,
family Hx of premature CAD) & men age 35
---------------------------------------------------------------Minors & consent
medical circumstances emergencies, STDs, prenatal
that do not need consent care, mental health services,
substance abuse, contraception
unemancipated minors consent from one parent or
guardian is legally sufficient
emancipated minors
homeless, parent, married,
do not need consent
financially independent,
military, high school grad
minors who are parents can consent for Rx of
their own minor children
parents cannot deny their children life-saving
treatment unless benefits are minimal or would
not alter the prognosis

--------------------------------------------------------------- innocent murmurs result from blood flow from a

structurally normal heart; grade I or II intensity, &
changes intensity with position ( with standing)
Rx: reassurance
pathologic murmurs are grade III
--------------------------------------------------------------- live-attenuated virus vaccine can be given with
routine inactivated vaccinations
live virus vaccines
given 4 weeks apart of routine vaccinations
o do not give to pregnant women
o can be given to household contacts of pregos
--------------------------------------------------------------- quadrivalent meningococcal vaccine: 11 12 yrs
followed by a booster at age 16
rotavirus vaccine: @ age 2 8 months due to
risk of dehydration from severe gastroenteritis
--------------------------------------------------------------- MCC of gastroenteritis in infants & young
children worldwide: Rotavirus
highly contagious, fecal-oral transmission
fever, vomiting, watery osmotic diarrhea
results in severe dehydration
prevention: rotavirus vaccine
o age 2 6 months
o live attenuated virus vaccine
o A/E: risk of intussusception
C/I: Hx of intussusception, Hx of uncorrected
GI malformations (Meckels), SCID
--------------------------------------------------------------- isolated thrombocytopenia & petechiae after viral
infection (URI): immune thrombocytopenia
o petechiae & ecchymosis most common
o also mucocutaneous bleeds (epistaxis,
hematuria, GI bleed) if severe
antibodies bind to PLTs, with destruction of
Ab/PLT complexes in the spleen
labs: PLT < 100,000 L, megakaryocytes on PBS
Rx children: age 2 5 yrs; spontaneous recovery
within 6 months, regardless of PLT count
Rx: skin manifestations only = observe
Rx: +bleeding = IV Ig or glucocorticoids
Rx adults:

Rx: PLT 30,000 L, no bleeding = observe

Rx: PLT 30,000 L, OR bleeding = IV Ig or
--------------------------------------------------------------- APGAR: Appearance, Pulse, Grimace, Activity,
Respiratory effort; measured at 1 & 5 minutes
blue extremities, pink body is common/benign
cyanosis of face or central body is concerning
score of 7 9/10 = no intervention
score < 7/10 = further evaluation & resuscitation
if HR < 100 & irregular respiration pulse
oximetry & positive-pressure ventilation
if HR < 60 CPR
--------------------------------------------------------------- confounder: extraneous factor which is
independently a/w both exposure & outcome of
interest; mixing up the effect of exposure with
the effect of an extraneous factor
smoking explains part of the association observed
between alcohol consumption & oral cancer
--------------------------------------------------------------- peripheral edema is a common side effect with
dihydropyridine CCB (amlodipine) due to
dilated peripheral vessels, leads to increased
capillary hydrostatic pressure
also headache, flushing, dizziness
Rx: ACE-I or ARBs causes post-venodilation
DDx of peripheral edema: CHF, renal disease,
liver disease, venous insufficiency
--------------------------------------------------------------- sudden, diffuse periumbilical tenderness out of
proportion to exam findings, metabolic acidosis:
acute mesenteric ischemia
MC site: SMA
labs: metabolic acidosis from serum lactate,
leukocytosis, amylase
CT: focal or segmental bowel wall thickening,
dilation, & mesenteric stranding
Dx: high index of suspicion with risk factors for
thromboembolic dz (a-fib, PVD, atherosclerosis)
confirm Dx: angiography
Rx: supportive, IV fluids, ABX, NGT
complications: bowel infarct, perforation,
peritonitis, sepsis, death

DDx: acute pancreatitis, DKA, gastric outlet

syndrome, peptic ulcer perforation
--------------------------------------------------------------- diuretic abuse: technique for rapid weight loss
hypovolemia, orthostatic hypotension, dizziness
hyponatremia, hypokalemia; urine Na+ & K+
suspect an eating disorder
DDx: self-induced vomiting, laxative abuse,
mineralocorticoid deficiency (low serum Na+,
high serum K+)
--------------------------------------------------------------- acute limb ischemia post-MI suggests possible
arterial embolus from LV thrombus
large anterior STEMI are high risk, LV thrombus
Rx: immediate IV heparin, vascular surgery
consult, TTE to screen for LV thrombus
--------------------------------------------------------------- always obtain a CXR to confirm placement of a
central venous catheters before use
o catheter tip should lie in the SVC
complications: arterial puncture, pneumothorax,
hemothorax, thrombosis, air embolism, sepsis,
myocardial perforation tamponade
---------------------------------------------------------------Heparin-induced thrombocytopenia (HIT)
MCC: unfractionated heparin, LMWH
50% drop in PLT count from baseline
Type I HIT: non-immune direct effect of heparin
on PLT activation; within 48 hr of exposure;
o mild, non-immune PLT degradation
o PLT count normalizes with continued heparin;
no clinical consequences
o no Rx; spontaneous recovery
Type II HIT: immune-mediated antibodies to
PF4-heparin complex; occurs within 5 10 days;
life-threatening; stop all heparin products
o necrotic skin lesions at injection sites
o prone to arterial & venous thrombosis:
warmth, erythema, swelling, tenderness
o Rx: direct thrombin inhibitor (argatroban)
or fondaparinux; Treat first, test later
o confirm Dx: serotonin release assay

thrombosis consumes PLTs & worsens

--------------------------------------------------------------- protamine sulfate: Rx heparin reversal; HIT
directly binds heparin
---------------------------------------------------------------Initial Rx of HTN
blacks: thiazide or CCB, alone or combo
(ACE/ARB not first-line)
o all others: thiazide, ACE-I/ARB, or CCB alone
or combo
o all with CKD or diabetes: ACE-I/ARB alone or
combo ( intraglomerular pressure)
--------------------------------------------------------------- statins: Rx all diabetics age 40 75, regardless
of baseline lipids
--------------------------------------------------------------- dyspnea, tachypnea, pleuritic chest pain: PE
--------------------------------------------------------------- factitious disorder: intentional falsification of
S/S to assume a sick role
Munchausens: severe factitious disorder, seeks
invasive/life-threatening surgical procedures
somatic symptom disorder: excessive anxiety
& preoccupation with 1 unexplained symptoms
illness anxiety disorder (aka hypochondriasis):
prolonged fear of a serious illness despite few/no
symptoms & negative evaluations
conversion disorder: neurologic symptoms
incompatible with any neurologic disease; acute

onset, a/w a stressor; not intentional, unconcerned

(la belle indifference)
--------------------------------------------------------------- diabetic nephropathy begins with hyperfiltration
( GFR) & microalbuminuria, then progresses to
macroproteinuria with progressive decline in GFR
screening: spot urine mciroalbumin/Cr ratio
hallmark: nodular glomerulosclerosis
intensive BP control is proven to slow GFR
decline once azotemia develops
o diabetics target BP: 140/90 mmHg
o diabetics with nephropathy: 130/80 mmHg
Rx: ACE inhibitors intraglomerular pressure;
but may induce acute GFR decline & hyperkalemia
--------------------------------------------------------------- abdominal USS for Dx & follow-up of AAA
---------------------------------------------------------------Metastatic brain tumors
o MC type of intracranial tumors
o MC @ grey-white matter junction
o MC mets from non-small cell lung cancer
Rx solitary brain mets in patients with good
performance status & stable extracranial disease:
surgical resection
whole brain radiation for multiple brain mets or
poor performance status
chemotherapy for mets from small cell lung cancer,
lymphoma, choriocarcinoma
--------------------------------------------------------------- HTN, mild hypernatremia, hypokalemia,
metabolic alkalosis, no peripheral edema:
primary hyperaldosteronism
MCC: mineralocorticoid-producing adrenal tumor
found incidentally
rapid hypokalemia in response to diuretics
o aldosterone, renin, bicarbonate
secondary hyperaldosteronism: Cushings,
renal artery stenosis, renin-secreting tumor
o aldosterone, renin, & bicarbonate
--------------------------------------------------------------- Cushings causes secondary HTN
ACTH-dependent hormones cause vasoconstriction
(HTN), insulin resistance (hyperglycemia), &
mineralocorticoid activity (hypokalemia)

also central obesity, facial plethora, ecchymosis,

proximal muscle weakness, erectile dysfunction,
amenorrhea, thin skin, abdominal striae
causes: exogenous steroid use, ectopic ACTH,
adrenal cortical adenoma, ACTH pituitary
adenoma (Cushings disease)
DDx: pheochromocytoma, renal artery stenosis,
hypothyroidism, renal parenchymal disease
--------------------------------------------------------------- primary hyperparathyroidism: hypercalcemia
(polyuria, polydipsia, constipation), kidney stones,
confusion, depression, psychosis
--------------------------------------------------------------- renal artery stenosis: flash pulmonary edema,
resistant heart failure, chronic kidney disease,
severe HTN > 180/120 after age 55
systolic-diastolic abdominal bruit
DDx: AAA (systolic bruit)
--------------------------------------------------------------- all chronic hepatitis C patients, including pregos,
should be immunized against hepatitis A & B;
both are safe during pregnancy
vertical transmission is a/w maternal viral load
o c-section is not protective
breastfeeding does not increase transmission risk,
unless nipple is actively bleeding
Ribavirin is teratogenic, avoid in pregos
--------------------------------------------------------------- frostbite Rx: rapid rewarming with warm water
immersion, continuously circulated
do not debride any devitalized tissue initially
--------------------------------------------------------------- splenectomy: Rx autoimmune hemolytic anemia,
symptomatic hereditary spherocytosis, massive
splenomegaly a/w -thalassemia major or HbH
--------------------------------------------------------------- splenectomy risk of sepsis by encapsulated spp
(S. pneumo, N. meningitides, H. influenza)
o impaired Ab-mediated phagocytosis by
risk of sepsis for up to 30 yrs after splenectomy
Rx: pneumococcal, Hib, & meningococcal vaccine
2 wks prior to or post-splenectomy
daily oral PCN prophylaxis 3 - 5 yr post-splenectomy

chronic granulomatous disease: defective

intracellular killing by phagocytes
o XR defect in NADPH oxidase
SCID: number of circulating lymphocytes
leukocyte adhesion defect: impaired chemotaxis
DiGeorge: defective cell-mediated immunity
o fungal & viral infections are common
--------------------------------------------------------------- Guillain-Barr: ascending radiculoneuropathy
preceded by URI or diarrhea illness (C. jejuni)
distal paresthesia, ascending flaccid paralysis,
diminished DTRs, respiratory compromise
autonomic disturbances: tachycardia, HTN,
orthostatic hypotension, urinary retention
risk of respiratory failure
monitor autonomic & respiratory function with
serial spirometry measurements of FVC
o declining FVC requires intubation
Rx: IV Ig or plasmapheresis
---------------------------------------------------------------CSF Analysis
Glucose Protein
40 -70
< 40
bacterial meningitis

TB meningitis

viral meningitis


Guillain-Barr: albuminocytologic dissociation

(high protein, normal WBC count)
herpes meningoencephalitis: high RBC &
protein, 2/2 temporal lobe hemorrhage
--------------------------------------------------------------- empyema occur from untreated pneumonia with
parapneumonic effusions or 2/2 hemothorax
low-grade fever, cough, dyspnea, chest pain
MCC: S. aureus, Strep pneumo, Klebsiella
CXR: loculated, abnormally contoured effusion
with adjacent consolidation
Dx: CT scan
Rx recent onset empyema: fibrinolytic
(streptokinase, urokinase) into the chest tube;
but contraindicated in MVAs
Rx: ABX for early empyema

Rx: complex, loculated effusion with thick rim

surgery for decortication & drainage
--------------------------------------------------------------- CHF due to LV systolic dysfunction is
characterized by cardiac output/index, SVR,
a holosystolic murmur at the apex is likely due to
functional mitral regurgitation, from mitral
annulus enlargement with LV dilatation &/or
papillary muscle displacement due to remodeling
Systemic LVED
c index vascular

Distributive shock

volume loss

LV systolic dysFx
--------------------------------------------------------------- epigastric pain, weight loss, jaundice, distended GB:
pancreatic cancer
nontender but palpable gallbladder in a jaundiced
patient is unlikely gallstones (Courvoisiers sign)
bilirubin & ALP suggest bile duct obstruction,
leading to intra- & extrahepatic bile duct dilation
Dx: abdominal USS for patients with jaundice
Dx: CT with contrast, patients without jaundice
ERCP is reserved for nondiagnostic USS & CT
percutaneous transhepatic cholangiogram (PTC)
if ERCP is not indicated
CA 19-9 is only useful for post-op monitoring &
evaluate response to chemotherapy
--------------------------------------------------------------- CA-125 antigen testing & pelvic USS can be used
to Dx ovarian cancer only for those with
suggestive symptoms or physical findings
women with a strong family Hx of ovarian cancer,
should test for BRCA1/BRCA2 genes
o positive results should be screened with
pelvic USS &/or CA-125
no screening for average risk patients

management of splenic trauma depends on

hemodynamic status & response to IV fluids
hemodynamically unstable & improves with
IV fluids: abdominal CT, admit to ICU
unresponsive to fluids: exploratory laparotomy
--------------------------------------------------------------- transient, painless, monocular vision loss,
curtain falling down: amaurosis fugax
MCC: retinal emboli due to atherosclerosis
fundoscopy may show zones of whitened retina
following the distribution of retinal arterioles;
Hollenhorst bodies (cholesterol particles)
Dx: duplex USS (MC site: carotid bifurcation)
--------------------------------------------------------------- light flashes, floaters, or curtain coming across
visual field from the periphery: detached retina
fundoscopy: wrinkled, detached retina
--------------------------------------------------------------- central retinal artery occlusion: painless
monocular vision loss; ophthalmic emergency!!
ophthalmic artery is 1st intracranial branch of ICA;
a/w amaurosis fugax
fundoscopy: diffuse ischemic retinal whitening
& cherry red fovea
Rx: ocular massage & high flow O2
--------------------------------------------------------------- central retinal vein occlusion: painless, sudden
vision loss 2/2 venous thrombosis
fundoscopy: dilated, tortuous veins leading to
diffuse hemorrhages (blood & thunder) with
disk swelling, & cotton wool spots
--------------------------------------------------------------- floaters in the visual field: vitreous hemorrhage
MCC: diabetic retinopathy
fundoscopy: fundus is difficult to visualize
--------------------------------------------------------------- progressive dyspnea on exertion, orthopnea,
hemoptysis, young immigrant: mitral stenosis
symptoms are precipitated by conditions causing
tachycardia (fever, anemia, pregnancy)
severe LA enlargement, leads to elevation of
left main bronchus on CXR, compresses
recurrent laryngeal nerve (hoarseness), or a-fib
CXR: pulmonary vascular congestion with
cephalization of blood flow to upper lobes

DDx: acute pericarditis, interstitial lung disease,

malignancy, sarcoidosis
--------------------------------------------------------------- orotracheal intubation with rapid-sequence
intubation is preferred for an apneic patient with
cervical spine injury, unless there is facial trauma
nasotracheal intubation is a blind procedure;
C/I in apneic/hypopneic patients & basilar skull fx
cricothyroidotomy is preferred over surgical
tracheostomy, but converted to formal tracheostomy
in 5 7 days if prolonged airway is necessary
--------------------------------------------------------------- p-value: probability of observing a given result by
change alone, assuming null hypothesis is true
if p = 0.001, there is a 0.1% probability of
observing a given relative risk by chance alone
both p-value & confidence interval measures
statistical significance
a confidence interval containing 1.0 (null value)
is not statistically significant
--------------------------------------------------------------- extreme fatigue, malaise, sore throat, fever,
generalized maculopapular rash, palatal petechiae,
posterior cervical adenopathy, splenomegaly:
infectious mono
labs: leukocytosis with atypical lymphocytes
Dx: heterophile antibodies peak 2 6 wks after
primary EBV infection; thus, an initial negative
antibody test does not exclude IM repeat test
alt Dx: anti-EBV antibodies
--------------------------------------------------------------- screen all pregos for syphilis, HIV, & Hep B
regardless of STI risk factors
screening for chlamydia, gonorrhea, & Hep C is
based on risk factors
--------------------------------------------------------------- cyanide toxicity can occur with nitroprusside,
for rapid BP control in hypertensive emergency
o nitroprusside metabolism releases nitric oxide
(arteriolar & venous dilation) & cyanide ions
altered mental status, lactic acidosis, seizures, coma
occurs with prolonged infusions or higher doses
of nitroprusside, MC with renal insufficiency
Rx: sodium thiosulfate

DDx: alcohol withdrawal, excessive hypotensive

response, hypertensive encephalopathy

Manifestations of cyanide toxicity

flushing (cherry-red)
headache, altered mental status,
hyperreflexia, seizure, coma
tachypnea followed by respiratory
depression, pulmonary edema
abdominal pain, N/V
metabolic acidosis 2/2 lactic acidosis,
renal failure
--------------------------------------------------------------- delusion: fixed, false beliefs not consistent with
cultural norms; grandiose, paranoid, or somatic
magical thinking: ones thoughts can control
events not explained by natural cause & effect
illusion: misinterpretation of external stimuli
hallucinations: sensory perception in the
absence of external stimuli
----------------------------------------------------------------- polycythemia: Hct > 65% in term neonates
lethargy, irritability, jitteriness, poor feeding,
cyanosis, respiratory distress
risk factors: in utero hypoxia (maternal HTN,
smoking), poor gas exchange (maternal diabetes),
delayed cord clamping, IUGR
hypoglycemia & hypocalcemia 2/2 cell uptake
asymptomatic Rx: hydration only by feeding or
parenteral fluids
symptomatic Rx: partial exchange transfusion
to normalized Hct
DDx: cyanotic heart disease, dehydration, RDS,
transient tachypnea of the newborn
--------------------------------------------------------------- anasarca, facial edema, HTN, pulmonary edema,
JVD, proteinuria & microscopic hematuria:
acute nephritic syndrome with fluid overload
primary glomerular damage leads to GFR &
retention of sodium & water resulting in volume
overload & peripheral edema
MCC: post-streptococcal glomerulonephritis,
lupus nephritis, IGA nephropathy, RPGN,
membranoproliferative GN

abnormal urinary sediments: RBCs, red cell casts

DDx: pretibial myxedema in Graves, cirrhosis,
hypoalbuminemia in nephrotic syndrome, renal
hypoperfusion 2/2 heart failure, RV failure
---------------------------------------------------------------Causes of peripheral edema
capillary hydrostatic pressure
(CHF, cirrhosis, renal disease)
capillary oncotic pressure
(hypoalbuminemia, nephrotic syndrome, cirrhosis)
capillary permeability
(burns, trauma, sepsis, ARDS)
interstitial oncotic pressure
(lymphatic obstruction)
--------------------------------------------------------------- uncomplicated diverticulitis: fever, leukocytosis,
LLQ pain/tenderness, Hx of constipation
o Dx: CT scan shows soft tissue stranding &
colonic wall thickening
o stable patients are managed as outpatient:
bowel rest, oral ABX, observation
o immunocompromised, comorbidities, or
elderly hospitalization & IV ABX
complicated diverticulitis: a/w abscess,
perforation, obstruction, or fistula
o Dx: CT scan
o fluid collection 3 cm Rx: IV ABX & observe
fluid collection 3 cm Rx: CT-guided drainage
failure of CT drainage: surgical drainage
CT guided percutaneous drainage is standard
Rx for complicated diverticulitis with abscess
surgery with sigmoid resection is reserved for
patients with fistulas, perforations with peritonitis,
obstruction, or recurrent diverticulitis
--------------------------------------------------------------- B/L hip, thigh, or buttock claudication, impotence,
symmetric atrophy of LEs due to chronic ischemia:
aortoiliac occlusion (Leriche syndrome)
arterial occlusion at the aortic bifurcation into the
common iliac arteries; pulse is soft/absent B/L
impotence is always present in men; otherwise
seek out another Dx
--------------------------------------------------------------- Mycoplasma pneumonia is MCC of atypical
pneumonia the ambulatory setting

indolent course, nonproductive cough, higher

incidence of extrapulmonary symptoms
(headache, sore throat, skin rash)
CXR out of proportion to physical findings
erythema multiforme is typical of Mycoplasma
Gram stain reveals only PMNs, but no organisms
--------------------------------------------------------------- Strep pneumoniae (Gram+ diplococci): MCC of
community-acquired pneumonia
productive cough, rusty colored sputum
few extrapulmonary symptoms; more virulent
Rx: high-dose oral amoxicillin
--------------------------------------------------------------- Legionella pneumophilia causes pneumonia with
extrapulmonary symptoms: bradycardia, headache,
confusion, watery diarrhea
Dx: urine antigen testing
--------------------------------------------------------------- fever, tender posterior cervical lymphadenopathy,
significant fatigue, pharyngitis, tonsillar exudates,
palatal petechiae, young adult: infectious mono
heterophile (Monospot) test: 25% false-negative
rate during the first week; initial negative test
does not rule out IM
mild leukocytosis with atypical lymphocytes
can cause autoimmune hemolytic anemia &
thrombocytopenia up to 2 3 wks after onset
due to cross-reactivity of EBV-induced antibodies
against RBCs & PLTs; Coombs positive
DDx: Strep pharyngitis, acute HIV infection
--------------------------------------------------------------- acute HIV infection causes febrile illness
similar to infectious mono
o rash & diarrhea more common in HIV
o tonsillar exudate common in mono
---------------------------------------------------------------Centor criteria for pharyngitis
o fever by history
o tender anterior cervical lymphadenopathy
o tonsillar exudates
o absence of cough
score 0 to 1: no testing or treatment
score 2 to 3: rapid streptococcal antigen testing;
oral PCN or amoxicillin for positive results

score 4: antigen testing; or empiric oral PCN or

--------------------------------------------------------------- endothelial cell dysfunction or vasospasm is the
pathophysiologic finding in preeclampsia due to
abnormal placental vasculature development in
early pregnancy
previously normotensive patients, preeclampsia
is diagnosed as new onset HTN ( 140/90 mmHg)
@ 20 wks gestation, with new onset proteinuria
OR signs of end-organ damage
proteinuria is not required for Dx if signs of
end-organ damage is present
end-organ damage (severe headache, RUQ
or epigastric pain, renal insufficiency,
pulmonary edema) are considered to have
preeclampsia with severe features
Preeclampsia with severe features
o BP 160/110, 4 hrs apart during bedrest
o thrombocytopenia < 100,000
serum creatinine > 1.1 or doubling
o elevated transaminases
o pulmonary edema
o new onset visual or cerebral symptoms
--------------------------------------------------------------- normal pregnancy: C.O., renal perfusion, &
GFR, results in low baseline creatinine (0.4 0.8)
--------------------------------------------------------------- chronic HTN: BP 140/90 mmHg @ < 20 wks
gestation or prior to conception
gestational HTN: new onset HTN @ 20 wks
gestation; no proteinuria or end-organ damage
chronic HTN with superimposed preeclampsia:
chronic HTN + new onset proteinuria or worsening
proteinuria @ 20 wks gestation above baseline,
worsening HTN, or signs of end-organ damage
--------------------------------------------------------------- IV hydralazine & labetalol (or PO nifedipine) used
for pregos, Rx hypertensive emergencies
o (BP 160/110)
methyldopa is safe for pregos but not for
hypertensive emergencies; slow onset & sedative
magnesium sulfate for seizure prophylaxis
o definitive Rx: removal of the placenta

ACE inhibitors are contraindicated in pregos

o fetal growth restriction, renal failure,
pulmonary hypoplasia, oligohydramnios,
skeletal abnormalities in 2nd or 3rd trimester
--------------------------------------------------------------- viral arthritis presents as symmetric polyarticular
small joint inflammation; resolves within 2 months
positive ANA & rheumatoid factor may occur
Rx: NSAIDs; no antivirals necessary
DDx: RA, OA, polyarthritis in sarcoidosis, septic
& psoriatic arthritis, ankylosing spondylitis,
polymyalgia rheumatica
--------------------------------------------------------------- earliest manifestation of vaso-occlusive disease
in sickle cell anemia = dactylitis
presents @ age 6 months - 2 years with acute
onset pain, symmetric swelling of hands & feet
--------------------------------------------------------------- clubbing of toes & fingers, enlarged extremities,
swollen joints: hypertrophic osteoarthropathy
MCC: pulmonary adenocarcinoma
--------------------------------------------------------------- staphylococcal osteomyelitis: localized bone pain,
soft tissue swelling, erythema
sinus tracts with purulent drainage on skin surface
XR: initially normal but later show periosteal
elevation & necrotic areas
--------------------------------------------------------------- elevated DHEA-S levels are specifically seen
with androgen producing adrenal tumors
DHEA-S is produced in adrenal glands only
androstenedione, testosterone, & DHEA are
hormones produced by ovaries & adrenals
androstenedione, DHEA, DHEA-S are not true
androgens because they do not interact with
androgen receptors, but converted to testosterone
o overproduction of these hormones can lead
to clinical features of androgen excess
--------------------------------------------------------------- dihydrotestosterone (DHT) is a product of
testosterone conversion in peripheral tissues by
5- alpha-reductase
a potent androgen that interacts with testosterone Rc

always consider substance abuse in any

child/adolescent with significant changes in
behavior, emotions, & social circles
interview the patient & parents individually
urine toxicology screen is indicated
--------------------------------------------------------------- null hypothesis: statement of no relationship
between exposure & outcome
alternative hypothesis opposes the null hypothesis
---------------------------------------------------------------Feature of anorexia
cholesterol & carotene
prolonged QT, arrhythmias
euthyroid sick syndrome
anovulation, amenorrhea, estrogen deficiency
2/2 hypothalamic-pituitary axis dysfunction
hyponatremia 2/2 polydipsia
pregos are at risk of IUGR, prematurity,
hyperemesis gravidarum, postpartum depression
--------------------------------------------------------------- anorexia nervosa patients require hospitalization
for unstable vital signs, severe bradycardia or
cardiac arrhythmias, or electrolyte disturbances
Rx: CBT, nutritional rehab & weight gain;
monitor for refeeding syndrome
Rx: olanzapine, if failure to gain weight & lack
response to CBT
--------------------------------------------------------------- Rx bulimia nervosa: SSRI + CBT, nutrition rehab;
does not aid in weight gain
Rx anorexia nervosa: CBT, nutrition rehab;
olanzapine if no response
--------------------------------------------------------------- olanzapine A/E: weight gain & sedation mainly
o also hyperglycemia, dyslipidemia, new DM
clozapine A/E: weight gain, agranulocytosis, &
lowers seizure threshold
--------------------------------------------------------------- Bupropion is C/I with eating disorders as it can
provoke seizures
--------------------------------------------------------------- refeeding syndrome: potentially fatal complication
of nutritional rehabilitation in anorexia nervosa

resuming CHO intake, PO or IV, stimulates an

insulin surge, which promotes cellular uptake of
phosphorus, K+, & Mg++
o phosphorus is the primary deficient electrolyte
o K+ & Mg++ deficiency potentiate arrhythmias
aggressive initiation of nutrition rehab without
adequate electrolyte repletion results in clinical
o arrhythmias, cardiopulmonary failure
o CHF (pulmonary edema, peripheral edema)
o seizures
o Wernicke encephalopathy
anorexia nervosa: a/w euthyroid hypothyroxinemia
(normal TSH, low/normal T3/T4) 2/2 starvation &
--------------------------------------------------------------- African-American, gradual peripheral vision loss,
high ocular pressure with cupping of optic disc:
open angle glaucoma
annual fundoscopic exam in high-risk groups
Rx: Timolol ( aqueous humor production)
o laser trabeculoplasty as adjunct Rx
--------------------------------------------------------------- acute severe U/L eye pain, halo around lights,
blurred vision, non-reactive fixed & dilated pupil,
& unilateral orbitofrontal headache a/w N/V:
angle closure glaucoma
conjunctival erythema, corneal opacification
aggravated by pupil dilation 2/2 darkness, stress,
medications (decongestants, anticholinergics,
avoid atropine (mydriatic; precipitates glaucoma)
Dx: tonometry (increased IOP)
o gonioscopy is gold standard
#1 Rx: IV mannitol (rapid effect)
#2 Rx: acetazolamide & timolol ( aqueous humor
production), topical pilocarpine ( drainage)
untreated complication: permanent vision loss
--------------------------------------------------------------- moderate pain, blurred vision, hazy cornea,
anterior chamber shows flare & cells on slit lamp,
constricted pupil & poor light response: uveitis
--------------------------------------------------------------- diabetic retinopathy: MCC of acquired blindness;
MC 2/2 vitreous hemorrhage

non-proliferative: retinal hemorrhages,

dilated veins, microaneurysms, hard exudates
o proliferative: neovascularization
--------------------------------------------------------------- ToF presents with varying degrees of cyanosis,
depends on the degree of RV outflow obstruction
tet spell: sudden hypoxemia & cyanosis due to
sudden spasm from exertion or agitation
o pulmonary vascular resistance
Rx: knee-chest position decreases right-to-left
ventricular shunt & improves cyanosis by SVR,
pulmonary blood flow
Rx: inhaled O2 stimulates pulmonary vasodilation
o pulmonary vascular resistance
DDx: VSD typically does not cause cyanosis,
late stage pulmonary HTN with shunt reversal
leads to cyanosis (Eisenmengers)
--------------------------------------------------------------- maternal risk factors for fetal macrosomia:
advanced age, obesity, diabetes, multiparity
African & Hispanic males are at increased risk
for fetal macrosomia & shoulder dystocia
excessive traction on the neck during delivery
can result in Erb-Duchenne palsy
o involves 5th, 6th, 7th CN
o most recover spontaneously within 3 months
o Rx: gentle massage, PT to prevent contractures
females, 30s 40s
unpredictable, erratic, focal neurologic dysFx
symptoms last a few weeks; variable recovery
transient arm weakness
B/L trigeminal neuralgia**
--------------------------------------------------------------- depression, subcortical dementia, chorea,
atrophy of caudate nucleus (enlarged lateral
ventricles): Huntingtons
--------------------------------------------------------------- periodic back pain radiating to thigh & buttocks,
related to walking & climbing stairs, numbness
& tingling of lower extremities, relieved with
lumbar flexion: lumbar spinal stenosis
aka neurogenic claudication

compression of spinal roots due to enlarging

osteophytes at facet joints &/or hypertrophy of
ligamentum flavum; degenerative joint disease
normal peripheral pulses
neuro exam can be normal
confirm Dx: spinal MRI
DDx: lumbar disk herniation, metastatic disease,
iliac artery atherosclerosis, ankylosing spondylitis
--------------------------------------------------------------- low back pain radiating to calf & foot, worsens
with prolonged sitting, positive straight leg test,
unilateral symptoms: herniated lumbar disk
exertion-dependent pain, relieved with rest;
decreased peripheral pulses, cool extremities,
decreased hair growth: vascular claudication
back pain, paralysis, hyperreflexia, urinary &
fecal incontinence: spinal cord compression
chronic back pain, worse at night, non-radiating,
dull, does not change with activity: metastatic
disease of the vertebrae
--------------------------------------------------------------- progressive back stiffness, worse in AM, improves
with activity, young male: ankylosing spondylitis
apophyseal (facet) joint arthritis
lumbar spine mobility & tender SI joint
anterior uveitis (monocular pain, redness, blurring)
Dx: sacro-iliac XR shows B/L sacroiliitis, fusion of
SI joint &/or bamboo spine
HLA-B27 is not specific for AS, not needed for Dx
--------------------------------------------------------------- pulmonary aspergillosis: fever, chronic cough,
dyspnea, weight loss, intermittent hemoptysis
risk factors: immunocompromised, asthma, COPD,
TB, sarcoidosis, malignancy
aspergilloma MC with pre-existing lung cavity (TB)
CXR: rapidly progressing, mobile cavitary lesion
CT scan: pulmonary nodules with a halo sign or
lesions with an air crescent
Dx: CXR & Aspergillus IgG
Aspergilloma Rx: surgical resection
invasive aspergillosis: itraconazole or caspofungin
--------------------------------------------------------------- histoplasmosis: SE & central US
o acute pneumonia, cough, fever, malaise

o CXR: hilar adenopathy, areas of pneumonitis

blastomycosis: north/south central, Ohio/Miss
o flu-like S/S; severe in immunocompromised
o ulcerated skin lesion, lytic bone lesions
coccidioidomycosis: southwestern US
o primary pulmonary infection, arthralgia
erythema multiforme & erythema nodosum
sporotrichosis: subcutaneous papules at
inoculation site, ulcerates; along lymphatic flow
--------------------------------------------------------------- suspected sarcoidosis (cough, hilar adenopathy,
erythema nodosum, noncaseating granulomas) that
deteriorates after high-dose corticosteroids:
sarcoidosis & histoplasmosis present with
similar symptoms & CXR
biopsy reveals yeast forms in histoplasmosis
Dx: urine antigen testing
--------------------------------------------------------------- fever, night sweats, productive cough, weight loss,
acute & chronic pneumonia, wart-like violaceous
nodules & skin ulcers with yeast: blastomycosis
primary infection via inhalation pulmonary
infection with hematogenous spread to skin
heaped-up verrucous ulcerated skin lesions that
evolve into microabscesses
sputum: broad-based budding yeast
CXR: upper lobe consolidation & lytic lesions
Dx: urine antigen testing
Rx mild pulmonary dz, immunocompetent: no Rx
Rx moderate pulmonary disease: oral itraconazole
Rx severe pulmonary disease, immunocompromised:
IV amphotericin B
--------------------------------------------------------------- MCC of priapism
o drug-induced (trazodone, prazosin)
o sickle cell disease & leukemia (children)
o perineal or genital trauma (laceration)
o neurogenic lesions (SCI, cauda equina)
--------------------------------------------------------------- SSRIs: a/w impotence, sexual dysfunction,
delayed orgasm
o Rx: premature ejaculation

lightening-like pain on the face, 20 -30x per day,

distributed in CN V branches: trigeminal neuralgia
Rx: carbamazepine
(A/E: aplastic anemia, fetal hydantoin syndrome)
DDx: maxillary sinusitis, herpes zoster
MS can present with B/L trigeminal neuralgia
--------------------------------------------------------------- hypopituitarism with mild/moderate prolactin
(35 ng/mL): non-functioning pituitary adenoma
central hypogonadism & hypothyroidism
arise from gonadotrophs in pituitary gland;
dysfunctional cells overproduce only -subunits
of dimeric hormones (LH, FSH)
symptoms 2/2 mass effect with disruption of
dopaminergic pathways that normally suppress
Rx: trans-sphenoidal surgery
DDx: prolactinoma (> 200 ng/mL), Klinefelter,
excessive alcohol intake, antipsychotics
---------------------------------------------------------------Common etiologies of interstitial lung disease
o sarcoidosis, amyloidosis
o vasculitis (granulomatosis with polyangitis)
o infection
o occupational/environmental (silicosis,
hypersensitivity pneumonitis)
o connective tissue disease (SLE, scleroderma)
o idiopathic pulmonary fibrosis
o cryptogenic organizing pneumonia
--------------------------------------------------------------- idiopathic pulmonary fibrosis: excess collagen
deposition in peri-alveolar tissue, causes
interstitial lung disease
scarring leading to lung volumes (TLC, FRC, RV)
with preserved or FEV1/FVC ratio
impaired gas exchange; DLCO, A-a gradient,
results in hypoxemia due to V/Q mismatch
progressive exertional dyspnea, persistent dry cough,
fine crackles, digital clubbing
o resting ABG may be normal
o exertion can cause significant hypoxemia
CXR: reticular or nodular opacities
CT: fibrosis, honeycombing, traction bronchiectasis
o lung biopsy required for equivocal Dx

> 50% with significant +smoking Hx

--------------------------------------------------------------- cryptogenic organizing pneumonia: dry cough,
chronic systemic symptoms
CXR: B/L ground glass infiltrates
--------------------------------------------------------------- receiver operating characteristic (ROC) curve:
shifting upward, sensitivity
shifting ROC curve to the right, specificity
accuracy = total area under the ROC curve

--------------------------------------------------------------- sensitivity & specificity depend on the cutoff value

raising the cutoff value, it is harder to obtain a
true positive result & easier to obtain a negative
o causes FN to increase & TP to decrease,
leads to sensitivity & specificity
lowering the cutoff point increases # of TP
(directly proportional to sensitivity), but also
decreases # of FP ( specificity)
specificity is important for confirmatory tests
to minimize FPs

--------------------------------------------------------------- syringomyelia: fluid-filled cavity within the
cervical & thoracic spinal cord
a/w Arnold Chiari malformation type I & SCIs
areflexic upper extremities weakness,
dermatomal cape-distribution loss of pain/temp,
with preserved vibration & proprioception
(dissociated sensory loss)
may present with burn injury 2/2 loss of sensation
DDx: anterior cord syndrome (2/2 aortic surgery),
transverse myelitis (2/2 MS), ALS (no sensory loss),
subacute combined degeneration (2/2 Vit B12 def.),
cervical spondylosis (neck pain & stiffness)
--------------------------------------------------------------- Rx of hyperkalemia depends on severity, cause
& rapidity of rise in K+ levels
3 approaches to Rx hyperkalemia
1. antagonize cardiac effects of K+ with Ca++
o hyperkalemia a/w EKG changes (peaked T,
PR prolonged, wide QRS)
IV calcium gluconate
o rapid & transient effect
2. drive extracellular K+ into cells
o moderate hyperkalemia, no EKG change
insulin/glucose (fastest), beta-2-agonist
(albuterol), sodium bicarbonate
o rapid-acting, but transient effects
3. remove excess K+ from the body
o severe hyperkalemia, ESRD
sodium polystyrene sulfonate (Kayexelate),
diuretics (furosemide), cation exchange resins
(stool elimination), hemodialysis (definitive Rx)
o slow-acting (2 24 hr)

---------------------------------------------------------------Classification of psychiatric illness by phase

acute phase aims to achieve remission of acute
symptoms (absent/minimal symptoms)
o treatment response = 50% reduction from
baseline of severity; significant improvement
continuation phase: sustained remission to prevent
maintenance phase: recovery signifies the
episode is over; prevent recurrence
--------------------------------------------------------------- sarcoidosis: young/mid-aged African-American
females, insidious onset dyspnea & dry cough,
absence of constitutional symptoms
erythema nodosum & anterior uveitis is common
B/L ankle arthritis
auscultation: dry rales
CXR: B/L hilar lymphadenopathy, diffuse
interstitial infiltrates
DDx: PCP pneumonia, CHF (bibaslar infiltrates),
idiopathic pulmonary fibrosis, ankylosing spondylitis
--------------------------------------------------------------- Pneumococcus is MCC of sepsis in patients
with sickle cell anemia
clumping of sickled cells slows blood flow in the
spleen, permits splenic sequestration of RBCs,
results in auto-infarction & functional asplenia
susceptible to encapsulated species (S. pneumo,
H. influenza, N. meningitides)
pneumococcal vaccination & PCN prophylaxis
until age 5 prevents pneumococcal sepsis
o 13-valent conjugate & 23-valent polysacch
o H. influenza Type B vaccine
o meningococcal conjugate vaccine
PCN prophylaxis protects against other
pneumococcal serotypes
--------------------------------------------------------------- renal biopsy is required for classification of all
new onset lupus nephritis for baseline histology
& determine appropriate Rx
low complement levels & positive antibodies
(ANA, anti-dsDNA, anti-Smith)

thermal or smoke inhalation injury in burn victims,

warrant early intubation to prevent supraglottic
airway obstruction by edema & blistering
carboxyhemoglobin > 10%, stridor, Hx of
confinement in a burning building, blistering
Rx: high-flow O2 with non-rebreather, with a
low threshold for intubation
--------------------------------------------------------------- weakness & decreased pain sensation of B/L LE
after a MVA suggests a spinal cord injury
in absence of pelvic injury & blood at the urethral
meatus, urinary catheter can assess for retention
& prevent bladder injury due to acute distension
---------------------------------------------------------------Medications to withhold prior to cardiac stress testing
48 hr hold -blocker, CCB, nitrates
ACE-I/ARBs, digoxin, statins, diuretics

stress tests detect reversible ischemia or prior MI

medications should be continued for those with CAD
undergoing stress testing to assess the efficacy of
antianginal therapy
--------------------------------------------------------------- TB is a common cause of primary adrenal
insufficiency (Addisons) in endemic areas
no rise in serum cortisol with cosyntropin
CT: B/L adrenal calcification (hallmark)
non-anion gap metabolic acidosis with hyperK+,
hyponatremia, hypoglycemia, eosinophilia
deficiency of aldosterone results in inappropriate
sodium loss, while retaining K+ & H+
Rx of TB does not normalize adrenal function
Rx: lifelong glucocorticoid & mineralocorticoid
--------------------------------------------------------------- candida vaginitis & bacterial vaginosis are
caused by an imbalance of vaginal flora, not
sexual transmission; but increases risk for STDs
recent systemic corticosteroid use, ABX, DM

thin, off-white
discharge, fishy

DDx of vaginitis
thin, frothy,

thick, cottage

NO inflammation


normal pH

pH > 4.5
ph > 4.5
clue cells, +Whiff
motile, pear-shape
(amine odor in
strawberry cervix
oral metronidazole metronidazole;
(OK for pregos)
treat partner
(pregos OK)
normal: white/transparent, odorless discharge
vaginal inflammation: vulvar pruritus, erythema,
burning, dyspareunia, dysuria
confirm Dx: wet mount & vaginal pH
--------------------------------------------------------------- patients with PID should also be screened for
HIV, syphilis, hepatitis B, cervical cancer (pap);
also hepatitis C if Hx of IVDA
--------------------------------------------------------------- N-acetylcysteine
o acetaminophen hepatotoxicity
o mucolytic for cystic fibrosis
o contrast-induced nephropathy prevention
--------------------------------------------------------------- child with sudden-onset respiratory distress
without preceding illness, focal findings on
pulmonary exam: foreign body aspiration
MC in right mainstem bronchus
focal monophonic wheezing on affected side
generalized wheezing, inspiratory stridor, hoarse
CXR: hyperinflation in partial obstructions, or
atelectasis in complete obstructions
Dx & Rx: rigid bronchoscopy
--------------------------------------------------------------- umbilical hernia: MC in A-A infants; reducible,
low risk of incarceration or strangulation
o defects at linea alba, covered by skin
o a/w Beckwith-Wiedemann, hypothyroidism,
o spontaneously resolves by age 5 yr
gastroschisis: protrusion of bowel to the right side
of normal umbilicus; no membrane coverage
o elevated AFP
o Rx: cover with sterile saline dressing &
plastic wrap, NGT, ABX
o surgical repair with single-stage closure

omphalocele: umbilical cord inserts at apex of

defect; covered by peritoneum
o Rx: surgical staged closure with silastic silo
--------------------------------------------------------------- AFP in pregos: a/w open NTD (anencephaly),
ventral wall defects, multiple gestation
Dx: USS, clarify # of fetuses
DDx: HCC, gonadal tumors, viral hepatitis
--------------------------------------------------------------- regression of milestones can be a complication
of previous episode of bacterial meningitis
long-tern neurologic sequelae a/w meningitis
o loss of cognitive function
o hearing loss
o seizures
o mental retardation
o spasticity or paresis
---------------------------------------------------------------Liver disorders of pregnancy
intrahepatic cholestasis of pregnancy
acute fatty liver of pregnancy
--------------------------------------------------------------- life-threatening complication of pre-eclampsia

HELLP Syndrome
Hemolysis: microangiopathic hemolytic anemia,
schistocytes, bilirubin, haptoglobin
Elevated LFTs: AST or ALT x2 upper limit
Low Platelets: < 100,000 L

abnormal placentation triggers systemic

inflammation, with activation of coagulation &
PLT consumption
hepatocellular necrosis cause elevated LFTs,
liver swelling, & distension of Glissons capsule
RUQ or epigastric pain, N/V
proteinuria, elevated LDH
Rx: prompt delivery at 34 wks, Mg-sulfate
o c-section only for normal OB indications
complication: DIC with multi-organ failure
DDx: acute fatty liver of pregnancy, ITP, HUS,
intrahepatic cholestasis, placental abruption

complication of severe preeclampsia: acute

pulmonary edema
acute onset dyspnea, hypoxia, crackles, LE edema
due to generalized arterial vasospasm leading
to SVR & pulmonary capillary pressure
also due to renal function, albumin, &
vascular permeability
Rx: supplemental O2, fluid restriction, &
diuretics with caution due to third-spacing
--------------------------------------------------------------- intrahepatic cholestasis of pregnancy: functional
disorder of bile formation during 2nd & 3rd trimester
intense pruritus on palms & soles, worse at night
bile acids; hyperbilirubinemia; no jaundice
aminotransferases x10 (r/o viral hepatitis)
Dx of exclusion
Rx: symptomatic, pruritus resolves after delivery;
ursodeoxycholic acid may be helpful
--------------------------------------------------------------- acute fatty liver of pregnancy: acute hepatic
failure in 3rd trimester; due to acute microvesicular
fatty infiltration of hepatocytes
N/V, abdominal pain
significantly elevated LFTs, prolonged PT & PTT,
hypoglycemia, leukocytosis, encephalopathy
Rx: prompt delivery
--------------------------------------------------------------- Dresslers: pericarditis presenting weeks months
post-MI; immune-mediated
chest pain, worse with deep inspiration,
improves by leaning forward
elevated ESR
EKG: diffuse ST elevation, except aVR;
consistent with pericarditis
Rx: NSAIDs; corticosteroids for refractory cases
--------------------------------------------------------------- primary Raynaud phenomenon: vascular
response to cold temp or emotional stress
symmetric episodic attacks; women age < 30
absence of peripheral vascular disease, tissue injury,
or abnormal nailfold capillary exam
Rx: CCB (nifedipine, amlodipine) & avoid
aggravating factors, smoking cessation

secondary Raynauds: a/w connective tissue dz

asymmetric attacks; males, age > 40
tissue ischemia & digital ulcers
work-up: ANA, RF, ESR
Rx: underlying cause, CCB
--------------------------------------------------------------- Tourette disorder: multiple motor tics & at least 1
vocal tic; must persist for 1 yr after initial onset
before age 18; exacerbated by stress
a/w comorbid OCD & ADHD
Rx: risperidone & habit reversal training
only haloperidol & pimozide are FDA-approved
--------------------------------------------------------------- pleuritic chest pain, dyspnea, tachypnea,
tachycardia in a long-distance truck driver: PE
CXR has poor sensitivity & specificity, but can
exclude other causes of chest pain & dyspnea
DDx for chest pain & dyspnea: acute MI,
pneumonia, pneumothorax, aortic dissection,
pericardial effusion, peptic ulcer perforation
--------------------------------------------------------------- very large PEs may cause hypotension due to
acute RV failure
--------------------------------------------------------------- SIRS: non-infectious causes of sepsis
two out of four criteria
a/w pancreatitis, autoimmune dz, vasculitis, burns
Systemic Inflammatory Response Syndrome (SIRS)
Temp 38.5C (101.3F) or 35C (95F)
Pulse 90 bpm
RR 20/min
WBC 12,000, 4000 cells/mm3, or 10% bands
sepsis: SIRS with known infection
o infection or injury leading to inflammation
& dysregulated host response
o severe sepsis = end-organ dysfunction
(hypotension, thrombocytopenia, oliguria,
metabolic acidosis, hypoxemia)
--------------------------------------------------------------- patients with severe burns manifest evidence of
SIRS & hypermetabolic response in the 1st week

if significant total body surface area burns, major

cause of morbidity/mortality is hypovolemic shock
in the setting of adequate fluid resuscitation,
bacterial infection (bronco pneumonia or burn
wound infection) leading to sepsis & septic shock
are pneumonia & wound infections
MCC: S. aureus & P. aeruginosa
criteria indicating development of sepsis:
worsening hyperglycemia (worsening insulin
resistance), leukocytosis, thrombocytopenia,
hyperthermia, tachypnea, tachycardia
following a severe burn injury, in circulating
cortisol & catecholamines cause protein losses as
muscle degradation is used for gluconeogenesis;
extensive protein breakdown is a normal response
= hypermetabolic phase
--------------------------------------------------------------- weakness, cold intolerance, hoarseness, dry skin,
constipation, depression, menorrhagia,
bradycardia, myxedema: hypothyroidism
--------------------------------------------------------------- plasmapheresis removes pathogenic autoantibodies:
--------------------------------------------------------------- S. aureus is MCC of lactational mastitis
Dx: based on history & exam
Rx: nurse every 2 to 3 hours; direct feeding with
both breasts to completely drains milk ducts
Rx: ibuprofen, frequent feeding/pumping, ABX
empiric Rx for MSSA: dicloxacillin, cephalexin
empiric Rx for MRSA: clindamycin, TMP-SMX,
or vancomycin
--------------------------------------------------------------- benztropine: Rx/prevent EPS a/w antipsychotics
clozapine: Rx treatment-resistant schizophrenia
methylphenidate: Rx ADHD
--------------------------------------------------------------- Duchenne muscular dystrophy: age 2 5 yrs,
X-linked recessive, B/L calf pseudohypertrophy
screening: serum creatine kinase & aldolase
fibrosis & fatty infiltration on calf muscle biopsy
support the Dx
confirm Dx: genetic studies show deletion of
dystrophin gene

progressive dyspnea, exercise tolerance, a-fib

with rapid ventricular response, LV systolic dysFx:
tachycardia-mediated cardiomyopathy
develops in patients with persistent or recurrent
tachyarrhythmias with prolonged periods of
rapid ventricular rate (a-fib, a-flutter, AVNRT)
Rx: aggressive rate or rhythm control using
AV nodal blocking agents, antiarrhythmics, or
catheter ablation
--------------------------------------------------------------- infants with hydrocephalus may present with
the following findings:

poor feeding
decreased activity

physical findings
tense & bulging fontanelle
prominent scalp veins
widely spaced cranial sutures
rapidly increasing circumference

Dx: brain CT scan

o USS requires a widely open anterior fontanelle;
infants < age 6 months
lumbar puncture for suspected meningitis
skull radiograph to evaluate abnormal head shape
phosphate PTH

10 hyper-PTH


normal normal
normal osteoporosis/Pagets
--------------------------------------------------------------- osteomalacia due to vitamin D deficiency:
o mildly low serum Ca++
o marked hypophosphatemia
o PTH & alkaline phosphatase
o low plasma 25-OH vitamin D
o decreased urinary Ca++
secondary hypo-PTH brings serum Ca++ to
normal/near-normal by increasing bone & renal
Ca++ reabsorption & urinary phosphate
bone pain, muscle weakness, cramps
causes: malabsorption (Crohns, Celiac), GI
bypass surgery, chronic liver/kidney disease

XR: reduced bone density, thinning cortex,

symmetric pseudofratures (Looser zones)
--------------------------------------------------------------- 2 major treatment issues for all new-onset a-fib
1. rate or rhythm control strategy
2. risk assessment of systemic embolization
CHA2-DS2-VASc score: assesses long-term
stroke risk in patients with non-valvular a-fib
o score 0: low risk, no therapy
o score 1: intermediate risk, no therapy or
ASA or oral anticoagulation
o score 2: high risk, oral anticoagulation
warfarin reduces risk of embolization in groups
at moderate- to high-risk of thromboembolism

CHA2-DS2-VASc score
Age 75
vascular disease (prior-MI, 1
PAD, aortic plaque)
Age 65 74
Max score
--------------------------------------------------------------- DM Type 2 a/w physiologic stressor (infection)
are prone to nonketotic hyperosmolar syndrome
risk factors: URI, MI, stroke, trauma, burns
stress causes catecholamines & cortisol, both
insulin counterregulatory hormones
severe hyperglycemia (> 600 mg/dL), with
resultant osmotic diuresis, causes dehydration
& serum hyperosmolarity (> 320 mOsm/L)
altered consciousness (confusion) & acute onset
of blurred vision are common
#1 Rx: IV fluids can reduce hyperglycemia
o if hypovolemic: NS until euvolemic, then
replace with 0.45% saline
#2 Rx: insulin
#3 Rx: K+ supplementation once K+ reaches
normal levels
DDx: cataracts, diabetic retinopathy, uveitis

--------------------------------------------------------------- altered mental status, volume depletion, polyuria:

hyperosmolar hyperglycemic state (HHS)
hyponatremia in HHS is due to osmotic shift of
H2O into extracellular space & Na+ renal loss
from osmotic diuresis
Type I diabetics
Type II diabetics
younger age
older age
rapid onset of symptoms
gradual symptoms onset
altered mental status
abdominal pain
neurologic symptoms
glucose 250 500 mg/dL
glucose > 600 mg/dL
bicarbonate < 18 mEq/L
bicarbonate > 18 mEq/L
anion gap metab. acidosis
normal anion gap
negative ketones
serum Osm < 320
serum Osm > 320
total body K+ deficit due to osmotic diuresis
Thiazides can precipitate HHS by reducing
intravascular volume, thus GFR, leads to
decreased renal glucose excretion
osmolality leads to altered mentation, lethargy, &
Dx: serum glucose, plasma Osm, absent ketonemia
--------------------------------------------------------------- best markers for resolution of DKA
o serum anion gap
o beta-hydroxybutyrate assay (ketones)
measure serum glucose every hour
measure electrolytes & anion gap every 2 4 hr

Management of DKA & HHS

high-flow 0.9% NS; change to D5% in
0.45% @ serum glucose < 200 mg/dL
initial continuous IV infusion;
switch to SC when patient is able to eat,
glucose < 200, anion gap < 12, or
HCO3 > 15
if < 5.2 mEq/L
HCO3only if pH < 6.9
phosphate if phosphate < 1.0, cardiac dysFx, or
respiratory depression,
monitor serum Ca++
IV fluids

--------------------------------------------------------------- cataracts can manifest in chronic diabetics with

suboptimal glycemic control
gradual accumulation of intralenticular sorbitol
--------------------------------------------------------------- unexplained thrombocytopenia & hemolytic anemia
in a patient with renal failure & neuro deficits
(headache, confusion): TTP-HUS
o schistocytes are characteristic
idiopathic TTP-HUS: ADAMTS-13 deficiency, a
von Willebrand factor cleaving protease;
accumulation of large von Willebrand factor
multimers & PLTs
Rx: plasmapheresis (removes autoantibodies &
repletes ADAMTS-13)
o PLT transfusion is contraindicated
--------------------------------------------------------------- advanced COPD: supplemental O2 improves
hypoxia, but worsens hypercapnia due to
1) increased dead space perfusion & loss of
compensatory vasoconstriction worsens
V/Q mismatch
2) decreased affinity of oxyHb for CO2;
reduces uptake of CO2 from tissue
3) reduced alveolar ventilation due to
decreased respiratory drive; slows RR
lethargy, confusion, seizures (reflex cerebral
--------------------------------------------------------------- pre-existing atopic dermatitis (eczema)
increases risk for latex allergy
--------------------------------------------------------------- adrenal insufficiency should be suspected in
patients who becomes suddenly hypotensive
under stress (surgery)
--------------------------------------------------------------- risk factors for aspiration pneumonia include
altered consciousness due to excessive alcohol,
neurologic dysphagia, disruption of GE junction
(GERD), mechanical disruption of glottis closure
recurrent pneumonia involving same lung region
is 2/2: bronchial obstruction or recurrent aspiration
CXR: infiltrate in lower or posterior upper lobes
Dx: chest CT scan

humoral immune deficiency leads to impaired

antibody production; presents with recurrent,
upper & lower RTI due to encapsulated bacteria
--------------------------------------------------------------- MCC of hypernatremia is hypovolemia
mild cases: 5% dextrose in 0.45% saline
severe cases (mental status changes): 0.9% saline
initially (isotonic saline is hypoosmolar compared
to the hypernatremic plasma); once volume deficit
is restored, switch to 0.45% saline
plasma Na+ correction 1 mEq/L/hr; rapid correction
of hypernatremia leads to cerebral edema
--------------------------------------------------------------- 5% dextrose in water (D5W): Rx euvolemic &
hypervolemic hypernatremia
IV free water can cause RBC lysis due to
osmotic shock
--------------------------------------------------------------- isolated, symmetric lower extremity weakness,
loss of sensation & UMN signs: spinal cord
causes: disk herniation, abscess, malignancy
epidural abscess is common with IVDA
Dx: spine MRI; medical emergency!
o lumbar puncture is contraindicated for
possible epidural abscess
Rx: high-dose IV glucocorticoids
--------------------------------------------------------------- acute Lyme disease: erythema migrans,
headache, arthralgia, myalgia
late disseminated Lyme disease (months/yrs) can
manifest as subacute encephalopathy
--------------------------------------------------------------- Becks Triad (hypotension, JVD, muffled heart
sounds) suggests cardiac tamponade
MC: viral pericarditis due to recent viral URI
due to an exaggerated shift of the interventricular
septum towards the left ventricular cavity which
reduces LV preload, stroke & C.O.
clear lungs, pulsus paradoxus, hepatojugular reflux;
worsens with inspiration
--------------------------------------------------------------- pulmonary HTN can be due to pulmonary
arterial pressure (primary pulmonary HTN), or
pulmonary venous pressure (LV failure)

loud S2
--------------------------------------------------------------- macrovesicular steatosis, polymorphonuclear
infiltrates, & necrosis in a non-drinker:
nonalcoholic steaohepatitis (NASH)
risk factors: obesity, DM, hypertriglyceridemia,
medications, TPN, endocrinopathies
impaired responsiveness to insulin causes fat
accumulation in the liver, progressing to fibrosis
& steatohepatitis; 2/2 lipid peroxidation &
oxidative stress
hepatomegaly is common, mild LFT elevations
Dx: percutaneous liver biopsy
complications: hepatic fibrosis, cirrhosis
Rx: treat underlying conditions,
ursodeoxycholic acid to improve LFTs
--------------------------------------------------------------- cyclosporine & tacrolimus: calcineurin-inhibitors
both: nephrotoxic, HTN, hyperkalemia, tremor
cyclosporine A/E: gum hypertrophy & hirsutism
--------------------------------------------------------------- azathioprine A/E : dose-related marrow suppression,
leukopenia, hepatotoxic, pancreatitis
mycophenolate A/E: bone marrow suppression
glucocorticoid A/E: Cushings, osteoporosis,
poor wound healing, adrenocortical atrophy
--------------------------------------------------------------- female, jaundice, marked pruritus, +AMA:
primary biliary cirrhosis
noncaseating granulomatous inflammation
portal tracts are infiltrated by lymphocytes,
macrophages, plasma cells, eosinophils
portal tract scarring & bridging fibrosis leads to
cirrhosis; a/w ductopenia of intrahepatic ducts
--------------------------------------------------------------- inflammation, fibrosis, & stricturing of
intrahepatic & extrahepatic bile ducts
Primary sclerosing cholangitis
fatigue & pruritus, or asymptomatic
a/w comorbid ulcerative colitis
labs, imaging cholestatic pattern: LFTs, ALP
liver Bx
fibrous obliteration of small bile ducts,

concentric replacement by connective

tissue = onion skin pattern
cholangiogram: periductal portal tract
fibrosis; segmental stenosis of
extrahepatic & intrahepatic bile ducts
ursodeoxycholic acid,
liver transplant
complications biliary stricture,
cholangitis, cholelithiasis, cholestasis
end-stage liver disease, portal HTN
cholangiocarcinoma, colon cancer
cholangiogram: ERCP or MRCP
--------------------------------------------------------------- asymptomatic bacteriuria in pregos risk of
cystitis, pyelonephritis, low birth weight,
prematurity, & perinatal mortality
MCC is E. coli
screen all pregos @ 12 16 wks gestation
Dx: positive urine culture 100,000 colonies/mL
without symptoms of cystitis
Rx options
o nitrofurantoin 5 - 7 days
o amoxicillin or augmentin 3 - 7 days
o fosfomycin as a single dose
fluoroquinolones (fetal cartilage abnormalities)
& TMP-SMX should be avoided
F/U urine culture after one week to document
resolution of bacteriuria, then monthly for the
duration of pregnancy to monitor recurrent infections
--------------------------------------------------------------- benign growths with a waxy, well-circumscribed
stuck on, appearance: seborrheic keratosis
o Dx: clinical appearance; no therapy
sudden onset of multiple occurrence may
indicate occult internal malignancy
papulosquamous patches with a fine, loose, &
greasy yellow scale on an erythematous base:
seborrheic dermatitis
o scalp, central face, eyebrows, nasolabial folds
o all age groups; infant cradle cap
o MC a/w Parkinsons, HIV
o Rx: moisturizer, antifungals, dandruff shampoo
dry, scaly papules with an erythematous base &
central scale; sandpaper-like; may turn into
cutaneous horns: actinic keratosis

o genetically predisposed @ age 40 60

o excessive sun exposure; premalignant for SCC
patchy, fine, white, adherent scales on the scalp:
tinea capitis
o Rx: oral griseofulvin
pruritic ring-shaped, scaly, erythematous rash
with central clearing: tinea corporis
o MCC: Trichophyton rubrum
o Dx: KOH reveals hyphae
o Rx: topical antifungals (terbinafine) or
griseofulvin (extensive disease)
recurrent, pruritic, eczematous eruption on flexors
& extensor surfaces: atopic dermatitis (eczema)
o Type I hypersensitivity
o light microscopy: spongiosis
erythematous, pruritic vesicles & edema 2/2 to
contact with allergen/irritant: contact dermatitis
salmon-colored, sharply demarcated, scaling lesions
that coalesce into oval plaques on extensors,
covered by a thick silvery scale: psoriasis
slow-growing papule or nodule with a pearly
rolled border & overlying telangiectasia with
ulceration: basal cell carcinoma
solitary, firm, reddish, dome-shaped nodule &
central keratinous plug: keratoacanthoma
smooth-surfaced, dome-shaped melanocytic plaque
< 1 cm with blue color: blue nevi

skin tag, flesh-colored or pedunculated papules

in high friction regions: acrochordon
--------------------------------------------------------------- rosy hue with telangiectasia on cheeks, nose, chin,
& scalp; 30 60 y/o: rosacea
chronic inflammatory disorder
intermittent flushing precipitated by hot drinks,
heat, emotion, rapid body temp changes
papules & pustules may be present
Rx: metronidazole or laser surgery
---------------------------------------------------------------Clinical features of melanoma (screening)
Border irregularities
Color variegation
Diameter 6 cm
Evolving size, shape, color

---------------------------------------------------------------Tinea capitis
dermatophyte infection, MC in A-A children
feature scaly erythematous patch on scalp,
alopecia with residual black dot,
transmission: human-human or fomite
clinical; KOH of hair shaft: spores
oral griseofulvin,
household contacts: selenium sulfide or
ketoconazole shampoo
--------------------------------------------------------------- flank pain, N/V, fever 38C (100.4F), CVA
tenderness: acute pyelonephritis in pregnancy
Rx: hospitalization for IV ABX (ceftriaxone),
then switch to oral ABX for 10 - 14 days after
being afebrile for 24 hours
avoid aminoglycosides in pregnancy
--------------------------------------------------------------- Whipples disease: rare, multi-systemic illness
Tropheryma whippelii (G+ bacillus)
white males, age 40 - 60
chronic malabsorptive diarrhea (weight loss,
steatorrhea, flatulence, distension)
intermittent low-grade fever, chronic cough,
pigmentation, lymphadenopathy
migratory polyarthropathy, myocardial/valvular
involvement leads to CHF or regurgitation
late stage: dementia, ophthalmoplegia, myoclonus
PAS-positive macrophages in lamina propria
of small intestine biopsy
DDx: Celiacs, Crohns, cystic fibrosis, HIV
--------------------------------------------------------------- gallstones & chronic alcohol abuse are MCC of
acute pancreatitis
o other etiologies: hyperlipidemia, medications,
infections, trauma, iatrogenic (post-ERCP)
Dx requires 2 out of 3 criteria: acute epigastric pain
radiating to back, lipase 3x normal, imaging
o imaging not necessary if first two criteria met
Dx: abdominal USS to evaluate for
cholelithiasis or choledocholithiasis
o equivocal USS endoscopic USS or ERCP
abdominal CT is used for those who fail to
improve with conservative Rx for pancreatitis

HIDA scan to diagnose acute cholecystitis if

USS is non-diagnostic
complications: pleural effusion, ileus, ARDS,
pancreatic pseudocyst/abscess/necrosis, ARF
--------------------------------------------------------------- HIV a/w fever, malabsorptive diarrhea, weight loss:
Mycobacterium avium-intracellulare
PAS-positive macrophage & acid-fast
--------------------------------------------------------------- intussusception: ileocecal junction is MC
preceding viral infection (gastroenteritis) inflames
intestinal lymphatic tissue (Peyer patches) can
serve as a lead point
risk factors: Meckels, polyps, rotavirus vaccine,
hematomas (Henoch-Schonlein purpura)
periodic abdominal pain with drawing up the legs
emesis may follow episodes of abdominal pain
ongoing obstruction causes mucosal ischemia,
leading to currant jelly stools
RUQ sausage-shaped mass
Dx: abdominal USS shows target sign
Rx: air enema (or water-soluble contrast)
complications: bowel necrosis
--------------------------------------------------------------- hypercalcemia of malignancy: 80% due to
PTHrP production
breast cancer MC 2/2 locally produced PTHrP
via bone metastasis
metastatic tumor cells do not directly cause
bone resorption, but secrete factors that
activate osteoclasts
ectopic PTH is a rare cause
--------------------------------------------------------------- Technetium-99m scan can detect gastric mucosa
in Meckels diverticulum
--------------------------------------------------------------- COPD have increased TLC, FRC, & RV leading
to hyperinflation & diaphragmatic flattening,
thus increases work of breathing
lung hyperinflation preserves max expiratory
airflow as higher lung volume increases elastic
recoil pressure, thus more difficult to decrease
intrathoracic pressure during inhalation
Rx: lung volume reduction surgery

Schizoaffective disorder: significant manic

episodes with concurrent psychotic symptoms &
at least 2 weeks without mood symptoms
delusions/hallucinations 2 wks in absence
of major mood episode (depressive or manic)
mood symptoms present for majority of illness
o bipolar disorder or major depression with
psychotic features: psychotic symptoms
occur only during mood episodes
o schizophrenia: absence of mood symptoms
--------------------------------------------------------------- schizophreniform: > 1 month, but < 6 months
schizophrenia: > 6 months
--------------------------------------------------------------- maculopapular eruption on wrists & ankles,
spreads to trunk, extremities, palms & soles on
day 5: rickettsial infection
fever, conjunctivitis, headache, diffuse myalgias
--------------------------------------------------------------- erythema, edema, severe pruritus, vesicles &
weepy crusted lesions 24 48 hr after contact
with an allergen: contact dermatitis
cell-mediated hypersensitivity (Type IV)
involves T-cell activation
due to allergic reaction or chemical irritant
requires sensitization before a reaction develops
antigen is presented to sensitized lymphocytes,
which release cytokines within 24 48 hr
Rx: topical glucocorticoids
also seen in PPD skin test, SJS/TEN
--------------------------------------------------------------- Type I hypersensitivity: IgE- mediated; allergen
binds & cross-links IgE molecules on a mast cell
releases vasoactive substances
causes mast cell & basophil degranulation
atopy, urticaria, anaphylaxis
--------------------------------------------------------------- Type II hypersensitivity: antibody-mediated;
cytotoxic reaction of IgG or IgM to cell antigens
leads to complement activation & cell damage
Rh hemolytic anemia of newborns

Type III hypersensitivity: immune-complex

mediated; antibodies of IgG or IgM form
complexes with antigens to activate complement
Serum sickness, Arthus reaction, drug fever
--------------------------------------------------------------- prodrome fever & influenza-like symptoms,
conjunctivitis, mucositis, mucocutaneous lesions,
erythematous & pruritic macules, desquamation &
bullae progressing to epidermal necrosis &
sloughing, +Nikolsky sign: SJS
inflammatory hypersensitivity reaction
< 10% of body surface area = SJS
> 30% = Toxic epidermal necrolysis (TEN)
triggers: allopurinol, sulfonamides, lamotrigine,
phenytoin, carbamazepine, NSAIDs, sulfadiazine,
Mycoplasma pneumo, vaccination, GVHD
Rx: supportive, wound care, IV fluids
--------------------------------------------------------------- asymmetric tingling & burning of the hand a/w
vesicular rash: herpetic whitlow
inoculation of HSV 1 or 2 by direct contact with
orotracheal secretions via broken skin
non-purulent vesicles on volar hand
Dx: Hx of exposure & multinucleated giant cells
on Tzank smear
Rx: self-limited; oral acyclovir
--------------------------------------------------------------- cutaneous flushing & intense generalized pruritus:
A/E of high-dose niacin therapy for
prostaglandin-induced peripheral vasodilatation
Rx: prevented with low-dose ASA, taken 30 min
prior to niacin
--------------------------------------------------------------- painless chancres that resolves in 3 6 wks:
primary syphilis
o recurs weeks/months later as 20 syphilis
fever, malaise, sore throat, lymphadenopathy,
diffuse maculoopapular rash on the trunk that
spread peripherally to extremities + palms & soles,
condyloma lata: secondary syphilis
Rx: IM benzathine penicillin
o A/E: Jarisch-Herxheimer reaction (acute
febrile reaction with headache & myalgias)
non-prego, PCN-allergic: doxycycline x14 days

Rx pregos: PCN
o PCN-allergic should confirm with skin testing,
then undergo PCN desensitization
DDx: cutaneous drug reaction. pityriasis rosea,
psoriasis, rickettsial infection
--------------------------------------------------------------- black stool, epigastric pain, nausea, pain relieved
with food, weight gain: PUD
MCC: H. pylori or NSAIDs
duodenal ulcer symptoms occur in absence of
food buffers (2 -5 hr after meals, nighttime)
PUD is MCC of melena
Dx: upper endoscopy
DDx: gastric cancer, colon cancer, diverticulosis,
inflammatory bowel disease, ischemic colitis,
mesenteric ischemia
--------------------------------------------------------------- ischemic colitis: inflammation & injury of the
colon result from inadequate blood supply
a/w procedures on aortoiliac vessels
MC @ splenic flexure
abdominal pain, fever, vomiting; followed by
hematochezia or bloody diarrhea within 24 hr
risk factor: atherosclerosis
Dx: colonoscopy or flexible sigmoidoscopy
--------------------------------------------------------------- mesenteric ischemia: injury of small intestine
occurs due to inadequate blood supply
abdominal pain out of proportion to relatively
normal physical exam
pain exacerbated by eating, bloody diarrhea,
food aversion, weight loss
risk factors: atherosclerosis, a-fib, heart failure,
CRF, risk of forming blood clots, previous MI
Dx: angiography
--------------------------------------------------------------- megaloblastic (impaired DNA synthesis due to
B12 or folate deficiency) vs. nonmegaloblastic
(alcoholism, hypothyroidism, liver disease)
macrocytic anemia
o MCV & MCH, normal MCHC
megaloblastic: MCV > 110, low reticulocytes,
macroovalocytes, hypersegmented neutrophils,
anisiocytosis, poikilocytosis
nonmegaloblastic: reticulocyte count varies

alcoholism can also cause basophilic stippling;

nonspecific to lead poisoning & Thalassemias
--------------------------------------------------------------- all patients with hypotension/shock after MVA
should be presumed to have hypovolemic shock
PCWP at baseline & increases after saline
infusion without systolic BP change: myocardial
o LV dysfunction results in filling pressures
Dx: urgent echocardiogram
--------------------------------------------------------------- anaphylaxis: a type of distributive/vasodilatory
shock due to severely decreased SVR
o /normal PCWP, improves with fluids
hypovolemic shock: C.O., SVR
o PCWP at baseline, improves with fluids
--------------------------------------------------------------- tension pneumothorax after MVA can present
with hypotension & shock due to extracardiac
compression of the right/left ventricle
PCWP is /normal, only slight change with fluids
--------------------------------------------------------------- massive PE after MVA (air/fat embolism) can
lead to hypotension & shock
PCWP is /normal; minimal change with fluids
---------------------------------------------------------------Gross painless hematuria
initial test: U/A to rule out UTI & confirm
bladder tumors are MC malignancy a/w
painless hematuria in age > 35 & smoking Hx
o Dx: CT urogram & cystoscopy
DDx: neoplasms, infection, trauma, ADPKD,
nephrolithiasis, glomerulonephritis, BPH
--------------------------------------------------------------- obesity is a common cause of amenorrhea
secondary to anovulation
anovulation: FSH/LH are normal, ovaries are
producing estrogen, but progesterone is not
produced at normal post-ovulation levels, thus
progesterone withdrawal menses does not occur
--------------------------------------------------------------- premature ovarian failure: FSH > LH; age < 40
---------------------------------------------------------------Pulmonary auscultation findings



TVF Percussn Mdstinum

bronchial breath sounds ( expiratory)
crackles, egophony ( sound transmission),
bronchophony, whisper pectoriloquy




sound travels faster in solids (consolidation),

resulting in increased TVF in lobar pneumonia
consolidation presents with bronchial breath sounds,
airway patency causes over-transmission of sound
consolidation does not cause blunting of the
costophrenic angles
--------------------------------------------------------------- Torsades de pointes due to prolonged QT
Rx: Mg++ sulfate
--------------------------------------------------------------- CNS, cardiac, & anticholinergic abnormalities
altered mental status, hypotension, hyperthermia,
miosis, urinary retention,: TCA overdose
decreases myocardial conduction velocity, leads to
prolonged QRS & risk of ventricular arrhythmia
Rx: ABCs, supplemental O2, IV fluids
activated charcoal if within 2 hr of ingestion
Rx: sodium bicarbonate improves systolic BP,
shortens QRS, & prevents arrhythmias
QRS > 100 msec is an indication for NaHCO3
Rx: benzos for seizures 2/2 GABA Rc inhibition
--------------------------------------------------------------- intrauterine fetal death < 20 wk gestation; retained
products of conception, non-viable: missed
o closed cervix; Dx: transvaginal USS
any hemorrhage before 20th week of gestation with
active fetal heart tones: threatened abortion
o closed cervix, no passage of fetal tissue
vaginal discharge of blood/tissue, abdo cramps,
partial expulsion: incomplete abortion
o dilated cervix; retain conception products

vaginal bleeding, abdo cramps radiates to the back

& perineum, dilated cervix: inevitable abortion
o ruptured/collapsed gestational sac
o no fetal cardiac motion on USS
acute onset abdo pain, dark red vaginal bleed in the
1st trimester, adnexal mass: ectopic pregnancy
o no gestational sac in uterus on USS
fever, malaise, foul-vaginal discharge, uterine &
cervical motion tenderness: septic abortion
o infection of retained products of conception
o MC with induced abortions
Rx: suction curettage, IV fluids, IV ABX
o Rx: hysterectomy for severe cases
1st trimester vaginal hemorrhage a/w expulsion
of vesicles, N/V, enlarged uterus: molar prego
o -hCG, no fetal heart tones
--------------------------------------------------------------- Rx threatened abortion
o ascertain fetus is present & alive with USS
o reassurance & F/U USS in one week
no hospitalization required
--------------------------------------------------------------- hyperkalemia: peaked T-wave, followed by PR
& QRS lengthening; eventually bradycardia &
sine wave pattern
Rx: calcium gluconate (rapid, but transient)
--------------------------------------------------------------- smoking cessation has the greatest impact on
decreasing risk of pancreatic cancer
hereditary risk factors: hereditary pancreatitis,
pancreatic cancer in 1st degree relative, germline
mutation (BRCA 1/2, Peutz-Jegher)
environmental: obesity, low physical activity,
chronic pancreatitis
alcohol or caffeine reduction, & glycemic control
do not significantly incidence of pancreatic ca
---------------------------------------------------------------Causes of neonatal bacterial sepsis
Group B Strep,
MC of early- & late-onset sepsis
E. coli
(preterm MC due to E.coli)
S. aureus
skin, bone, or joint infections
early-onset sepsis during outbreaks
preterm infants
Coagulaseindwelling umbilical venous catheters

negative Staph
in neonatal ICU
(S. epidermidis)
other Gram(Klebsiella, Enterobacter, Pseudomonas)
late-onset sepsis, ICU
hypotonia, full/bulging fontanelles, nuchal rigidity,
seizures: bacterial meningitis
poor feeding, lethargy, hyper- or hypothermia,
respiratory distress, vomiting, jaundice: sepsis
neonatal sepsis: infants < 28 days old
o early-onset: age < 3 7 days
preterm infants: more likely hypothermic
MC infection during passage through birth canal
Dx: CBC, blood cultures PRIOR to ABX
(ampicillin + gentamicin) without waiting for LP
neutrophilia with significant left shift indicates
neonatal sepsis from bacterial infection
neonates have low risk of herniation after LP due
to their open fontanelles; head CT not required
--------------------------------------------------------------- Group B Strep: MC neonatal infection acquired
by exposure to amniotic fluid after ROM
screening: 3 -5 wks prior to estimated delivery
(@ 35 37 wks); vagina & rectum cultures
GBS negative status do not need prophylaxis for
prolonged ROM > 18 hr
ABX prophylaxis in labor without testing if
o Hx of GBS bacteriuria
o prior birth to infant with GBS
missed screening or unknown GBS status is
treated in labor if
o < 37 wks gestation
o intrapartum fever
o ROM > 18 hr
Rx: PCN (prophylaxis 4 hr prior to delivery)
--------------------------------------------------------------- neonatal HSV encephalitis presents with seizures;
acquired from infected genital tract
--------------------------------------------------------------- fever, headache, stiff neck nausea, hypotension:
meningococcal meningitis
MC in age 3 yr to adolescence; high contagious
myalgia is common

petechial or purpuric rash within 24 hrs on the

axilla, wrists, flanks, ankles
Rx: isolation, IV ABX, ICU setting
--------------------------------------------------------------- jaundice, maculopapular rash, microcephaly,
chorioretinitis, hepatosplenomegaly, hydrocephalus,
intracranial calcifications: congenital toxoplasmosis
maternal infection by feces of infected cats, ingest
infected raw meat, or unpasteurized goats milk
--------------------------------------------------------------- midshaft humerus fracture is a/w radial nerve,
passes via radial groove on the posterior humerus
o a/w wrist drop
supracondylar fracture is a/w brachial artery
o ischemia (pain, pallor, pulselessness,
paresthesia, paralysis)
--------------------------------------------------------------- winged scapula: injury of long thoracic nerve
results in paralysis of serratus anterior muscle
MC after axillary lymphadenectomy for breast ca
--------------------------------------------------------------- hypotension, hyperpigmentation, hyponatremia,
hyperkalemia, eosinophilia, low serum cortisol,
elevated ACTH: primary adrenal insufficiency
MC developed countries: autoimmune adrenalitis
infectious causes: CMV, fungal, TB
a/w autoimmune dz (vitiligo, pernicious anemia)
--------------------------------------------------------------- patients on warfarin can have adrenal hemorrhage
from acute stress (sepsis), even if INR is therapeutic
stress increases ACTH levels, which increase
adrenal blood flow, predisposing to hemorrhage
--------------------------------------------------------------- B/L, lower-extremity pain, occur only at night,
age 2 12 yrs: growing pains
monitor pain for increased frequency/intensity
Rx: observation, reassurance, massage, heat,
stretching, OTC analgesics
DDx: osteoid osteoma, osteosarcoma, osteomyelitis
--------------------------------------------------------------- sclerotic, cortical lesion with a central nidus of
lucency: osteoid osteoma
pain worse at night, unrelated to activity
benign, bone-forming tumor
MC in adolescent males

Rx: NSAIDS (suggestive of Dx); spontaneous

resolution over several years
--------------------------------------------------------------- changing the cutoff point of a quantitative
diagnostic test inversely affects sensitivity &
lower the cutoff INCREASES sensitivity &
decreases specificity (more true positives)
raising the cutoff DECREASES sensitivity &
increases specificity (more true negatives)
--------------------------------------------------------------- recurrent sinopulmonary infections, persistent
diarrhea, oral candidiasis, viral infections: SCID
adenosine deaminase (ADA) deficiency
Dx: absent lymph nodes & tonsils, lymphopenia,
absent thymic shadow on CXR, abnormal T, B,
& natural killer cell count by flow cytometry
--------------------------------------------------------------- Brutons (X-linked) agammablobulinemia:
male infant, asymptomatic until age 6 9 months;
recurrent pyogenic infections (S. pneumo, H.infl)
o decreased IgG, IgA, IgM, IgE, &
absent/decreased B cells
o sinusitis, bronchitis, otitis media, Giardia
CVID presents similar to Brutons, but CVID has
less severe symptoms & later onset (age 15 35 yrs)
o normal circulating B cells
o decreased IgG, IgA, IgM, IgE
--------------------------------------------------------------- thrombocytopenia, eczema, recurrent infections:
Wiskott-Aldrich (WAITER)
XR, defective WASP gene
young boy with eczema, thrombocytopenia,
recurrent encapsulated spp infections
o Strep pneumo, N. meningitidis, H. influenza
@ birth: petechiae, bleeding from circumcision,
bruises, bloody stools
PLT production, small PLTs
low IgM, high IgA & IgE
--------------------------------------------------------------- Chronic granulomatous disease (CGD): defective
phagocytes due to NADPH oxidase dysfunction
impaired oxidative metabolism within phagocytes;
defective intracellular killing

recurrent catalase-positive infections (S.

lymphadenitis, skin abscesses
Gram stain: neutrophils filled with bacteria
Dx: nitro blue tetrazolium test
--------------------------------------------------------------- Chediak-Higashi: chemotaxis, degranulation,
& granulopoiesis
mild coagulopathy, pancytopenia
partial albinism, peripheral & cranial neuropathy,
hepatosplenomegaly, infections (S. aureus),
progressive lymphoproliferative syndrome
Dx: neutropenia, giant lysosomes in neutrophils
Rx: daily TMP-SMX & ascorbic acid
--------------------------------------------------------------- Leukocyte adhesion defect (LAD): failure of
innate host defenses due to defective tethering,
adhesion, & targeting of myeloid leukocytes to
sites of microbial infection
o absence of neutrophils/pus at infection sites
recurrent bacterial infections of skin & mucosal
surfaces, necrotic periodontitis, gingivitis,
delayed umbilical cord separation (> 30 days)
early loss of deciduous & permanent teeth
leukocytosis with neutrophil predominance
cultures: S. aureus, G-negative bacilli
--------------------------------------------------------------- increased gastric residual volume, vomiting, &
abdominal distension in a preterm neonate:
necrotizing enterocolitis (NEC)
risk factors: prematurity, very low birth weight
gut immaturity & exposure to bacterial from
enteral feeds result in inflammation & damage to
bowel wall
XR: pneumatosis intestinalis (intramural air with
train tracks) & air in portal vein
leukocytosis, metabolic acidosis
Rx: decreased rates of NEC in premature infants
who are breastfed
complications: pneumoperitoneum
DDx: duodenal atresia, pyloric stenosis,
---------------------------------------------------------------DDx of delayed passage of meconium
(within 48 hrs)
level of

meconium ileus
meconium ileus results in microcolon
Dx: contrast enema
--------------------------------------------------------------- Hirschsprung disease should be suspected in a
newborn with failure to pass meconium within
48 hr, in the setting of Down syndrome
poor feeding, abdo distension, absent air in rectum
failure of neural crest cell migration in the
rectosigmoid; positive squirt sign on exam
Dx: rectal biopsy show absence of ganglion cells
--------------------------------------------------------------- C3 deficiency predisposes to encapsulated bacteria
C5 C7 deficiency: recurrent Neisseria infections
C1 esterase deficiency: hereditary angioedema
--------------------------------------------------------------- anticholinesterase toxicity due to
organophosphate poisoning
bradycardia, miosis, salivation
Rx: atropine & pralidoxime
--------------------------------------------------------------- hazard ratio: ratio of an event rate occurring in
treatment vs. control group
ratio < 1 = treatment group has lower event rate
ratio > 1 = treatment group has higher event rate
--------------------------------------------------------------- asymptomatic bacteriuria of pregnancy is
treated with ABX to prevent pyelonephritis,
preterm birth, low birth weight, perinatal mortality
risk of pyelonephritis is due to progesterone
causing smooth muscle relaxation, thus ureteral
screen all pregos @ 12 16 wks gestation
Rx: amoxicillin, nitrofurantoin, cephalexin are safe
C/I: tetracycline, fluoroquinolones, TMP-SMX
(interferes with folate metabolism in 1st trimester,
& risk of kernicterus in 3rd trimester)
--------------------------------------------------------------- strongest indicator for future suicide attempt: Hx
of previous attempt(s)
--------------------------------------------------------------- -blocker A/E: worsening of CHF, bradyarrhythmia,
airway resistance (asthma), sexual dysfunction

--------------------------------------------------------------- loop diuretics can cause hearing loss &/or tinnitus

ototoxicity occur with high doses, renal failure, or
combo with other ototoxic drugs (aminoglycosides)
--------------------------------------------------------------- HCTZ/thiazides can cause photosensitivity,
orthostatic hypotension, hypercalcemia
--------------------------------------------------------------- HTN & hypokalemia: 10 hyperaldosteronism
prone to diuretic-induced hypokalemia, resulting
in weakness & muscle cramps
also metabolic alkalosis, mild hypernatremia
no peripheral edema due to spontaneous diuresis
(aldosterone escape)
screening: morning aldosterone:renin ratio
o ratio > 20, with aldosterone > 15 ng/dL
suggests primary hyperaldosteronism
confirm Dx: adrenal suppression testing after
oral saline load
positive result requires adrenal CT
MCC: unilateral adenoma or B/L hyperplasia
Dx: CT scan to confirm unilateral mass; equivocal
results require adrenal venous sampling
U/L adenoma Rx: surgery (#1) or aldosterone
antagonist (spironolactone, eplerenone)
B/L hyperplasia Rx: aldosterone antagonists
--------------------------------------------------------------- spironolactone: aldosterone/progesterone/androgen
Rc antagonist
A/E: libido, gynecomastia, breast tenderness,
menstrual irregularities
eplerenone: selective mineralocorticoid antagonist
--------------------------------------------------------------- dehydration is a risk factor for venous thrombosis
due to hemoconcentration
sudden pleuritic chest pain, cough, dyspnea,
hemoptysis: PE
also tachycardia, tachypnea, & hypoxemia
chest CT: wedge shaped infarction
contrast-enhanced CT: filling defects
CXR: Hamptons hump, Westermark sign
causes transudative & exudative pleural effusion
DDx: TB, PCP, bacterial pneumonia, lung cancer

older patient with rapidly progressive dementia,

myoclonus, akinetic mutism, behavior changes:
Creutzfeldt-Jakob disease (CJD)
triphasic sharp wave complexes on EEG, &/or
14-3-3 CSF proteins
Dx: brain biopsy show spongiform changes
Rx: supportive; death within one year of onset
DDx: ALS, Lewy body dementia, Alzheimers,
NPH, peudodementia
--------------------------------------------------------------- scheduled cholecystectomy is indicated for all
symptomatic gallstones (acute pancreatitis), once
medically stable due to risk of recurrent episodes
Rx poor surgical candidate: ursodeoxycholic acid
asymptomatic gallstones should not be treated,
except morbidly obese undergoing gastric bypass or
presence of porcelain GB
--------------------------------------------------------------- genital HSV eruptions: painful vesicles on an
erythematous base that evolve to shallow,
punched-out ulcerations/erosions
Hx of genital HSV: Rx prophylactic acyclovir or
valacyclovir @ 36 wks to risk of outbreak
during delivery
neonatal HSV risk factors: maternal infection,
vaginal delivery with active lesions
Rx: c-section for pregos with active genital lesions
or prodromal symptoms (burning, pain)
vaginal delivery only in absence of active lesions
--------------------------------------------------------------- burning, localized pain & regional hyperesthesia or
allodynia, in the context of recent cancer therapy:
herpes zoster (shingles)
pain may precede rash by several days
--------------------------------------------------------------- acute arthritis of right knee, fatigue, constipation,
polyuria: pseudogout
hyperparathyroidism predisposes to pseudogout
acute formation of calcium pyrophosphate
dehydrate (CPPD) crystals, leading to
chondrocalcinosis (calcified articular cartilage)
attacks are precipitated by trauma, surgery, illness
Dx: synovial fluid (rhomboid-shaped positively
birefringent crystals)
DDx: gout, septic arthritis

--------------------------------------------------------------- hydroxyapatite: osteoarthritis

monosodium urate: gout
calcium oxalate: renal calculi
struvite: renal calculi; UTI of urease spp (Proteus)
--------------------------------------------------------------- osteoarthritis: non-inflammatory arthritis
age > 50, morning stiffness < 30 min
decreased ROM, stiffness after prolonged rest;
anterior hip pain exacerbated by walking
crepitus, no TTP, no warmth of joint
bony enlargement; Heberden & Bouchard nodes
XR: joint space narrowing, osteophytes,
subchondral sclerosis & subchondral cysts
Rx: weight loss slows OA progression
--------------------------------------------------------------- Rx mild/moderate OA pain: acetaminophen
Rx OA exacerbation: NSAID, intra-articular steroid
Rx OA refractory to NSAID & intra-articular steroid:
--------------------------------------------------------------- recurrent hemarthrosis & skeletal muscle
hemorrhage after mild trauma: hemophilia A & B
menorrhagia & mucosal bleeding is common in
women with von Willebrand disease (AD)
--------------------------------------------------------------- MCC of nephrotic syndrome in children age < 10:
minimal change disease
periorbital edema in the AM, pretibial pitting,
nephrotic range proteinuria, hypoalbuminemia
T-cell mediated injury to podocytes cause
increased permeability to albumin
renal biopsy not required for Dx
Rx: empiric steroids upon suspicion of Dx
o 90% have complete remission of proteinuria
renal biopsy indicated in age > 10, or if
unresponsive to steroid Rx; exclude other causes
--------------------------------------------------------------- bradycardia, miosis, rhonchi, fasciculations,
salivation, lacrimation, urination, defecation:
organophosphate poisoning
Rx: removal of clothing & washing of the skin
prevents transcutaneous absorption
Rx: atropine & pralidoxime

--------------------------------------------------------------- TCA overdose Rx: sodium bicarbonate & EKG

--------------------------------------------------------------- bicuspid aortic valve, aortic coarctation, & aortic
root dilation; risk of aortic dissection: Turners
ovarian dysgenesis; low estrogen & amenorrhea
results in a high FSH/LH & low inhibin
normal GH levels
---------------------------------------------------------------Social anxiety disorder (social phobia)
anxiety about 1 social situations, > 6 months
fear of scrutiny, humiliation, embarrassment
marked functional impairment
generalized social anxiety disorder
o Rx: SSRI (paroxetine) & CBT
performance-only social anxiety disorder
o Rx: propranolol 30 - 60 minutes prior & CBT
o alt: benzodiazepine (avoid if substance abuse)
Buspiron: Rx GAD only, not social anxiety
--------------------------------------------------------------- ischemic cardiac pain can be mistaken for
epigastric pain
SLE & chronic steroid use are risk factors for
accelerated coronary atherosclerosis
exercise stress test without imaging if baseline
EKG is normal
o positive stress test coronary angiography
--------------------------------------------------------------- acute exacerbation of MS Rx: methylprednisone
(high-dose IV corticosteroid)
long-term steroid therapy provides no benefit
& does not prevent future relapses
long-term Rx: beta-interferon can decrease
frequency of acute exacerbations & relapses
o also glatiramer acetate, IV Ig,
cyclophosphamide, or plasmapheresis
--------------------------------------------------------------- MCC of constrictive pericarditis in developing
countries: TB
MCC in the US: viral pericarditis
pericardial scarring & thickening results in
diastolic dysfunction; pericardial calcifications
decreased cardiac output & venous overload

pericardial knock, pulsus paradoxus, Kussmaul

sign, prominent x & y descents
--------------------------------------------------------------- CXR: parenchymal nodules (silicosis)
CXR: pleural plaques (asbestosis)
--------------------------------------------------------------- hard, irregular, fixed breast mass: malignancy
rubbery, firm, freely mobile mass: fibroadenoma
Hx of 1st-degree relative with breast cancer
requires diagnostic (vs. screening) breast imaging
palpable breast mass age < 30: USS
palpable mass age > 30: mammogram, then USS
simple cyst Rx: needle aspiration
complex cyst/solid mass: image-guided core Bx
suspicious malignancy: core needle biopsy
--------------------------------------------------------------- both folate & Vit B12 are involved in conversion
of homocysteine methionine, thus a deficiency
in either results in homocysteine levels
Vit B12 is involved in conversion of
methylmalonyl-CoA succinyl-CoA
Vit B12 deficiency results in methylmalonic acid
--------------------------------------------------------------- haptoglobin binds free Hb to form Hb-haptoglobin
complexes removed by the liver
haptoglobin in hemolytic anemias
--------------------------------------------------------------- alpha-fetoprotein is elevated in HCC &
testicular germ cell tumors
--------------------------------------------------------------- low-grade fever & leukocytosis are common
during the first 24 hr postpartum
intrapartum & postpartum chills are common
lochia rubra (bloody discharge) is characteristic
postpartum; after 3 4 days lochia serosa
(pale) lochia alba (white/yellow)
foul-smelling lochia suggests endometritis
fever & elevated WBCs beyond 24 48 hr
requires UTI work-up: U/A, blood cultures
--------------------------------------------------------------- blunt deceleration trauma (MVA, fall from > 10 ft),
must rule out blunt aortic injury
high mortality rate
Dx: CXR widened mediastinum

DDx: myocardial contusion (tachycardia)

--------------------------------------------------------------- ipsilateral ataxia, nystagmus, intention tremor,
loss of coordination: cerebellar tumor
patient falls/sway TOWARD the lesion side
--------------------------------------------------------------- age > 40, personality change, dementia, chorea:
wide-based gait, steppage gait: Tabes dorsalis
affected arm adducted, affected leg extended; leg
is swung out in a semicircle: hemiparesis/stroke
waddling gait: muscular dystrophy
--------------------------------------------------------------- risk factor for cervical insufficiency: Hx of
maternal OB trauma, prior GYN surgery (LEEP,
cone Bx), multiple gestation, Hx preterm birth,
or 2nd trimester abortion
o Dx: transvaginal USS
risk factors for placental abruption: chronic HTN,
smoking, cocaine use, Hx of maternal trauma, Hx
of external cephalic version
risk factors for uterine rupture: multiparity, Hx
of c-section or myomectomy, adv maternal age,
fetal macrosomia
--------------------------------------------------------------- abdo pain that refers to one or both shoulders
suggests subdiaphragmatic peritonitis due to
irritation of subdiaphragmatic parietal peritoneum
blunt traumatic bladder injuries, bladder dome
is the only region covered by peritoneum, most
susceptible to rupture
MC site of extraperitoneal bladder rupture:
bladder neck
--------------------------------------------------------------- unfractionated heparin is preferred over
enoxaparin (LMWH), fondaparinux, &
rivaroxaban for severe renal insufficiency
reduced renal clearance anti-Xa levels,
thus bleeding risk
monitor unfractionated heparin with aPTT
once therapeutic, initiate warfarin
o warfarin takes 5 7 days to be therapeutic;
must bridge with heparin

Rivaroxaban has immediate onset of action, does

not require bridging with heparin; but no antidote
--------------------------------------------------------------- upper GI bleeding, depressed consciousness level,
& ongoing hematemesis due to esophageal
variceal hemorrhage should first be intubated
Rx: endoscopic band ligation or sclerotherapy
after patient is stabilized & intubated
---------------------------------------------------------------Acute intoxication
appetite, dry mouth,
conjunctival injection,
tachycardia, slow reaction time,
psychomotor impairment (days)
gynecomastia (chronic use)
phencyclidin violent behavior, impulsivity,
hallucinations, amnesia,
dissociation, vertical
mydriasis, ataxia
visual hallucinations,
perceptual intensification,
euphoria, agitation,
formication (cocaine bugs)
chest pain, stroke, MI, seizures
tachycardia, HTN, mydriasis
violent behavior, tooth decay
diaphoresis, tachycardia, HTN,
choreiform movements,
euphoria, miosis,
respiratory depression,
depressed mental state,
constipation, hypotension,
hypothermia, & bradycardia
amphetamin agitation, paranoia, delirium,
palpitations, tachycardia, HTN,
diaphoresis, mydriasis,
seizures, hyperthermia,
intracerebral hemorrhage
slurred speech, unsteady gait,
disinhibition, nystagmus

esophageal perforation MC occurs following

instrumentation of the esophagus
o less commonly due to Boerhaaves
retrosternal pain & crepitus @ suprasternal notch
due to pneumomediastinum
DDx: Mallory-Weiss (self-limited hematemesis)
--------------------------------------------------------------- cat bites: prophylactic augmentin for 5 days
Pasteurella multocida
--------------------------------------------------------------- fluoroquinolones is a/w tendon rupture in children
--------------------------------------------------------------- large thymic silhouette in the anterior mediastinum
is a normal finding on CXR in age < 3 yrs
triangular shape, sail sign, scalloped border
residual thymic tissue can undergo malignant
transformation into a thymoma
DDx: lymphoma
--------------------------------------------------------------- home O2 therapy & smoking cessation have
been shown to decrease mortality in COPD
--------------------------------------------------------------- hyperpigmentation of palmar creases, anorexia,
fatigue, GI complains, weight loss, hypotension:
primary adrenal insufficiency (Addisons)
hyponatremia, hyperkalemia
hyponatremia is due to volume contraction
(aldosterone deficiency) & increased vasopressin
(lack of cortisol suppression)
mild hyperchloremic acidosis
--------------------------------------------------------------- hypernatremia, hypokalemia: Cushings
--------------------------------------------------------------- Wolff-Parkinson-White: accessory pathway
that bypasses AV node; atrioventricular reentrant
tachycardia (AVRT)
persistent a-fib with rapid ventricular response
can deteriorate to v-fib
Rx hemodynamically unstable: cardioversion
Rx hemodynamically stable: procainamide
AV nodal blockers (adenosine, -blocker, CCB,
digoxin) can accessory pathway conduction,
thus worsen WPW

best predictor of opioid intoxication: RR

Rx of severe psychomotor agitation a/w PCP
intoxication: benzo
--------------------------------------------------------------- cocaine withdrawal: dysphoria, appetite,
hypersomnia, difficulty concentrating
opioid withdrawal: yawning, mydriasis,
lacrimation, rhinorrhea, diaphoresis, N/V,
diarrhea, arthralgia, muscle spasms
--------------------------------------------------------------- recurrent fractures, hearing loss, opalescent teeth,
blue sclerae: osteogenesis imperfecta (AD)
normal intelligence, osteopenia
--------------------------------------------------------------- pain, followed by well-demarcated lesions & bullae
with skin necrosis: warfarin-induced necrosis
MC @ breasts, buttocks, thighs, abdomen
a/w protein C deficiency
Rx: vitamin K; discontinue warfarin if lesions
progress, maintain anticoagulation with heparin
--------------------------------------------------------------- worsening renal function, HTN, & distal ischemia
following an invasive arterial procedure:
cholesterol embolization
livedo reticularis on skin exam
--------------------------------------------------------------- plantar warts are due to HPV infection
painful hyperkeratotic papules on the soles
common in young adults & immunocompromised
--------------------------------------------------------------- scaly, erythematous, ulcerated skin lesion that is
slow-growing, non-resolving with irregular growth
on sun-exposed area: squamous cell ca
--------------------------------------------------------------- suspected appendicitis with delayed presentation
(> 5 days) after onset of symptoms: appendiceal
abscess (contained, perforated abscess = phlegmon)
Dx: CT scan
if stable, Rx: hydration & IV ABX, bowel rest,
elective appendectomy
--------------------------------------------------------------- anemia, constipation, weight loss: colon cancer
fever, dysuria, flank pain: pyelonephritis

AV nodal reentry tachycardia (AVNRT) 2 separate

conducting pathways (slow/fast) within AV node
sudden onset & termination, absent P, narrow QRS
--------------------------------------------------------------- abrupt onset of sharply-demarcated, edematous,
erythematous, tender skin lesion with raised border,
& fever: erysipelas
inflammation of superficial dermis
legs most common, or face
MCC: Group A strep
--------------------------------------------------------------- Todds paralysis: focal neurologic deficit
following a seizure
--------------------------------------------------------------- muscle weakness & dry mouth: Lambert-Eaton
a/w lung small cell carcinoma & Hodgkins
antibodies against presynaptic voltage-gated Ca++
channels in motor nerves
muscle response to motor nerve stimulation
increases with repetitive stimulation
diminished/absent DTRs
Rx: plasmapheresis & immunosuppressants
--------------------------------------------------------------- Myasthenia crisis can be exacerbated by RTI
diplopia, ptosis, proximal muscle weakness, &
weakness of bulbar muscles & diaphragm can
lead to respiratory distress
Rx MG with respiratory failure: intubation, then
corticosteroids + IV Ig or plasmapheresis (preferred)
--------------------------------------------------------------- Myasthenic crisis: exacerbation of symptoms due
to undermedication of AChE-ases or infection
Rx: withhold AChE-ase inhibitors
(pyridostigmine), remove respiratory secretions
Cholinergic crisis: exacerbation of symptoms due
to overmedication with AChE-ases
Rx: atropine (anticholinergic, prevents A/E
of AChE inhibitor therapy)
Dx: edrophonium (Tensilon) test (short-acting
o myasthenic crisis improves muscle strength
o MG cholinergic crisis worsens weakness
--------------------------------------------------------------- polyuria & polydipsia are classic for new-onset
Type I DM

bimodal onset: age 4 6 yrs or early puberty

nocturnal enuresis can be a presenting
symptom in toddlers
DDx: UTI, maturational delay of sphincter,
psychological stress, nephrogenic DI
--------------------------------------------------------------- enuresis: urinary incontinence in age 5 yrs
primary enuresis: never achieved dryness
secondary enuresis: return of incontinence after
6 months of dryness
--------------------------------------------------------------- immune-mediated muscle inflammation:
multicentric CNS inflammation & demyelination:
--------------------------------------------------------------- infertility: inability to conceive for > 1 yr
infertility for women age > 35: > 6 months
o MCC of fertility in the 4th decade who are
menstruating: age-related decreased
ovarian reserve
Dx: early follicular phase FSH level, clomiphene
challenge test, or inhibin-B level
DDx: premature ovarian failure (amenorrhea &
menopause before age 40)
--------------------------------------------------------------- rapid & massive increase in transaminases with
modest elevations in total bilirubin & ALP in the
setting of hypotension (septic shock, heart failure):
ischemic hepatic injury
DDx: alcoholic liver disease (AST rarely >300),
acute hepatitis (significant hyperbilirubinemia),
TB, sarcoidosis, acalculous cholecystitis,
autoimmune hepatitis (elevated bilirubin)
--------------------------------------------------------------- if suspicion for subarachnoid hemorrhage is high,
but head CT is negative lumbar puncture
--------------------------------------------------------------- sudden & unexpected travel, confusion about
personal identity, inability to remember the past:
dissociative fugue
episodes of inability to recall important personal
info; related to a traumatic or stressful event:
dissociative amnesia

two or more distinct identities that alternatively

assume control behavior: dissociative identity
disorder (multiple personality disorder)
persistent/recurrent feelings of detachment from
ones own physical or mental processes, with
intact sense of reality; significant impairment:
depersonalization disorder
experiencing familiar persons & surroundings as
if strange or unreal: derealization disorder
--------------------------------------------------------------- proximal DVT of lower extremities; MCC of PE
o continue warfarin for 3 months for patients
with reversible risk factors
o continue warfarin for 6 12 months for
idiopathic DVT
--------------------------------------------------------------- glucose-6-phosphatase deficiency (Von-Gierkes):
Type I glycogen storage disease
affects liver, kidneys, intestinal mucosa
@ age 3 4 months, hypoglycemia, lactic acidosis,
hyperuricemia, hyperlipidemia
doll-like face (fat cheeks), thin extremities,
protuberant abdomen, short stature
hypoglycemic seizures
--------------------------------------------------------------- Acid maltase deficiency (Pompes): Type II
glycogen storage disease
floppy baby with feeding difficulties,
macroglossia, cardiomegaly, hepatomegaly
--------------------------------------------------------------- glycogen debranching enzyme deficiency: Type
III glycogen storage disease
elevated liver transaminases, fasting ketosis,
normal blood lactate & uric acid levels
--------------------------------------------------------------- branching enzyme deficiency: Type IV glycogen
storage disease (amylopectinosis)
age 18 months, hepatosplenomegaly, failure to
thrive, progressive liver cirrhosis
--------------------------------------------------------------- new onset neurologic deficits (confusion),
occipital headaches, Hx of HTN & a-fib &
vascular disease, on warfarin: stroke
Dx: non-contrast head CT
o ischemic stroke not evident until > 24 hrs

o hemorrhagic stroke white hyperdense regions

--------------------------------------------------------------- all patients with B/L carpal tunnel syndrome
(CTS) should be screened with TSH
CTS 2/2 hypothyroidism is a/w deposition of
mucopolysaccharide protein complexes within
perineurium & endoneurium of median nerve;
commonly B/L, more severe
--------------------------------------------------------------- accumulation of fluid can cause CTS in pregos
amyloid fibril deposition causes CTS in systemic
amyloidosis (ESRD, chronic hemodialysis)
soft-tissue enlargement due to synovial edema &
tendon hyperplasia causes CTS in acromegaly
inflammation of tendon & synovial sheaths cause
--------------------------------------------------------------- severe hypovolemic hypernatremia Rx: isotonic
normal saline or lactated Ringers
hypernatremia causes weakness, lethargy, irritability,
altered mental status, seizures, muscle cramps &
decreased DTRs
--------------------------------------------------------------- periodic abdo pain, multiple duodenal ulcers & a
jejunal ulcer: Zollinger-Ellison syndrome
steatorrhea due to pancreatic enzyme inactivation
--------------------------------------------------------------- pancreatic enzyme deficiency: chronic pancreatitis
reduced bile salt absorption: ileal resection
--------------------------------------------------------------- hyperventilation decreases CO2 concentration
promotes vasoconstriction syncope
---------------------------------------------------------------brief psychotic
> 1 day, < 1 month; sudden onset,
return to full function
Schizophreniform > 1 month, < 6 months;
functional decline not required
at least 6 months;
functional decline required
at least 2 week Hx of psychotic
symptoms w/o mood symptoms
1 delusion, at least > 1 month,
no other psychotic symptoms,
normal functioning otherwise

asthma may present with chronic cough (> 8 wk)

that is predominantly nocturnal
Dx: spirometry to asses bronchodilator response
o Methacholine challenge test if no
bronchodilator response is seen
Rx: empiric inhaled glucocorticoids 2 4 wks;
improvement is diagnostic
--------------------------------------------------------------- febrile seizures are common, benign causes of
convulsions in children; no not cause brain injury
risk factors: family Hx of febrile seizures, fever
from infection, recent immunization
Dx: age 6 months 6 yrs, 380C (100.40F), no
previous of afebrile seizure, no CNS infection;
normal neurologic exam
Rx: acetaminophen & reassurance
no hospitalization for observation or work-up
prognosis: normal development & intelligence
--------------------------------------------------------------- #1 Rx of acute variceal bleeding: vascular access
o 2 large bore IV needles or central line
o prophylactic ABX
#2 Rx: control bleeding with terlipressin
(vasopressin analogue), IV octreotide, or
somatostatin (splanchnic vasoconstriction)
Rx within 12 hrs: endoscopic sclerotherapy or
band ligation for active bleeding
o Rx: balloon tamponade is temporary Rx for
uncontrollable bleeding
o Rx: TIPS for refractory or recurrent cases
secondary prophylaxis once bleeding controlled: blocker (propranolol) + endoscopic band ligation 12 wk later
o Rx small, non-bleeding varices
o -blocker decreases progression to large varices
& risk of variceal hemorrhage due to
unopposed alpha-mediated vasoconstriction &
decreased portal venous flow
--------------------------------------------------------------- hydroxyurea: increases HbF
Rx frequent vaso-occlusive crises episodes a/w
sickle cell disease; frequency & severity
also risk of acute chest syndrome & need for
blood transfusions

A/E: myelosuppression (pancytopenia) predisposes

to infection
acute Rx: hydration, analgesia (NSAIDs)
maintenance Rx: folate, pneumococcal vaccine,
PCN until age 5 yrs, hydroxyurea
--------------------------------------------------------------- thyroid storm is triggered by trauma, infection,
surgery, iodine contrast, or childbirth; due to
underdiagnosed or undertreated hyperthyroidism
tachycardia, HTN, arrhythmias (a-fib), high fever,
N/V, tremor, altered mentation, lid lag, goiter
Dx: clinical & thyroid function studies
thyroid storm Rx
o propranolol (symptom control)
o PTU (block new hormone synthesis)
o iodine solution (block hormone release)
o glucocorticoids ( peripheral conversion)
--------------------------------------------------------------- epidural hematomas do not cross suture lines
Rx: emergent craniotomy
--------------------------------------------------------------- glucocorticoids cause neutrophilia by mobilizing
marginated neutrophil pool & bone marrow
also eosinophils & lymphocytes
--------------------------------------------------------------- dark brown discoloration with lymph follicles
shining as pale patches on colon biopsy:
laxative abuse (factitious diarrhea)
o melanosis coli develops within 4 months
--------------------------------------------------------------- PLT dysfunction is MCC of abnormal hemostasis
in patients with chronic renal failure
o abnormal bleeding & bruising
o due to uremic coagulopathy
BT is prolonged (normal PT, PTT, PLT count)
Rx: desmopressin (DDAVP), which increases
release of factor VIII:von Willebrand multimers
from endothelial storage sites
do not transfuse PLTs (quickly become inactive)
--------------------------------------------------------------- respiratory quotient (RQ): steady-state ratio of
CO2 produced to O2 consumed per unit time
steady state RQ close to 1.0 indicates predominant
oxidation of CHO as fuel source

RQ for lipid (0.7) & protein (0.8) as sole sources

of energy
normal full-body steady-state RQ ~ 0.8
assessment of RQ is used when weaning patients
from mechanical ventilation
--------------------------------------------------------------- chronic HTN: 140/90 @ < 20 wks gestation or
persisting beyond 12 wks postpartum
o Rx: labetalol
gestational HTN & preeclampsia: HTN 20 wks
trace urine protein & mild peripheral edema is
common in normal pregnancy
o 3+ proteinuria is abnormal
HTN is MC risk factor for placental abruption
o other complications: preterm birth, IUGR,
oligohydramnios, superimposed preeclampsia
--------------------------------------------------------------- risk factors for placental abruption: HTN, DM,
prior placental abruption, cocaine use, smoking
risk factors for placenta previa: prior c-section,
multiparity, multiple gestation, adv maternal age
--------------------------------------------------------------- 10 amenorrhea: absence of menses by age 15,
normal growth & secondary sexual character
o can be normal up to age 16
o MCC is Turners
Evaluation of primary amenorrhea
initial test: pelvic exam & pelvic USS
uterus absent karyotype & serum testosterone
o 46,XX & normal female testosterone =
abnormal Mullerian development
o 46,XY & normal male testosterone =
androgen insensitivity syndrome
uterus present serum FSH
FSH (peripheral) karyotype
(hypergonadotropic amenorrhea)
FSH (central) pituitary MRI
(hypogonadotropic amenorrhea)
--------------------------------------------------------------- secondary amenorrhea: absence of menses 6
months in those who menstruated previously
initial test: -hCG for pregnancy
next: prolactin, TSH, FSH
o prolactin brain MRI

o TSH hypothyroidism
o FSH premature ovarian failure
if Hx of uterine procedure or infection, may have
scarring of uterine cavity (Asherman syndrome)
o hormone therapy to test for ability to grow a
uterine lining
o hysteroscopy to visualize uterine adhesions
---------------------------------------------------------------boobs organs
pubic hair
absent uterus
& upper
or absent
absent or
uterus &
upper vagina
normal uterus
streak ovaries normal
normal uterus
---------------------------------------------------------------Androgen insensitivity syndrome (46, XY)
end-organ resistance to androgens
testicular descent is an androgen-dependent process
cryptorchid testes secretes testosterone which is
aromatized to estrogen breast development
external female genitalia
no axillary or pubic hair
primary amenorrhea; no uterus or upper vagina
due to anti-Mullerian hormone from testes
o Wolffian ducts degenerate
cryptorchid gonads risk of dysgerminoma or
gonadoblastoma after puberty
Rx: gonadectomy after puberty + estrogen
--------------------------------------------------------------- Mullerian agenesis (Mayer-Rokitansky-KusterHauser syndrome): hypoplastic/absent mullerian
ductal system; normal ovaries
genotypic & phenotypic female
no menstruation due to absent/underdeveloped
uterus, cervix, & upper 2/3 vagina

5--reductase deficiency: 46, XY

o male gonads
o female/undermasculinized/ambiguous
external genitalia at birth
o often raised as girl, but male identity
o masculinization at puberty; phallus size,
muscle growth, but lack breasts
o infertility; risk of cryptorchidism
--------------------------------------------------------------- Lyme arthritis is the MC late manifestation of
untreated Lyme disease (months/years)
migratory arthralgias progress into
monoarticular arthritis of the knee; travel history
Dx: synovial fluid show inflammatory profile
confirm Dx: ELISA & Western blot
Rx: doxycycline or amoxicillin
DDx: reactive arthritis (1 4 wks after urethritis
or diarrheal infection), acute osteomyelitis, gout
--------------------------------------------------------------- 17-hydroxyprogesterone = nonclassic CAH
due to 21-hydroxylase deficiency
hyperandrogenism in late childhood
male pattern hair distribution, severe acne
non-classical CAH presents similar to PCOS
--------------------------------------------------------------- DDx of stridor: croup, foreign body aspiration,
epiglottitis, laryngomalacia, vascular rings,
retropharyngeal abscess
laryngomalacia is MCC of chronic stridor
--------------------------------------------------------------- high-grade fever, sore throat with odynophagia,
muffled voice, drooling, stridor: epiglottitis
tripoding with inspiratory stridor
neck hyperextension provides relief
MCC in adults: Hib & Strep pyogenes
o especially unvaccinated immigrants
CXR: enlarged epiglottis thumbprint
Dx: clinical, high suspicion
Rx: emergency intubation in the OR
DDx: peritonsilar abscess (uvular deviation),
angioedema, vascular ring, croup, foreign body
--------------------------------------------------------------- inspiratory stridor that worsens when supine &
with crying or feeding: laryngomalacia

laxity of supraglottic structures

peaks @ age 4 8 months
increased risk for GERD
Dx: flexible laryngoscopy, shows collapse of
supraglottic structures on inspiration; omega sign
Rx: reassurance; self-limited by age 18 months;
PPI for GERD symptoms; supraglottoplasty for
severe symptoms (cyanosis, apnea)
DDx: vocal cord paralysis
--------------------------------------------------------------- biphasic stridor, difficult feeds: vascular rings
screening: barium swallow
Dx: MRI with angiography
--------------------------------------------------------------- fever, drooling, dysphagia, neck pain, stridor:
retropharyngeal abscess
high risk of infection into posterior mediastinum
acute necrotizing mediastinitis
Dx: neck CT scan
--------------------------------------------------------------- headache, palpable B/L abdominal masses,
microhematuria, +family Hx: ADPKD
hepatic cysts are the MC extrarenal manifestation
intracranial berry aneurysms also common;
MVP or aortic regurgitation, colonic diverticula,
abdominal wall & inguinal hernia
--------------------------------------------------------------- distortion: altered perception of disturbing aspects
of external reality to make it more acceptable
displacement: shifting of emotions a/w an
upsetting object/person to a safer alternate
object/person that represents the original
acting out: directly expressing an unconscious
wish or impulse to avoid addressing the
accompanying emotion (temper tantrum)
introjection: assimilating of another persons
attitude into ones own perspective
suppression: intentionally postponing
exploration of anxiety-provoking thought by
substituting other thoughts
denial: failure to accept a disturbing aspect of
external reality
dissociation: blocking disturbing thoughts/feelings
from consciousness to avoid emotional upset

N/V, myalgias, arthralgias, diarrhea, rhinorrhea,

lacrimation, cramps: opioid withdrawal
mydriasis, piloerection, hyperactive bowel sounds
within 6 12 hr, peaks @ 24 48 hr
Rx: methadone
--------------------------------------------------------------- Streptokinase is a fibrinolytic for STEMI only
Cilostazol: anticoagulant for chronic claudication,
not acute limb ischemia
--------------------------------------------------------------- GnRH stimulation test: precocious puberty
--------------------------------------------------------------- anovulation & amenorrhea in lactating mothers
is due to prolactin, which suppresses GnRH,
thus LH/FSH
o not a reliable method of birth control
--------------------------------------------------------------- human placental lactogen (hPL): insulin antagonist
causes maternal lipolysis & insulin resistance, thus
delivery of fatty acids & glucose to the fetus
--------------------------------------------------------------- significant blood loss from MVA, receives
several units of pRBCs
whole blood is mixed with citrate coagulant
pRBCs derived from whole blood contains citrate
infused citrate chelates Ca++ & Mg++, thus
reducing serum levels paresthesia 2/2 hypoCa++
Rx: Ca++ gluconate
--------------------------------------------------------------- spontaneous abortion: < 20 wks gestation
advanced maternal age is a significant risk factor
absent fetal movement on USS is the most
significant indicator of fetal loss


Types of miscarriages
products of
+fetal heart tones
no cardiac activity,
or empty sac
no cardiac activity,
collapsed sac
partial expulsion
conceptus expelled

Complete abortion
whole conceptus expelled before 20 wks gestation
solid white mass covered with blood
abdo pain & contractions subsides
-hCG still positive; undetectable after 4 -6 wks
risk factors: smoking, advanced maternal age,
previous spontaneous abortion
Management of spontaneous abortion
expectant management until
symptom resolution OR progression to
inevitable, incomplete, or missed
hemodynamically unstable, heavy bleed:
Inevitable, surgical evacuation (D&C)
hemodynamically stable, mild bleeding:
expectant O/P management, misoprostol,
or surgical evacuation
blood & endometrial cultures,
broad-spectrum ABX,
surgical evacuation (D&C)
(inhibits actively proliferating fetal cells)
--------------------------------------------------------------- IV oxytocin: augment labor, Rx postpartum
hemorrhage, expel a retained fetus or POC
--------------------------------------------------------------- progesterone: prevention of preterm labor of a
singleton pregnancy in patients with a Hx of
spontaneous preterm delivery
---------------------------------------------------------------Congenital diaphragmatic hernia
pulmonary hypoplasia, pulmonary HTN,
polyhydramnios from esophageal compression,
right heart deviation, gasless abdomen
worsened with positive-pressure ventilation as
air into GIT compresses the lungs
Rx: intubation, then gastric tube to prevent
bowel distension against the lungs
--------------------------------------------------------------- pulmonary cavitation in HIV patients DDX: TB,
atypical mycobacteria, Nocardia, G-negative rods,
Nocardia: aerobic, G-positive, weakly acid-fast,
beaded, branching, filamentous rod

o CXR: pulmonary nodules

--------------------------------------------------------------- persistent culture-negative monoarthritis that
fails to respond to ABX: TB arthritis
--------------------------------------------------------------- pain, pulselessness, paresthesia, poikilothermia
(coldness), pallor (5 Ps): acute limb ischemia
sudden-onset severe pain
numbness due to nerve ischemia (not compression)
Dx: angiography
Rx: IV heparin immediately
definitive Rx: intra-arterial thrombolysis or
surgical embolectomy
DDx: thrombosis (insidious), arterial vasculitis
--------------------------------------------------------------- patients with acute renal failure, liver failure, or
sepsis (community-acquired pneumonia) should
discontinue metformin until renal function returns
risk of lactic acidosis
--------------------------------------------------------------- ACE-I/ARB can temporarily worsen renal function
& hypotension, thus should not be started in the
setting of acute kidney injury
--------------------------------------------------------------- bedwetting is normal before age 5 yrs
interventions including enuresis alarms &
desmopressin should not begin before age 5
--------------------------------------------------------------- status epilepticus (any single seizure > 5 min)
risk of permanent injury due to excitatory
cortical necrosis is hallmark
may cause intracranial pressure
--------------------------------------------------------------- chi-square test: compares two proportions
o if the difference between observed vs expected
values is large, assumes an association is
two sample z-test/t-test: compares two means
o t-test: uses sample variance
o z-test: uses population variance
o both are used to obtain the p-value
ANOVA: compares means of 3 or more variables

# needed to treat (NNT): # that need to receive

treatment to prevent 1 additional adverse event
NNT = 1/ARR (absolute risk reduction)
--------------------------------------------------------------- ankylosing spondylitis patients can develop
restrictive lung disease due to diminished chest
wall & spinal mobility
PFT show a mild restrictive pattern
(reduced VC & TLC, but normal FEV1/FVC)
FRC & RV due to fixation of the rib cage in an
inspiratory position
--------------------------------------------------------------- obstructive lung disease
o FEV1 (< 80%) & FEV1/FVC (< 70%)
restrictive lung disease
o FEV1 (< 80%) & FEV1/FVC (> 70%)
--------------------------------------------------------------- pupil dilation, rhinorrhea, myalgia & arthralgia,
cramps & spasms, nausea, diarrhea, lacrimation,
HTN, diaphoresis: heroin withdrawal
o resolves within 24 hrs; not life-threatening
---------------------------------------------------------------Alcohol withdrawal
acute phase (12 48 hr): sweating,
hyperreflexia, insomnia, seizures, then acute
hallucinosis in absence of autonomic symptoms
final phase (2 4 days): delirium tremens, HTN,
fever, agitation, tachycardia, hyperthermia
Rx: chlordiazepoxide (long-acting benzo)
--------------------------------------------------------------- nicotine withdrawal: irritability, anxiety,
insomnia, depression, poor concentration,
increased appetite, weight gain, bradycardia
--------------------------------------------------------------- 3 treatment options for Graves
o radioactive iodine (RAI)
o antithyroid drugs (PTU, methimazole)
o thyroidectomy
RAI is preferred, hypothyroid within 2 6 months
RAI is a/w worsening of Graves ophthalmopathy
due to destroyed thyroid cells
Rx: prophylactic glucocorticoids or antithyroidal
to deplete existing stores prior to RAI
C/I to RAI: severe ophthalmopathy & pregos

normally, newborns have enlarged RV appears as

right-axis deviation & R waves in V1 V3 on
EKG since blood is shunted away from the lungs
by the PDA in utero
newborn with left-axis deviation & small/absent
R-waves in precordial leads: tricuspid valve
atresia due to a hypoplastic RV
o cyanotic congenital defect
o ASD & VSD are necessary for survival
CXR: pulmonary markings
Rx: surgical repair
--------------------------------------------------------------- complete AV canal defect
o a/w Down syndrome
o CXR: pulmonary markings, cardiomegaly
Ebsteins anomaly
o a/w lithium use during pregnancy
o droopy tricuspid valve RA enlargement &
tricuspid regurgitation
o EKG: tall P wave, right-axis deviation
Total anomalous pulmonary venous return
o pulmonary veins fail to make normal
connections to left atrium
o right atrium receives blood from pulmonary
& systemic circulation
o RA & RV enlargement
--------------------------------------------------------------- hyperkalemia-inducing medications:
nonselective -blockers, ACE-I/ARBs, NSAIDs,
K+ sparing diuretics (amiloride)
--------------------------------------------------------------- E. histolytica: bloody diarrhea, trophozoites on
stool exam; flask-shaped colonic ulcers
--------------------------------------------------------------- fatigue, dyspnea, abdo pain, dark urine,
hypercoagulable state (portal vein thrombosis):
paroxysmal nocturnal hemoglobinuria (PNH)
LDH, haptoglobin, hemoglobinuria,
hemolytic anemia, pancytopenia
Dx: flow cytometry absence of CD55 & CD59 on
RBC surfaces, which normally inhibits activation of
complement on RBCs
o absence of CD55 causes hemolytic anemia
induced by the complement system
Rx: eculizumab (inhibits complement activation)

DDx: acute intermittent porphyria, aplastic anemia,

G6PD deficiency, hereditary spherocytosis
--------------------------------------------------------------- ectopic ACTH production is commonly a/w
small cell lung cancer & carcinoid
rapidly growing malignant tumors cause HTN,
hypokalemia, metabolic alkalosis, hyperpigmentation
without other features of Cushings (moon facies,
dorsal hump, central obesity, striae)
o benign/slow-growing tumors cause more
characteristic features of Cushing syndrome
high levels of cortisol from ectopic ACTH can
saturate 11-beta hydroxyl dehydrogenase & bind
to mineralocorticoid receptors directly to cause
HTN & hypokalemia
-------------------------------------------------------------- uncomplicated cases of acute epigastric pain with
amylase or lipase ( 3x normal) do not need
imaging for diagnosing acute pancreatitis
risk factors: alcohol, gallstones, hyperTGemia
Dx: abdominal CT with contrast for patients
with unclear diagnosis or failing to improve with
conservative Rx
--------------------------------------------------------------- hypochromic/microcytic anemia, depressed iron
& ferritin levels: iron deficiency anemia
MCC: chronic blood loss
initial management: test for blood in stool
DDx: right-sided colon cancer, PUD, diverticula,
--------------------------------------------------------------- acute respiratory distress, hypoxemia, smoking Hx:
acute exacerbation of COPD
COPD management
o supplemental O2 (target: 88 92%)
o inhaled bronchodilators
albuterol (beta-2-agonist)
ipratropium (short-acting anti-muscarinic)
o systemic glucocorticoids
oral prednisone (mild/moderate)
IV methylprednisolone (severe)
o ABX if 1 cardinal symptom
( dyspnea, cough, sputum)
azithromycin, levofloxacin, or augmentin

noninvasive positive pressure ventilation

(NPPV) for moderate/severe exacerbations
o tracheal intubation (no improvement after
2 hr trial of NPPV or NPPV is C/I)
NPPV is a/w decreased mortality, rate of intubation,
hospital stay, & incidence of nosocomial infections
maintenance Rx: salmeterol (long-acting 2 agonist)
inhaled corticosteroids are indicated in long-term
Rx of asthma, not COPD
--------------------------------------------------------------- acetylcysteine: mucolytic (Rx cystic fibrosis)
--------------------------------------------------------------- phenelzine: MAOI; Rx refractory depression
MAOIs are a/w dietary restriction, foods high in
tyramine (aged meats, cheese, wine)
o a/w hypertensive crisis
--------------------------------------------------------------- anemia, painless GI bleed, aortic stenosis murmur:
angiodysplasia (AVM) of GIT
MC @ age > 60
MC discovered with underlying aortic stenosis or
ESRD (uremic PLT dysfunction)
angiodysplasia: dilated, distended, thin-walled
vessels lined by endothelium, prone to recurrent &
chronic painless bleeding
Dx: colonoscopy or endoscopy
--------------------------------------------------------------- homocysteine levels predisposes to venous
thrombosis & atherosclerosis
thus, patients with DVT in the setting of elevated
homocysteine requires supplementation with
pyridoxine (B6) & folate
--------------------------------------------------------------- statins inhibit intracellular HMG-CoA reductase,
prevent conversion of HMG-CoA to mevalonic acid,
& LDH receptors to remove circulating LDH
A/E: statin-induced myopathy ( CPK)
--------------------------------------------------------------- osteophytes are MC finding in cervical spondylosis
o also narrowing of disk spaces &
hypertrophic vertebral bodies
Hx of chronic neck pain, limited neck rotation &
lateral bending

chronic diarrhea, malabsorption, Hx of living in

endemic areas 1 month: tropical sprue
glossitis, cheilosis, protuberant abdomen, pallor,
pedal edema, fatty diarrhea, fatigue, weight loss
hyperactive bowel sounds (boborygmi)
Dx: biopsy: blunting of villi with infiltration of
chronic inflammatory cells (lymphocytes,
eosinophils, plasma cells)
--------------------------------------------------------------- hypotension is a common side effect of
epidural anesthesia due to blood redistribution
to lower extremities & venous pooling from
sympathetic blockade
prevented by aggressive IV fluids prior to
epidural placement
Rx: left decubitus position to improve venous
return, or vasopressors
--------------------------------------------------------------- episodes of dysphagia, regurgitation, &/or chest
pain radiating to the back, precipitated by
emotional stress: diffuse esophageal spasm
resolution of chest pain with nitroglycerin
Dx: esophageal manometry shows repetitive,
non- peristaltic, high amplitude contractions
--------------------------------------------------------------- acute otitis media
MCC: Strep pneumo, H. influenza, Moraxella
MC age 6 36 months
otalgia, middle ear effusion + acute inflammation
(bulging, fever, erythema)
Rx: empiric amoxicillin; or augmentin
Rx: myringotomy with tympanostomy tube
placement for recurrent episodes
complications: conductive hearing loss, mastoiditis,
---------------------------------------------------------------DDx of menorrhagia
endometriosis chronic pelvic pain, endometrioma,
pain peaks 1-2 days before menses,
dyspareunia, infertility,
endometrial glands outside uterus
heavy menses with clots,
firm, irregular, enlarged uterus,
constipation & urinary frequency
due to extrinsic compression


dysmenorrhea, menorrhagia,
chronic pelvic pain,
bulky, globular, tender uterus
Hx chronic anovulation, obesity,
nulliparity (estrogen excess),
irregular, intermenstrual,
postmenopausal bleeding,
small, nontender uterus
recent procedure of the uterus
(instrumentation, IUD, abortion),
PROM, prolonged labor,
foul-smelling discharge,
fever, tender uterus

adenomyosis: endometrial glands invade the

uterine myometrium, results in blood deposition
between smooth muscle fibers
o risk factors: multiparous, age > 40
o Dx: surgical pathology after hysterectomy
fibroids: benign, smooth muscle tumor arising
from myometrium; does not cause intermenstrual
or postmenopausal bleeding
o Dx: pelvic USS
--------------------------------------------------------------- all women age > 45 with irregular bleeding
require endometrial biopsy
--------------------------------------------------------------- side effects of depot medroxyprogesterone acetate
(DPMA) can overlap with pregnancy symptoms
o weight gain, nausea, breast tenderness
o Rx: offer alternative contraception method
initial test: exclude pregnancy
DPMA suppresses ovulation, given every 3 months
causes menstrual irregularities in the 1st 6 months
amenorrhea after 1 yr of use
--------------------------------------------------------------- otitis media with effusion: middle ear effusion
without acute inflammation
otitis externa: erythematous & swollen external
auditory canal, ear discharge, hearing loss, &
pain with tragal traction
chronic suppurative otitis media: hearing loss,
otorrhea > 6 wks, lack of fever & ear pain,
tympanic membrane perforation

B/L retinal hemorrhages: suspect child abuse

repetitive acceleration-deceleration forces cause
shearing of subdural veins
seizures, head circumference, bulging/tense
anterior fontanelle, altered mental status
Dx: non-contrast head CT & skeletal survey
AR mutation of phenylalanine hydroxylase for
conversion of phenylalanine to tyrosine
o phenylalanine is neurotoxic
severe intellectual disability, musty body odor,
seizures, fair complexion (skin, hair, eyes)
Dx: tandem mass spectrometry (newborn
screening); quantitative amino acid analysis
(late presentations)
Rx: dietary restriction of phenylalanine
--------------------------------------------------------------- aldolase B deficiency: fructose intolerance
accumulation of fructose-1-phosphate
vomiting, poor feeding, lethargy, seizures
Rx: restrict fructose from diet (fruits, veggies)
--------------------------------------------------------------- jaundice, hepatomegaly, failure to thrive after
first few days after consumption of breast milk
or regular formula: galactosemia
absent galactose-1-phosphate uridyl transferase
G-1-P accumulates in liver, brain, kidney, leads
to cirrhosis, mental retardation, Fanconis
Rx: breastfeeding is C/I
--------------------------------------------------------------- acute onset dyspnea, tachypnea, normal lung exam,
right-axis deviation on EKG: PE
Dx: CT angiography (test of choice)
contrast allergic or renal insufficient Dx: V/Q scan
o large perfusion defect without ventilation defect
--------------------------------------------------------------- chronic TPN or fasting causes gallbladder stasis,
predisposes to gallstones & bile sludging, leading
to cholecystitis
o due to absence of stimulus for CCK release
& GB contraction
small bowel resection & ileal Crohns contributes
to gallstones, due to enterohepatic circulation
of bile acids

--------------------------------------------------------------- estrogen-induced cholesterol secretion results in

cholesterol gallstones during pregnancy & on OCPs
progesterone contributes by reducing bile acid
secretion & slows GB emptying
--------------------------------------------------------------- ADHD is a clinical diagnosis
Hx of core inattention & hyperactive/impulsive
symptoms for 6 months & prior to age 7
functional impairment in at least 2 settings
Rx: methylphenidate (A/E: loss of appetite,
weight loss, nausea, insomnia, nervousness)
--------------------------------------------------------------- sickle cell trait have no specific clinical symptoms
& no change in life expectancy
renal complications: painless hematuria, UTI,
renal medullary cancer, hyposthenuria
MCC of hematuria is papillary necrosis due to
low pO2 in the vasa rectae
U/A: normal-appearing, intact RBCs
DDx: acute cystitis, acute glomerulonephritis,
--------------------------------------------------------------- dysuria, urinary frequency, WBCs on U/A,
positive nitrite & LE: acute cystitis
o MCC: Staph saprophyticus
hematuria, HTN, proteinuria, dysmorphic RBCs,
RBC casts: acute glomerulonephritis
medication use, rash, eosinophilia, serum Cr,
WBC casts: acute interstitial nephritis
cola-colored urine, hematuria, elevated creatinine,
granular casts, renal tubular epithelial cells: ATN
--------------------------------------------------------------- delayed sleep phase syndrome: inability to fall
asleep at normal hours (10 pm midnight)
advanced sleep phase disorder: inability to stay
awake in the evening (after 7 pm)
--------------------------------------------------------------- dominant frontal lobe lesion: expressive
(Brocas) aphasia, C/L hemiparesis, C/L apraxia
conjugate gaze deviation TOWARD the lesion
--------------------------------------------------------------- dominant parietal lobe lesion: C/L sensory loss,
C/L inferior homonymous quadrantanopsia
(superior optic radiations)

--------------------------------------------------------------- dominant temporal lobe lesion: receptive &

conductive aphasia, C/L superior homonymous
quadrantanopsia (Meyers loop)
intact expressive speech, motor, primary sensory
--------------------------------------------------------------- hepatojugular reflux can differentiate between
cardiac vs. liver disease-related cause of LE edema
+ test: due to heart failure (reflects a failing RV)
o constrictive pericarditis, RV infarction,
restrictive cardiomyopathy
- test: due to hepatic disease/cirrhosis
o increase in venous return below the liver
--------------------------------------------------------------- subtle memory loss, language difficulties,
apraxia, followed by impaired judgement &
personality changes: Alzheimers
o CT scan: diffuse cortical atrophy, especially
temporal & parietal lobes, hippocampus;
used to exclude other causes, not diagnostic
euphoria, disinhibition, apathy, compulsive
behavior, hyerorality, impaired memory: Picks
o visuospatial function intact
fluctuating cognitive impairment, Parkinsonism,
visual hallucinations: Lewy body
o worsening of features with neuroleptics
sudden deterioration of cognitive, motor, sensory
function with each attack: multi-infarct dementia
o MRI: multiple hypodense areas, periventricular
--------------------------------------------------------------- anterior horn cells impaired: ALS,
poliomyelitis, spinal muscular atrophy
peripheral nerves impaired: Guillain-Barre,
diabetic neuropathy
muscle fibers impaired: muscular dystrophy,
polymyositis, dermatomyositis, hypothyroidism
neuromuscular junction impaired: botulism
(descending flaccid paralysis), Myasthenia Gravis,
Lambert-Eaton, organophosphate poisoning
--------------------------------------------------------------- acute ascending polyneuropathy after a recent
URI or GI infection: Guillain-Barre
demyelination of peripheral motor nerves
ascending weakness, then flaccid paralysis with
absent DTRs & autonomic symptoms

CSF: elevated proteins, normal WBCs

--------------------------------------------------------------- S. epidermidis is a common cause of prosthetic
valve endocarditis
Enterococcal endocarditis affects older men after
GU manipulation or women after OB procedures
--------------------------------------------------------------- transient spike in Cr within 24 hr; returns to baseline
5 7 days: contrast-induced nephropathy
Rx: non-ionic contrast, pre-CT IV hydration &
prednisone minimizes hypersensitivity reactions
to contrast media & dye allergies
withhold NSAIDS; causes renal vasoconstriction
--------------------------------------------------------------- painless hematochezia in a toddler: Meckels
due to incomplete obliteration of vitelline duct
ectopic gastric tissue causes mucosal ulceration
severe anemia or hemorrhagic shock
Dx: technicium-99m pertechnitate scan
complications: intussusception, obstruction
--------------------------------------------------------------- pruritic lesions on flexor wrist, web spaces, elbows,
&/or penis with short, linear burrows: scabies
excoriations with small, crusted, red papules
contagious by direct person-to-person contact
delayed Type IV hypersensitivity reaction
Dx: skin scrapings under light microscopy
Rx: topical permethrin or oral ivermectin
Rx: sheets & clothing cleaned or in plastic bag
for 3 days (mites cannot live without humans)
DDx: eczema, tinea, seborrheic dermatitis
--------------------------------------------------------------- stroke is a complication of sickle cell disease
2/2 sludging & occlusion in cerebral vasculature
Rx: exchange transfusion, continue hydroxyurea
o fibrinolytics, heparin, & warfarin are not
useful; not a true thrombus
--------------------------------------------------------------- I/L shoulder pain, Horners (I/L ptosis, miosis,
anhidrosis), supraclavicular node enlargement,
weakness/atrophy of hand muscles,
pain/paresthesia in the arm: Pancoast tumor
MCC non-small cell lung cancer

Horners occurs due to tumor invasion of

paravertebral sympathetic chain or inferior
cervical ganglion
Dx: CXR initially, chest CT for staging
--------------------------------------------------------------- dilated pupils, blood-crusted nose: cocaine abuse
o Rx: CCB & alpha blocker (phentolamine)
severe cocaine-induced vasospasm can cause
cocaine-induced STEMI
o Rx: PTCA or thrombolysis
avoid -blockers, due to unopposed alpha activity
avoid fibrinolytics due to ICH risk
avoid thrombolytics for suspected aortic dissection

Acute cocaine intoxication

tachycardia, HTN, dilated pupils,
atrophic nasal mucosa,
chest pain (coronary vasoconstriction)
psychomotor agitation, seizures
complications o acute myocardial ischemia
o aortic dissection
o intracranial hemorrhage
management supplemental O2,
IV benzodiazepine (BP & anxiety),
ASA (prevent thrombus formation),
nitro & CCB (prevent vasoconstrictn)
cocaine enhances thrombus formation by
promoting PLT activation & aggregation
--------------------------------------------------------------- IVDA are at risk for tricuspid valve endocarditis
with pulmonary septic emboli
MCC: S. aureus
cough, chest pain, & hemoptysis
CXR: scattered, round alveolar infiltrates;
peripheral cavitary lesions
Rx: vancomycin (native valve) covers MRSA
--------------------------------------------------------------- pruritic, elevated, serpiginous skin lesions, through
contact with sand: cutaneous larva migrans
o helminthic disease by dog/cat hookworm
--------------------------------------------------------------- Vit B12 deficiency: subacute degeneration of
dorsal & lateral spinal columns
ataxia, B/L paresthesias, loss of vibration/position,
memory deficits, irritability

--------------------------------------------------------------- Legionella: MC in immunosuppressed receiving

o fever with bradycardia, cavitary lesions,
watery diarrhea
S. epidermidis: a/w infection of prosthetic valves,
intravascular shunts, & prosthetic joints
o uncommon cause of native valve endocarditis
--------------------------------------------------------------- premenstrual syndrome (PMS) begins 1 2 wks
prior to menses & regress around menstrual flow
symptoms occur repeatedly & predictably
confirm Dx: menstrual symptom diary
Rx: SSRI, caffeine reduction
--------------------------------------------------------------- DDx of hematochezia in a toddler: Meckels,
infectious colitis, intussusception, hemorrhoids,
milk protein allergy, inflammatory bowel disease
--------------------------------------------------------------- bloody, mucousy, loose stools or severe constipation:
milk protein allergy causes painless rectal bleed
exclusive to infants, resolves by age 1 yr
Rx: elimination of milk/soy from maternal diet if
breastfed; hydrolyzed formula if formula-fed
--------------------------------------------------------------- 5-HT antagonists (ondansetron) to Rx/prevent
chemotherapy-induced N/V
o add corticosteroids for better prophylaxis
--------------------------------------------------------------- scopolamine: anticholinergic to Rx vomiting &
reduce motion sickness
--------------------------------------------------------------- IV erythromycin is a motilin receptor agonist
o Rx nausea 2/2 gastroparesis; prokinetic
metoclopramide: DA Rc antagonist
o prokinetic & anti-emetic
o peristalsis, gastric contractions, relaxation
of pyloric sphincter
o Rx: diabetic gastroparesis & N/V
--------------------------------------------------------------- relative risk (RR): probability of an outcome of
interest occurring in the exposed group compared
to the non-exposed group; a/w cohort studies

RR = 1.0: null value; no association;

outcome occurs with equal frequency
o RR > 1.0: exposure is a/w risk of disease
o RR <1.0: exposure is a/w risk of disease
confidence intervals & p-values are interrelated,
expresses statistical significance (p < 0.05)
o confidence interval must not contain null value
wider CI corresponds to smaller sample size
larger sample narrows CI power
95% confidence 99% confidence
null value is
p < 0.05
p < 0.01
outside CI
null value is
p 0.05
p 0.01
inside CI
--------------------------------------------------------------- fever, nonproductive cough, tachypnea, dyspnea,
pleuritic chest pain: acute eosinophilic pneumonia
CXR: diffuse reticular or ground glass opacities
a/w pulmonary edema & pleural effusions
--------------------------------------------------------------- pain relief is the prime objective in management
of rib fractures, to allow proper ventilation, &
prevent atelectasis & pneumonia
Rx: opiates &/or NSAIDs
intercostal nerve block provides relief without
affecting respiratory function
--------------------------------------------------------------- mild metatarsus adductus: feet that overcorrect
passively & actively into abduction (Type I)
o spontaneously corrects; no Rx needed
Type II: feet that overcorrect into neutral position
o Rx: orthosis or corrective shoes
Type III: rigid feet that do not correct
o Rx: serial casts
--------------------------------------------------------------- fever, confusion, focal neurologic deficits, seizures,
lymphocytic pleocytosis: HSV encephalitis
Rx: IV acyclovir
--------------------------------------------------------------- pulmonary hemorrhage is a manifestation of
Goodpastures or Wegeners; nephritic syndromes
--------------------------------------------------------------- ARDS: diffuse injury to the pulmonary capillary
endothelium & alveolar epithelium, results in

leakage of protein-rich fluid into alveolar

interstitial spaces forms hyaline membranes
o impaired gas exchange
o lung compliance
o pulmonary HTN
ARDS causes shunting increased A-a gradient
ARDS is a/w hypoxemia (PaO2/FiO2 300) &
B/L alveolar opacities
o mild: 200 300 mmHg
o moderate: 100 200 mmHg
o severe: < 100 mmHg
MCC: sepsis, pneumonia, pulmonary contusion,
fractures, transfusions, pancreatitis
ARDS can be due to acute pancreatitis
o pancreatic enzymes leak across pulmonary
capillaries & damage surfactant; inflammation
leads to breakdown of endothelial barrier,
recruits inflammatory cytokines, results in
diffuse alveolar damage
Dx of exclusion: exclude hydrostatic pulmonary
edema in patients w/o ARD risk factors
--------------------------------------------------------------- hepatic encephalopathy (HE): CNS complication
of cirrhosis; inability to convert ammonia to urea
precipitated by medications, hypovolemia,
infection, excess nitrogen load (GI bleed),
electrolyte disturbances (hypokalemia)
hypokalemia increases renal ammonia production
metabolic alkalosis stimulates conversion of
ammonium (NH4+) to ammonia (NH3) (cross BBB)
hyperactive DTRs, +Babinski, nystagmus
initially: diurnal sleep disturbances (insomnia,
hypersomnia) anorexia, cognitive deficits, mental
status change, & neuromuscular (asterixis)
Rx precipitating causes (IVF, electrolytes)
Rx: oral lactulose (lowers serum ammonia into
non-absorbable ammonium)
Rx: Rifaximin ( # of ammonia-producing
colonic bacteria), laxatives (catharsis)
furosemide improves ascites, but not HE
--------------------------------------------------------------- confusion, gait ataxia, nystagmus: Wernickes

indications for electroconvulsive therapy (ECT):

severe depression, depression in pregnancy, NMS,
refractory mania, catatonic schizophrenia
MC A/E: amnesia (anterograde & retrograde)
--------------------------------------------------------------- MC complication seen post-thyroidectomy:
o non-specific: fatigue, anxiety, depression
o severe: tetany, seizures, QT prolongation
---------------------------------------------------------------Nephrotic syndrome
o 3+ proteinuria
o hypoalbuminemia
o edema
o hyperlipidemia
hypercoagulability is a common manifestation, as
venous or arterial thrombosis
renal vein thrombosis is most common,
especially in membranous glomerulopathy
---------------------------------------------------------------Placental abruption
maternal HTN, pre-eclampsia/eclampsia,
abdominal trauma, prior placental abruption
cocaine use or tobacco use
feature acute onset vaginal bleeding,
hyperactive, hypertonic & tender uterus,
high-frequency, low-intensity contractions,
constant abdominal pain, late decelerations
clinical presentation primarily;
USS used only to r/o placenta previa
unstable maternal VS or non-reassuring
fetal tracing: emergency c-section
stable maternal VS, reassuring fetus, 34
wks gestation: trial of vaginal delivery
complication: DIC

vaginal bleeding in 80%, but lack of bleeding does

not exclude the Dx
Rx: 2 large-bore IV lines & urethral catheter
--------------------------------------------------------------- undescended testicles by age 6 months are
unlikely to descend spontaneously
Rx: orchiopexy before age 1 yr
early surgery improves fertility, but sperm count
& quality remain substandard

--------------------------------------------------------------- distended neck veins: PTX or cardiac tamponade

collapsed neck veins: hemothorax, hypovolemia
Patients to treat (positive PPD)
5 mm
recent contact with TB
previously healed TB on CXR
organ transplant recipients
immunosuppressed patients
10 mm recent TB-endemic immigrants (< 5 yrs)
residents/employees in high-risk settings
(prisons, nursing homes, shelters)
high risk for reactivation TB (diabetes,
ESRD, chronic malabsorption)
age < 4 yrs or exposed to high-risk adults
15 mm all of the above & healthy individuals
active TB Rx: INH, rifampin, ethambutol,
pyrazinamide (8 wks)
o then INH + rifampin (4 months)

Treatment options for latent TB infection

INH & rifapentine weekly: 3 months
(direct observation therapy)
o INH monotherapy: 9 months
o INH (6 months) & Rifampin (4 months)
o INH & rifampin: 4 months

pyridoxine is added for those taking INH &

presence of diabetes, uremia, alcoholism,
malnutrition, HIV, pregnancy, or epilepsy
o does not prevent INH-induced hepatitis
rifampin A/E: benign red/orange discoloration
of body fluids; normal U/A
--------------------------------------------------------------- INH can cause peripheral neuropathy, hepatitis,
& sideroblastic anemia
o INH is a pyridoxine antagonist, which
impairs early protoporphyrin synthesis
causes microcytic, hypochromic anemia
simulating iron-deficiency anemia
dimorphic RBCs: hypochromic, normochromic
serum iron, TIBC

Dx: bone marrow sampling ringed sideroblasts

Rx: Vit B6 supplementation
--------------------------------------------------------------- INH causes idiosyncratic liver injury
not dose dependent; variable latent period
LFTs & liver Bx presents similar to viral hepatitis
liver Bx: panlobular mononuclear infiltration &
hepatocyte necrosis
--------------------------------------------------------------- severe isoniazid hepatitis presents clinically
similar to viral hepatitis; discontinue INH
mild INH hepatotoxicity with mild elevations
of aminotransferases has excellent prognosis;
hepatic injury is self-limited, continue INH with
regular F/U of LFTs
pyridoxine does not prevent INH-induced hepatitis
--------------------------------------------------------------- Kleihauer-Betke test: measures the amount of
fetal Hb transferred to the maternal bloodstream
performed in Rh-negative prego with Rh-positive
fetus to determine dosage of Rh Ig to prevent Rh
also differentiates maternal vs. fetal blood during
vaginal bleeding
--------------------------------------------------------------- Dumping syndrome: postgastrectomy complication
rapid emptying of hypertonic gastric content into
the duodenum & small intestine releases
vasoactive polypeptides
Rx: dietary modification of small, frequent meals
Rx: octreotide for resistant cases
--------------------------------------------------------------- acute bacterial rhinosinusitis
o persistent symptoms 10 days
o severe symptoms: 39C (1020F), purulent
nasal discharge, face pain 3 days
o worsening symptoms 5 days after initial
improving viral URI
viral URI is MC predisposing factor
MMC are Strep pneumo & H. influenza
Rx: oral augmentin for uncomplicated cases
adjunct Rx: intranasal corticosteroids for Hx of
allergic rhinitis
Dx: CT scan of sinuses for complications

o sinus XR are not useful

Rx: sinus aspiration for persistent symptoms
after 3 days of ABX
--------------------------------------------------------------- chronic sinusitis (> 12 wks): S. aureus
--------------------------------------------------------------- Jarisch-Herxheimer reaction: a/w syphilis Rx
10 or 20 syphilis Rx with PCN spirochetes die
rapidly releases antigen-antibody complexes
immunologic reaction
appears like an acute flare-up of syphilis
--------------------------------------------------------------- epistaxis, turbinate destruction, palatal eschars,
maxillary cyanosis: fungal sinusitis
MCC: Aspergillus fumigatus, Rhizopus
risk factors: poorly controlled DM, HIV
--------------------------------------------------------------- acute pancreatitis is MCC by gallstones &
alcohol use
Dx: USS of RUQ to detect gallstones
Rx: IV fluids, NG tube section, NPO, analgesia;
monitor Ca++ & Mg++
stable patients should undergo cholecystectomy
for biliary pancreatitis prior to discharge
--------------------------------------------------------------- Marfan: AD, fibrillin-1 gene mutation
upward lens dislocation, aortic root dilation
resulting in aortic regurgitation
complications: aneurysms, aortic dissection, MVP
--------------------------------------------------------------- homocysteinuria: AR cystathionine synthase
deficiency; a/w metabolism of methionine
elevated homocyteinuria & methionine
marfanoid habitus, fair complexion, thrombosis,
(CVA, stroke), intellectual disability
downward lens dislocation
Rx: Vit B6, folate, Vit B12; anticoagulation
--------------------------------------------------------------- scoliosis, joint laxity, aortic dilation: Ehlers-Danlos
--------------------------------------------------------------- seizure, diaphoresis, tremulousness, elevated
pulse & BP one day following hospitalization:
alcohol withdrawal
seizures likely at 12 48 hr

delirium tremens at 2 4 days; altered sensorium

& autonomic instability
Rx: lorazepam, diazepam, or chlordiazepoxide
o IV lorazepam for liver diseased
o phenobarbital (anti-convulsant) can be
adjunct in refractory cases
--------------------------------------------------------------- hematuria, arthralgia, colicky abdominal pain,
purpuric rash on LE without thrombocytopenia
following a minor infection (viral URI):
Henoch-Schonlein purpura
IgA-mediated leukocytoclastic vasculitis
normal PLT count
hematuria, RBC casts, proteinuria, mild Cr
renal biopsy: mesangial deposition of IgA
Rx: hydration & NSAIDs (pain control)
o severe Rx: hospitalize, systemic glucocorticoids
complications: intussusception, GI hemorrhage
--------------------------------------------------------------- hemophilia-associated arthropathy is a
delayed consequence of recurrent hemarthrosis, a
chronic inflammatory process
a/w hemosiderin deposition & fibrosis of joints
joint contractures & limited ROM
Rx: prophylaxis with factor concentrates
--------------------------------------------------------------- clenched fist injury, human bite, dog bite
Rx: amoxicillin-clavulanate (augmentin)
--------------------------------------------------------------- erythromycin: Rx Legionnaires & outpatient
Rx of community-acquired pneumonia
--------------------------------------------------------------- VZV incubation period: up to 3 weeks
o contagious from 2 days prior to rash onset
until all vesicles are crusted
Varicella post-exposure prophylaxis
Hx of immunity observation
if asymptomatic & no Hx of immunity
o immunocompetent varicella vaccine only
within 3 5 days of exposure
o immunocompromised VZ Ig within 10 days
varicella vaccine is live, attenuated, thus
contraindicated in pregos & immunocompromised

--------------------------------------------------------------- returning from a developing country with

chronic symptoms of malabsorption: giardiasis
trophozoites adhere to mucosal surfaces by
adhesive disks, producing malabsorption
Rx: empiric metronidazole
--------------------------------------------------------------- female between age 30s 40s, recurrent attacks
of multiple focal neurologic presentations, &
interspersed episodes,: MS
optic neuritis blurry vision, retrobulbar pain,
afferent pupillary defect
--------------------------------------------------------------- TIAs: emboli from carotid artery plaques, which
occlude the distal ophthalmic artery
o painless loss of vision
--------------------------------------------------------------- Stevens-Johnson syndrome involve mucosal
--------------------------------------------------------------- chronic scar (burn) that develops into a painless,
non-healing, bleeding skin ulcer suggests
squamous cell carcinoma
risk factors: smoking, radiation, immunosuppression
Dx: biopsy (punch, shave, excisional) that
includes deep reticular dermis
--------------------------------------------------------------- primary spontaneous PTX: no preceding event
or Hx of lung disease
secondary spontaneous PTX: complication of
underlying lung disease (COPD)
tension PTX: trapped air, with mediastinal shift
AWAY from affected side, & compromised
cardiopulmonary function
suspected tension PTX should be treated prior to
intubation, as PPV will worsen the PTX
o small: observation & O2
o large/stable: needle aspiration or chest tube
o unstable: urgent needle thoracostomy, then
chest tube under water seal
needle decompression @ 2nd or 3rd IC space,
midclavicular line
chest tube @ 5th IC space, mid-axillary line

neurocardiogenic (vasovagal) syncope: preceded

by nausea, diaphoresis, bradycardia, pallor
pallor & weak pulses suggest syncope
triggers: prolonged standing, stress, pain
benign & self-limited
immediate spontaneous return to baseline neuro
--------------------------------------------------------------- essential tremor: action tremor in absence of
additional neurologic signs
affects any part of the body, B/L hands MC
resolves with sleep, improves with alcohol
Rx: propranolol (especially if also hypertensive);
primidone or topiramate (anticonvulsants)
o primidone may precipitate acute intermittent
porphyria (abdominal pain, headaches,
confusion, hallucinations, dizziness)
o Dx: urine porphobilinogen
--------------------------------------------------------------- HTN is the most important risk factor for
intracerebral hemorrhage
MC site: putamen (basal ganglia)
--------------------------------------------------------------- occipital headache, neck stiffness, gait ataxia, N/V,
gaze palsy or nystagmus: cerebellar hemorrhage
o no hemiparesis or sensory loss
risk factor: HTN
Dx: non-contrast head CT, surgical decompression
--------------------------------------------------------------- intracranial hemorrhage: focal neuro deficits
worsen over minutes hours; not maximal at onset
headache, N/V, decreased LOC
MC risk factor: HTN

Intraparencymal brain hemorrhage

neurologic findings
C/L hemiparesis & hemisensory loss
homonymous hemianopsia
gaze palsy AWAY from lesion**
no hemiparesis, occipital headache,
neck stiffness, gait ataxia, nystagmus
C/L hemiparesis, hemisensory loss
nonreactive pinpoint pupil
upward gaze palsy
eyes deviate TOWARD hemiparesis**
frontal: C/L hemiparesis


parietal: C/L hemisensory loss

occipital: homonymous hemianopsia
eyes deviate AWAY from hemiparesis
total paralysis in minutes followed by
(pinpoint) deep coma, pinpoint reactive pupils,
decerebrate rigidity
internal capsule lies adjacent to putamen, leads
to C/L dense hemiparesis
--------------------------------------------------------------- elderly with dementia have increased risk of
agitated delirium in the hospital
MCC: medications, infection, electrolytes,
metabolic, systemic illness, CNS
Rx: low-dose haloperidol for acute agitation in
elderly with dementia
o typical & atypical antipsychotics are safe
o prolonged use increases mortality in elderly
typical antipsychotics not for Lewy body dementia
--------------------------------------------------------------- benzos OK for Rx agitation in young patients
--------------------------------------------------------------- firm, hyperpigmented nodule with dark edges, &
central dimple when pinched: dermatofibroma
o benign fibroblast proliferation; MC on LE
o Rx: no treatment unless symptomatic,
bleeds, change color or size
pearly plaque/papule with small telangiectasias
on sun-exposed areas: BCC
firm, scaly papule/plaque/nodule on sun-exposed
area: SCC
multicentric, red/purple/brown macules/papules,
or nodule on trunk/face/extremities: Kaposi
small red papule grows rapidly into a pedunculated
or sessile shiny mass on lip or oral mucosa, bleeds
with minor trauma: pyogenic granuloma
o benign vascular skin tumor
--------------------------------------------------------------- hazard ratio: chance of an event occurring in
the treatment group compared to control group
HR < 1: event is more likely in the control group
HR > 1: more likely in the treatment group
HR = 1: no difference
--------------------------------------------------------------- cyclophosphamide: alkylating immunosuppressant
Rx for SLE, vasculitis, & cancer

a/w hemorrhagic cystitis & bladder carcinoma

caused by acrolein
Rx: mesna, hydration, frequent voiding
--------------------------------------------------------------- cisplatin & carboplatin: a/w cochlear dysfunction
-blockers & ergotamine: a/w Raynauds
cyclosporine: a/w gout
amiodarone & lithium: a/w thyroid dysfunction

--------------------------------------------------------------- breech presentation before 37th wk gestation

does not require intervention; routine follow-up
external cephalic version is indicated 37th wk
o contraindications: placental abnormalities,
feto-pelvic disproportion, hyperextended head
--------------------------------------------------------------- heat stroke: thermoregulatory center fails to
dissipate heat at the necessary rate
o risk factors: hot/humid weather, obesity, meds
(anticholinergics, TCAs, antihistamines)
non-exertional heat stroke: chronic illness or
medication causes impaired thermoregulation
o Rx: evaporative cooling
exertional heat stroke: failure of thermoregulation
in healthy individuals in extreme heat/humidity
o > 400C (1050F)
CNS dysfunction (altered mental status),
hypotension, tachycardia, tachypnea, ARDS
o rhabdomyolysis (large blood, but no RBCs),
coagulopathic bleeding (epistaxis), DIC
Rx: ice water immersion, fluids & electrolytes;
no antipyretics
DDx: anticholinergic toxicity, serotonin syndrome,
malignant hyperthermia,
--------------------------------------------------------------- heat exhaustion: inadequate fluid & Na+
replacement; unable to maintain C.O.
o no CNS dysfunction

--------------------------------------------------------------- fever results from the thermoregulatory centers

temporary upregulation of body temp by the
--------------------------------------------------------------- high fever, muscle rigidity, rhabdomyolysis,
metabolic acidosis, hemodynamic instability:
malignant hyperthermia
uncontrolled sarcoplasmic reticulum Ca++ efflux
AD inheritance; +family Hx
MCC: inhaled halothane & succinylcholine
---------------------------------------------------------------Serotonin syndrome
HTN, hyperthermia, diaphoresis, agitation,
tremor, muscle rigidity, clonus, hyperreflexia
Rx: benzo (lorazepam)
--------------------------------------------------------------- extracellular pH promotes binding of Ca++ to
albumin, thus ionized Ca++
--------------------------------------------------------------- warfarin-induced skin necrosis: due to rapid
decline of protein C in those with underlying
protein C deficiency
occurs within the first few days
skin lesions on extremities, breast, trunk, penis;
marginates over hours
Rx: stop warfarin, protein C concentrate
--------------------------------------------------------------- heparin-induced thrombocytopenia (HIT):
autoantibodies to PF4 complexes with heparin
occurs within 5 10 days
necrotic skin lesions @ injection sties
a/w arterial or venous thrombosis
PLT count reduction > 50 %
Rx: stop heparin; direct thrombin inhibitor
(argatroban, fondaparinux)
--------------------------------------------------------------- Factor V Leiden mutation increases risk for
venous thromboembolism (DVT, PE) due to
protein C resistance
--------------------------------------------------------------- risk of tick-borne disease is low if removed < 24 hr
--------------------------------------------------------------- Histoplasma is MC in bird/bat droppings
dimorphic fungus: yeast in tissue, mold in culture

endemic to Mississippi & Ohio River valley

usually asymptomatic; can cause acute pneumonia
CXR: asymptomatic pulmonary nodule or
patchy/multinodular infiltrates
--------------------------------------------------------------- rapidly developing hyperandrogenism with
virilization suggests an androgen-secreting tumor
of the ovary or adrenal
Dx: serum testosterone & DHEA-S
o elevated testosterone ovarian source
o elevated DHEA-S adrenal source
DHEA is secreted by ovaries & adrenals
--------------------------------------------------------------- panic disorder is a/w other psychiatric illnesses:
major depression, agoraphobia, bipolar,
substance abuse
high rate of suicide attempts & suicide ideations
immediate Rx: benzos
long-term Rx: SSRI/SNRI &/or CBT
--------------------------------------------------------------- pulmonary contusion symptoms develop in the
first 24 hours
tachypnea, tachycardia, hypoxia
CXR: patchy irregular alveolar infiltrates
DDx: ARDS (manifests after 24 to 48 hrs)
--------------------------------------------------------------- 3 Ds: dyspareunia, dysmenorrhea, dyschezia
(pain with defecation), infertility: endometriosis
disappears/improves during pregnancy
risk factors: nulliparity, early menarche, short
menstrual cycles, menstrual flow obstruction
--------------------------------------------------------------- tachypnea, tachycardia, mental status changes,
hypotension, thrombocytopenia, petechiae on
the chest after long bone fracture: fat embolism
--------------------------------------------------------------- hypotension unresponsive to IV fluids,
tachycardia, JVD after blunt thoracic trauma:
acute pericardial tamponade
CXR: may appear normal
Rx: pericardiocentesis or surgical pericardiotomy
--------------------------------------------------------------- exertional dyspnea, nocturnal cough, hemoptysis
rheumatic fever is MC in developing countries

mitral stenosis increases pulmonary vascular

pressure thus causing pulmonary congestion
--------------------------------------------------------------- temporal headache, jaw claudication, vision loss,
ESR: Giant cell (temporal) arteritis
chronic vasculitis of medium & large vessels
anterior ischemic optic neuropathy presents as
swollen pale optic disc with blurred margins
a/w polymyalgia rheumatica
Rx vision problems: high-dose IV corticosteroids
(methylprednisolone) immediately
Rx mild cases: oral prednisone
Rx polymyalgia rheumatica only: low-dose oral
--------------------------------------------------------------- acetazolamide: Rx open angle glaucoma &
benign intracranial HTN (ICH)
--------------------------------------------------------------- anovulation, hirsutism, acne, ovarian cysts: PCOS
abnormal GnRH secretion stimulates the pituitary
to secrete excess LH & insufficient FSH
o excess LH stimulates androgen production
by ovarian theca cells
anovulation is due to LH/FSH imbalance &
insulin resistance
---------------------------------------------------------------Pathogenesis of endometriosis
ectopic endometrial tissue form beneath pelvic
mucosal/serosal surfaces
cyclic hyperplasia & degeneration
chronic hemorrhaging leads to pelvic adhesions
risk of impaired fertility or infertility
--------------------------------------------------------------- chronic pelvic pain, dyspareunia, infertility,
bowel/bladder symptoms: endometriosis
rectovaginal tenderness or movement of uterus
MC in nulliparous, age 25 - 35
evaluation: pelvic USS to r/o endometrioma
(cystic ovarian mass); normal lab studies
Rx if no complications: empiric NSAIDs +/combined OCPs (ovulation suppression)
Rx if complications, or refractory to medical Rx:
laparoscopy (Dx & Rx)

pernicious anemia: MCC of Vit B12 deficiency

in N. European whites
atrophic glossitis, neurologic abnormalities
loss of position & vibration sense
comorbid autoimmune dz: vitiligo, thyroid disease
complication: gastric cancer risk
--------------------------------------------------------------- Ca++-phosphate stones: primary hyper-PTH
uric acid stones: acidic urine or cell turnover
cysteine stones: inborn error of metabolism;
hexagonal crystals on U/A, positive family Hx
struvite stones: alkaline urine due to infection
with urease-producing bacteria (Proteus)
struvite stones that fill the entire renal pelvis:
staghorn calculi
--------------------------------------------------------------- Td vaccine: every 10 yrs to all adults after age 18
Tdap vaccine: one-time dose in place of Td;
also with each pregnancy, regardless of status
influenza vaccine: annually to all adults
o healthy, non-pregnant adults age < 50 may
receive live-attenuated intranasal vaccine
--------------------------------------------------------------- 13-valent pneumococcal conjugate (PCV13)
induces a T-cell-dependent B-cell response
o improves immunogenicity
o Rx all infants & young children
23-valent polysaccharide vaccine (PPSV23)
induces a T-cell independent B-cell response
o less effective in children & elderly
o Rx adults age < 65 with comorbidities
--------------------------------------------------------------- 13-valent pneumococcal conjugate (PCV13) &
23-valent polysaccharide vaccine (PPSV23)
o all age 65, 6 12 months apart
o age < 65 at high-risk: sickle cell disease,
CSF leaks, cochlear implants, asplenia,
immunocompromised, chronic renal failure
PPSV23 alone
o age 19 64 with chronic heart, lung, or liver
disease; diabetic, alcoholic, current smoker
o subsequent PCV13 & PPSV23 @ age 65

small bowel disease, surgical resection or chronic

diarrhea leads to malabsorption of fatty acids &
bile salts, predisposing to calcium oxalate stones
o unabsorbed fatty acids chelate calcium,
making oxalate free for absorption
--------------------------------------------------------------- posterior shoulder dislocation is common after
a tonic-clonic (grand mal) seizure
arm is held adducted & internally rotated
XR: light bulb sign, rim sign, trough line sign
--------------------------------------------------------------- anterior shoulder dislocation is a/w direct blow,
forceful abduction, or fall on outstretch arm
arm is held slightly abducted & externally rotated
Dx: evaluate axillary nerve function
--------------------------------------------------------------- transient unilateral weakness following a tonicclonic seizure that is self-limited: Todd paralysis
---------------------------------------------------------------Infantile hypertrophic pyloric stenosis
first-born male, age 3 5 wks
erythromycin use, formula feeding
features projectile non-bilious emesis
poor weight gain, good appetite,
dehydration, sunken fontanelles
tachypnea, olive-shaped mass
hypochloremic, hypokalemic metabolic
alkalosis with compensatory respiratory
abdominal USS
IV hydration

formula-fed infants have slow gastric emptying

& consume more volume in less time, which
stimulates growth of the pylorus muscle
prior to surgery, stabilize electrolytes with IVF;
alkalosis increases risk of post-op apnea
---------------------------------------------------------------Pediatric immunizations
inactivated (killed) polio, hepatitis A
toxoid (inactivated) diphtheria, tetanus
subunit (conjugate) hepatitis B
H. influenza Type B

influenza (injection)
live attenuated
influenza (intranasal)
administer vaccines according chronologic age
except Hep B: weight should be 2 kg
--------------------------------------------------------------- compartment syndrome can be a complication
of supracondylar humerus fractures
severe pain, pallor, poikilothermia, paresthesia;
late findings of pulselessness or paralysis
Rx: remove bandages, measure compartment
pressures, orthopedic evaluation for fasciotomy
complication: Volkmann contracture
--------------------------------------------------------------- precocious puberty: 20 sexual development;
girls < 8 yrs, boys < 9 yrs
o initial test: bone age
o next: test: basal serum LH
all elevated LH requires MRI with contrast to
r/o hypothalamic or pituitary tumors
next test: GnRH stimulation test
high or low baseline LH, with GnRH stimulation:
gonadotropin-dependent (central) precocious
o idiopathic precocious puberty: premature
hypothalamic-pituitary-gonadal axis activation;
MC in girls; LH/FSH
premature adrenarche (axillary, pubic hair),
thelarche (breasts), & menarche
advanced bone age
o Dx: brain CT or MRI
o Rx: continuous GnRH agonist
low LH/FSH at baseline, does not increase with
GnRH stimulation = gonadotropin-independent
(peripheral) precocious puberty
o gonadal or adrenal release of sex hormones
Dx: USS of adrenals, ovaries/testes
o advanced bone age, coarse axillary/pubic hair,
severe cystic acne, normal testicular volume:
non-classic (late-onset) CAH

MCC: 21-hydroxylase deficiency

accumulation of 17-hydroxyprogesterone
normal bone age with isolated premature
thelarche or adrenarche Rx: reassurance
--------------------------------------------------------------- classic CAH neonates present with adrenal
insufficiency, ambiguous genitalia, salt-wasting
late-onset CAH occurs in late childhood with
androgen excess: premature adrenarche/pubarche,
Rx-resistant cystic acne, advanced bone age,
accelerated linear growth
--------------------------------------------------------------- Leydig cell tumor gonadotropin-independent
precocious puberty
o unilateral testicular enlargement/mass
--------------------------------------------------------------- MCC of primary hypogonadism: Klinefelters
o small testes, small phallus, hypospadias,
cryptorchidism, gynecomastia,
---------------------------------------------------------------o Calcium (hypercalcemia)
o Renal failure (IgG or Bence Jones proteins)
o Anemia (Hb < 12)
o Bones (lytic lesions, fractures)
CRABs present in multiple myeloma
monoclonal plasma cell proliferation of IgG
functional antibodies & leukopenia, risk for
recurrent infection
elevated protein:albumin gap > 4
paraproteinemia results in renal failure due to
obstruction by large laminated casts
---------------------------------------------------------------Normal physiologic changes during pregnancy
o GFR & renal size
o BUN & creatinine
o urinary frequency, nocturia
o mild hyponatremia ( ADH)
o dilutional anemia
( plasma volume & RBC mass)
o prothrombotic state (risk of DVT/PE)
o cardiac & renal blood flow
progesterone directly stimulates central
medullary respiratory centers: tidal volume &
minute ventilation, PaO2, PaCO2

chronic respiratory alkalosis with

metabolic compensation ( HCO3)
--------------------------------------------------------------- neonate with lethargy, hypocapnia, high-pitch cry,
rapidly head circumference, bulging fontanelles
intraventricular hemorrhage is a common
complication premature & underweight neonates
born at < 32 wk gestation or < 1500 g
due to capillary fragility of subependymal
germinal matrix
screening: serial head USS, shows B/L IVH &
dilated ventricles
Rx: antenatal corticosteroids
complication: communicating hydrocephalus,
cerebral palsy
--------------------------------------------------------------- Arnold-Chiari & Dandy-Walker: congenital
malformations that cause non-communicating
hydrocephalus due to obstruction a CSF flow in
the posterior fossa
--------------------------------------------------------------- hepatic hydatid cysts are due to Echinococcus
granulosus from close contact with dogs or sheep
causes unilocular cystic lesion in any organ
mostly asymptomatic or compressive symptoms
hepatomegaly, RUQ pain, N/V
encapsulated cysts containing fluid & budding
cells that become daughter cysts
CT scan: egg shell calcifications
Rx: surgical resection/aspiration & albendazole
o aspiration risk of anaphylactic shock
--------------------------------------------------------------- RUQ pain, nausea, liver USS shows a smooth,
round cyst with daughter cells: Echinococcosis
definitive host: dogs
intermediate host: sheep
dead end host: humans
transmission: dogs living in close proximity to
humans are fed viscera of home-slaughtered
animals; eggs excreted by dogs in feces
--------------------------------------------------------------- brachial artery injury is a concern with
supracondylar humerus fractures
--------------------------------------------------------------- hyperemesis gravidum occurs early in pregnancy

significant vomiting leads to hypochloremic

metabolic alkalosis ( HCO3)
--------------------------------------------------------------- diabetics are at high risk of erectile dysfunction
tight glycemic control does not improve symptoms
Rx: sildenafil (PDE inhibitor)
o if taking sildenafil & alpha-blocker together,
wait at least 4 hours in between
--------------------------------------------------------------- survivors of sexual assault are at highest risk for
PTSD, depression, & suicidality
--------------------------------------------------------------- consider carbon monoxide poisoning in patients
with environmental/occupational risk factors
20 polycythemia, headache, nausea, dizziness
Hct is due to carboxyhemaglobinemia
--------------------------------------------------------------- polycythemia can cause pulmonary HTN by
increasing viscosity in the pulmonary vasculature
severe pulmonary HTN can cause polycythemia
--------------------------------------------------------------- dyspnea, hemoptysis, ankle edema, dark urine, U/A
with proteinuria, dysmorphic RBCs, & red cell casts,
CXR: B/L alveolar infiltrates: Goodpastures
pulmonary-renal syndrome as a manifestation of
anti-GBM antibodies against collagen IV, damages
glomeruli & alveolar lining
affects lungs (cough, dyspnea, hemoptysis) &
kidneys (nephritic proteinuria, ARF, dysmorphic
RBCs & red cell casts)
a/w alveolar hemorrhage & glomerulonephritis
Dx: renal biopsy shows linear IgG deposits
along glomerular BM
Rx: emergency plasmapheresis to remove
anti-GBM antibodies minimizes kidney damage
--------------------------------------------------------------- fever, exertional dyspnea, non-productive cough,
severe hypoxia, CD4 < 200: PCP pneumonia
CXR: B/L diffuse interstitial infiltrates
Dx: bronchoalveolar lavage
TMP-SMX for PCP pneumonia may experience
initial worsening of pulmonary function
o add corticosteroids to minimize the initial
pulmonary complications

alt Rx for PCP: TMP + dapsone, IV pentamidine,

oral atovaquone, or clindamycin-primaquine
--------------------------------------------------------------- male adolescent with epistaxis, visible nasal mass,
bony erosion in back of nose: angiofribroma
benign, but can erode & invade locally
--------------------------------------------------------------- reactive nasal polyps do not cause bony erosions
a/w chronic infections or allergies
--------------------------------------------------------------- giant cell tumor of bone: locally aggressive
skeletal neoplasm, benign; MC in adolescents
knee pain, swelling, decreased joint ROM
distal femur or proximal tibia
XR: osteolytic bone lesion, soap-bubble in the
epiphyseal region of long bones
Rx: surgery
--------------------------------------------------------------- loss to follow-up in prospective studies has
potential for attrition bias (selection bias)
can over- or under-estimate the association
between exposure & disease
---------------------------------------------------------------Celiacs screening:
IgA anti-tissue transglutaminase Ab assay
o IgA anti-endomysial antibodies
may be absent with selective IgA deficiency
Dx: if suspicion is high, measure total IgA
confirm Dx: upper GI endoscopy with biopsy

Features of malabsorption in celiac disease

bulky, foul-smelling, floating stools
loss of subcutaneous fat & muscle mass
pallor, fatigue, iron deficiency anemia
Ca++, vit
osteoporosis, osteomalacia
Vit K
easy bruising
Vit A
Extraintestinal symptoms of Celiacs
fatigue, weight loss
dermatitis herpetiformis, vitiligo

hematology iron deficiency anemia

peripheral neuropathy, headache
autoimmune thyroiditis, Type I DM
depression, psychosis
--------------------------------------------------------------- lidocaine: class IB anti-arrhythmic
frequency of PVCs & risk of v-fib
do not use prophylactically to prevent v-fib in
patients with acute MI
risk of asystole
---------------------------------------------------------------Pain management for terminal cancer
initially Rx: short-acting morphine; subsequent
doses titrated to achieve complete pain control
once established, switch to long-acting narcotics
(patches), with short-acting morphine PRN for
break-through pain
--------------------------------------------------------------- vesiculoureteral reflux (VUR) is a risk factor
for recurrent UTIs, leading to renal scarring
all children age 2 24 months, first febrile UTI
should undergo renal USS
Dx recurrent UTIs: voiding cystourethrogram
o not routine for first UTI
not a/w bladder cancer, RCC, abscess, or calculi
---------------------------------------------------------------Immunologic blood transfusion reactions
rapid onset shock, hypotension,
(seconds minutes) angioedema/urticaria,
respiratory distress/failure
recipient anti-IgA IgG
transient hypotension,
patients on ACE-I, caused by
reaction (minutes)
bradykinin in blood products
normally degraded by ACE
acute hemolytic
fever, flank pain, hemolysis,
(within 1 hr)
hemoglobinuria, DIC
medical emergency! direct Coombs test positive**
ABO incompatibility
fever & chills (most common)
cytokine accumulation during
(within 1 6 hrs)
blood storage (from leukocytes)
urticarial, flushing, pruritus,
(within 2 3 hr)

acute lung injury
(within 6 hrs)
delayed hemolytic
(within 2 10 days)

recipient IgE & mast cell

respiratory distress, noncardiogenic pulmonary edema
donor anti-leukocyte Abs
mild fever & hemolytic anemia
direct Coombs test positive
anamnestic Ab response to
RBC antigen

leukocytes release cytokines during blood storage

that cause transient fever, chills, & flank pain;
causes febrile non-hemolytic reaction
o prevented by using leuko-reduced blood
IgA-deficient individuals are at risk for
anaphylactic transfusion reactions
o Rx: IM epinephrine, vasopressors, histamine
blockers, glucocorticoids
o future transfusions: IgA-deficient plasma &
washed RBC products
--------------------------------------------------------------- altered mental status, acute renal failure, fever,
hemolytic anemia, thrombocytopenia: TTP
reticulocytosis, indirect bilirubin, schistocytes
Dx: clinical; ADAMTS13 not used for diagnosis
Rx: plasma exchange

Indications for specialized RBC treatments

BM transplant recipients,
cellular immunodeficiency,
blood donated by 10 or 20 relative
Leukoreduced chronic transfusions,
CMV at-risk patients (AIDS),
Hx of febrile non-hemolytic rxn,
potential transplant recipient,
IgA deficiency,
complement-dependent autoimmune
hemolytic anemia,
urticaria despite antihistamines
--------------------------------------------------------------- Cat-scratch disease: Bartonella henselae
local skin lesion evolves through vesicular,
erythematous, papular phases
tender, localized, regional lymphadenopathy

Rx: azithromycin (5 days) to reduce symptoms,

but mainly self-limited
--------------------------------------------------------------- membranous glomerulonephritis is a/w Hep B
focal segmental glomerulosclerosis are MC a/w
HIV, blacks, HTN, obesity, IVDA, sickle cell
o segmental sclerosis & hyalinosis
--------------------------------------------------------------- collagenous colitis: chronic watery diarrhea
colonoscopy: normal mucosa
biopsy: mucosal subepithelial collagen deposits
--------------------------------------------------------------- anorexia, fatigue, weight loss, cognitive impairment,
Hx of IVDA: HIV testing
HIV patients are at risk of depression & dementia
DDx: MDD, chronic primary adrenal insufficiency,
iron deficiency anemia
--------------------------------------------------------------- phenytoin & carbamazepine: block voltage-gated
Na+ channels
Rx primary generalized tonic-clonic seizures
with/without secondary generalization
A/E for both: SJS/TEN, fetal hydantoin syndrome
phenytoin A/E: gingival hypertrophy
--------------------------------------------------------------- phenobarbital: acts at GABA receptors by
extending GABA-mediated Ca++ channels open
A/E: sedation
PaCO2 corrects
with O2?
reduced inspired O2
normal normal yes
tension (high altitude)
(CNS depression)
diffusion limitation

normal yes
(interstitial lung dz)
intracardiac shunt,

normal NO
extensive ARDS
V/Q mismatch

normal yes
(obstructive disease,
pulmonary edema,
atelectasis, pneumonia)

Alveolar-arterial gradient: estimates the degree

of alveolar oxygen transfer to blood
o normal: < 15 ( with age); > 30 is elevated
patients with Hx of CAD & sudden onset dyspnea
after IV fluids is likely pulmonary edema
o pulmonary edema the A-a gradient due to
V/Q mismatch; excess fluid reduces lung
compliance by preventing alveolar expansion
o Rx: supplemental O2
extensive ARDS results in a poorly aerated lung
that is stiff & less compliant
left-to-right shunts (VSD) lowers lung compliance
by pulmonary blood flow, causing fluid leakage
into the interstitium
--------------------------------------------------------------- Hx of travel to endemic area (Mexico), dysentery,
RUQ pain, single cyst in right lobe of liver:
amebic liver abscess (E. histolytica)
primary infection in the colon bloody diarrhea
Dx: trophozoites in stool, serology, or imaging to
r/o pyogenic abscess
Rx: empiric metronidazole
o also paromomycin (luminal agent to
eradicate intestinal colonization)
o do not drain the abscess
DDx: pyogenic liver abscess (2/2 surgery, GI
infection, acute pancreatitis), hepatic adenoma
(solid lesion), hydatid cyst (Echinococcus)
--------------------------------------------------------------- gross hematuria a/w URI, HTN, proteinuria,
RBC casts, AKI: glomerulonephritis


IgA nephropathy
within 5 days of URI
men, age 20 30 yrs,
recurrent gross


normal C3
Bx: mesangial IgA

Post-infectious GN
10 21 days after URI
age 6 10 or adults
gross hematuria
adults: asymptomatic
or acute nephritic
low C3**
elevated ASO &/or
anti-DNase B
Bx: subepithelial

humps with C3
children: good
if RPGN or nephrotic adults: CKD
syndrome (worse Px)
--------------------------------------------------------------- B/L sensorineural hearing loss, recurrent hematuria,
ocular abnormalities, renal insufficiency: Alports
X-linked defect in collagen IV formation
normal complement levels
EM: thin & thick capillary loops, GBM splitting,
tram-track appearance
--------------------------------------------------------------- necrotizing fasciitis: erythema & swelling,
severe pain out of proportion to physical exam
involves subcutaneous tissue & deep fascia
systemic symptoms: fever, hypotension
signs of tissue necrosis: crepitus, purulent drainage,
radiographic evidence of gas in deep tissues
rapidly progresses to discoloration, bullae, necrosis
MCC: Group A Strep
Rx: surgical debridement & ABX
DDx: abscesses, cellulitis, deep muscle hematoma,
--------------------------------------------------------------- anti-ischemic & anti-anginal effects of nitrates
are due to systemic vasodilation
o concomitant use of -blockers prevents
reflex tachycardia caused by nitrates
--------------------------------------------------------------- recurrent epistaxis, ruby-colored papules on the
lips that blanch, widespread AVMs: hereditary
telangiectasia (Osler-Weber-Rendu syndrome)
AVMs occur in mucous membranes, skin, GIT
diffuse telangiectasias, digital clubbing
pulmonary AVMs can cause R-to-L cardiac shunt,
resulting in hypoxemia & reactive polycythemia; &
massive hemoptysis
--------------------------------------------------------------- Henoch-Schonlein Purpura: systemic form of IgA
involvement of glomeruli, skin, joints, intestines
---------------------------------------------------------------Causes of postoperative fever (> 380C)
PE, pneumonia, aspiration



drug fever, IV lines
blood products

Timeline course of post-operative fever

immediate (0 -2 hr): prior trauma/infection,
transfusion reaction, malignant hyperthermia
acute (1 day 1 wk): nosocomial infections (UTI),
SSI (GAS, or C. perfringens), MI, PE/DVT
subacute (> 1 wk, < 1 mo): drug fever, PE/DVT,
C. difficile, other SSIs, catheter site infection
delayed (> 1 mo): viral, indolent SSIs, IE
--------------------------------------------------------------- fever, rash, peripheral eosinophilia: drug fever
--------------------------------------------------------------- severe, acute-onset mid-abdominal pain out of
proportion to physical exam findings, N/V: acute
mesenteric ischemia
MCC is an embolus
progression to bowel infarction causes
peritoneal signs & bloody stool
--------------------------------------------------------------- coagulase-negative staphylococci (S. epidermidis)
is the MCC of nosocomial bloodstream infections
with intravascular devices (triple-lumen catheter)
--------------------------------------------------------------- Staph saprophyticus (coagulase negative):
common cause of uncomplicated acute cystitis
a young, sexually active females
--------------------------------------------------------------- MCC of community-acquired pneumonia:
Strep pneumo, H. influenza, Mycoplasma
Rx: empiric ABX; isolating causative organism
is difficult
management of CAP requires risk assessment for
hospitalization using the CURB-65 algorithm
o Confusion
o Uremia (BUN > 20 mg/dL)
o Respiratory (RR > 30)
o BP (< 90/60 mmHg)
o age > 65
score > 2: inpatient
score 4 : ICU

healthy: doxycycline or macrolide

comorbidities: fluoroquinolone,
OR beta-lactam + macrolide
fluoroquinolone, OR
beta-lactam + macrolid
beta-lactam + macrolide (IV), OR
beta-lactam + fluoroquinolone
ICU patient ABX to cover: S. aureus, Legionella,
--------------------------------------------------------------- copious white/yellow vaginal discharge, nonmalodorous, absence of other findings on vaginal
exam: physiologic leukorrhea
--------------------------------------------------------------- stillbirth: 20 wks gestation
risk factors: HTN, DM, adv maternal age, smoking
Stillbirth delivery options
D&C (up to 24 wks)
spontaneous delivery
3rd trimester
induction with oxytocin (preferred)
(after 28 wks) spontaneous delivery
spontaneous delivery occurs within 2 wks
vaginal birth after c-section increases risk of
uterine rupture, but vaginal delivery is preferred
regardless of prior cesarean
--------------------------------------------------------------- hemarthrosis after minor trauma in a young child
is suspicious for bleeding disorder
screening: coagulation studies & CBC
--------------------------------------------------------------- fever, dysphagia, odynophagia, neck pain with
movement (particularly neck extension), trismus
(jaw spasm): retropharyngeal abscess
Dx: neck CT &/or lateral radiographs
Rx: IV ABX, drainage
DDx: meningitis, herpangina, epiglottitis, IM
--------------------------------------------------------------- high fever, severe sore throat with dysphagia,
ulcerative lesions on palate, tonsils, & pharynx:
MCC: Coxsackie A
gray vesicles/ulcers on posterior oropharynx
lesion on palms & soles = hand-foot-mouth disease
2nd trimester

Rx: supportive; self-limited within 1 wk

DDx: gingivostomatitis (anterior oropharynx)
--------------------------------------------------------------- peritonsilar abscess is a complication of tonsillitis
muffled voice, uvula deviation, & prominent
unilateral lymphadenopathy
Rx: IV ABX & urgent abscess needle aspiration
--------------------------------------------------------------- retroperitoneal hematoma can occur without a
supratherapeutic INR while on warfarin
back pain, hemodynamic compromise
Dx: abdominal CT
DDx: RCC, vertebral fracture, hydronephrosis
--------------------------------------------------------------- primary inciting event of acute cholecystitis is
gallstone obstruction in cystic duct; no jaundice
ALP is a/w cholangitis or choledocholithiasis;
+ jaundice
--------------------------------------------------------------- OGTT in all pregos @ 24 28 wk gestation to
screen for gestational diabetes
o screen with 1 hr 50g OGTT
o confirm with 3 hr 100g OGTT
risk factors: obesity, family Hx of DM, excessive
weight gain during pregnancy
high risk or symptomatics (polyuria, polydipsia)
should undergo HbA1C & fasting glucose at the
first prenatal visit
--------------------------------------------------------------- pregos at high risk of fetal aneuploidy require
cell-free fetal DNA testing
---------------------------------------------------------------Rx acute cystitis & pyelonephritis in non-pregos
uncomplicated oral nitrofurantoin (5 days)
TMP-SMX (3 days)
fosfomycin (single dose)
**requires urine culture prior to Rx
fluoroquinolones (5 14 days), but
not for pregos
**requires urine culture prior to Rx
outpatient: oral fluoroquinolones
(ciprofloxacin, levofloxacin)
inpatient: IV fluoroquinolones, or
aminoglycoside +/- ampicillin

dysuria, urinary frequency, suprapubic tenderness:

uncomplicated cystitis
Dx: U/A; urine culture only if initial Rx fails
--------------------------------------------------------------- complicated cystitis: factors that increase risk of
ABX resistance or Rx failure (diabetes, CKD,
urinary tract obstruction, nosocomial infection,
indwelling catheters, pregos, immunocompromised)
Dx: obtain urine culture prior to Rx
--------------------------------------------------------------- failure to thrive, persistent diarrhea, lymphopenia
recurrent fungal, viral & bacterial infections
ADA deficiency (SCID): deficient formation of
mature B & T lymphocytes 2/2 toxic accumulation
of adenosine
--------------------------------------------------------------- complement deficiencies risk of autoimmune
--------------------------------------------------------------- chronic granulomatous disease: defective
intracellular killing due to impaired respiratory
burst from active phagocytes
--------------------------------------------------------------- opsonization defects result from asplenia
o infection with encapsulated bacteria
--------------------------------------------------------------- insulin-like growth factor (IGF-1) is used to
screen for acromegaly
o GH levels fluctuate (diurnal)
IGF-1 oral glucose suppression test
o adequate GH suppression rules out acromegaly
o inadequate GH suppression brain MRI to
look for a pituitary mass
--------------------------------------------------------------- psychological defense mechanisms serve to
decrease anxiety
immature defense mechanisms: used by
children/adolescents, socially unacceptable
behavior that prevents coping with reality
neurotic defense mechanisms: used by adults,
short-term relief, with long-term complications
mature defense mechanisms: used by adults;
healthy & constructive approach to reality

reaction formation: substituting behavior/feelings

that are opposite of their own unacceptable feelings
sublimation: consciously unacceptable
instinctual drives are diverted into socially or
personally acceptable activities (channeling
explosive anger into athletic pursuits)
dissociation: temporarily eliminating a memory
or perception of themselves or environment to
avoid a problem or distressing situation
suppression: intentionally postponing the
exploration of anxiety-provoking thoughts by
substituting other thoughts
displacement: shifting emotions a/w an upsetting
object/person to a safer alternative that represents
the original in some regard
acting out: enacting an unconscious wish or
fantasy through impulsive physical action to
avoid painful feelings
--------------------------------------------------------------- fluid resuscitation & IV dexamethasone: Rx
acute adrenal insufficiency
IV dantrolene: Rx malignant hyperthermia
--------------------------------------------------------------- renal compensation for respiratory alkalosis:
excretion of HCO3 in urine (high urine pH)
contraction alkalosis occurs in states of
intracellular volume contraction, where levels
of aldosterone restores intravascular volume, but
also urinary H+ loss
--------------------------------------------------------------- orchitis is the MC complication of mumps
other complications: aseptic meningitis, encephalitis
--------------------------------------------------------------- SIDS is more frequent in males, age 2 4 months,
& low socioeconomic status
--------------------------------------------------------------- HTN can be a presenting sign of polycythemia
plethoric face, splenomegaly
incidence of peptic ulcers (histamine release
from basophils) & gouty arthritis ( cell turnover)
--------------------------------------------------------------- abrupt onset severe headache, meningeal irritation
with neck pain/stiffness: SAH
Dx: non-contrast head CT within 24 hr
o lumbar puncture if CT is normal

rebleeding is a major cause of death within 24 hrs

vasospasm is a delayed complication of SAH
(after 3 days), resulting in cerebral infarct
Dx: CT angiography
Rx: prevented with nimodipine (CCB)
--------------------------------------------------------------- lone A-fib: paroxysmal, persistent, or permanent
a-fib without cardiopulmonary or structural heart
disease; CHADS2 score = 0
Rx: no anticoagulation
--------------------------------------------------------------- smoke inhalation injury victims (house fire):
empiric Rx for cyanide toxicity
o HCN & CO
Rx: empiric IV hydroxocobalamin, or
sodium thiosulfate (directly binds CN)
o nitrates to induce methemoglobinemia;
increases ferric iron (Fe3+) to bind CN
Rx cyanide ingestion: activated charcoal
--------------------------------------------------------------- CN potently inhibits cytochrome oxidase a3 of the
ETC & binding Fe3+, thus prevents reduction to
Fe2+ & ATP production promotes anaerobic
metabolism metabolic acidosis (lactic acidosis)
with respiratory compensation (tachypnea)
--------------------------------------------------------------- methmoglobinemia occurs with exposure to
oxidizing agents: dapsone, nitrates, topical/local
anesthetics; formed by oxidation of Fe2+ Fe3+
affinity of Fe2+ to O2 (left shift), thus reduces
O2 delivery to tissues
Fe3+ binds avidly to CN; unable to bind O2
Rx: methylene blue
--------------------------------------------------------------- all pregos should receive inactivated influenza
& TdaP vaccinations
---------------------------------------------------------------Colon cancer screening options begin at age 50
o colonoscopy every 10 yr
(most sensitive & specific test, but $$$)
o FOBT annually
o flexible sigmoidoscopy every 5 yr
+ FOBT every 3 yr
high risk polyps: F/U colonoscopy ever 3 5 yrs

granulosa cell tumor: solid malignant ovarian

tumor that produce excess estrogen
bimodal age distribution
o presents as isosexual precocious puberty or
postmenopausal bleeding & uterine
Rx: tumor removal results in symptom regression
--------------------------------------------------------------- dysgerminoma: malignant ovarian tumor
women age < 20 yr
unilateral; can undergo torsion
undifferentiated gonadal germinal cells
neutral; does not secrete sex hormones
testes equivalent = seminoma
--------------------------------------------------------------- sertoli-leydig cell tumor: produce androgens,
causes defeminization, then masculinization in
child-bearing age women
serous cystadenomas: MC benign cystic ovarian
neoplasm; no estrogen or androgens
o ovarian mass & abdominal pain
---------------------------------------------------------------Constipation in children
risk factors
transition to solid foods & cows milk,
toilet training, & school entry


anal fissures, hemorrhoids, vomiting,

encopresis, enuresis, recurrent cystitis
dietary fiber, limit cows milk < 24 oz
oral laxative (polyethylene glycol,
mineral oil)

recurrent cystitis in toddlers 2/2 constipation can

cause rectal distension compresses the bladder
resulting in urinary stasis
--------------------------------------------------------------- musculoskeletal infections (osteomyelitis, abscess)
results from hematogenous spread from other
sites such as the skin (furuncles)
MCC S. aureus
--------------------------------------------------------------- if anion gap is markedly elevated with absence of
frank uremia, calculate osmolar gap to assess for
ethanol, methanol, or ethylene glycol intoxication
o high osmolar gap & severe metabolic acidosis

--------------------------------------------------------------- ethylene glycol poisoning (anti-freeze) is a/w

hypocalcemia & calcium oxalate deposition
flank pain, hematuria, oliguria, AKI, profound
anion gap metabolic acidosis (HCO3 < 8)
U/A: rectangular, enveloped-shaped crystals is
a/w Ca++ oxalate
Rx: fomepizole or ethanol to inhibit alcohol
dehydrogenase; sodium bicarbonate to relieve
acidosis, & hemodialysis for severe acidosis
&/or end-organ damage
--------------------------------------------------------------- methanol poisoning: vision loss & coma
within 24 hr: headache, N/V, epigastric pain
optic disc hyperemia
slurred speech,
high osmolar gap,
ketoacidosis unsteady gait,
anion gap
altered mentation
metabolic acidosis
due to ketosis
visual burning,
high osmolar gap,
central scotoma,
anion gap
afferent pupil defect, metabolic acidosis
altered mentation,
acute pancreatitis
flank pain, oliguria,
high osmolar gap,
hematuria, tetany,
anion gap
(KIDNEYS) CN palsy
metabolic acidosis,
CNS depression,
high osmolar gap,
disconjugate gaze,
NO anion gap,
absent ciliary reflex
NO metabolic
--------------------------------------------------------------- NPV: probability of being disease-free if test
result is negative
NPV varies with the pretest probability of disease
o high probability of disease = low NPV
o low probability of disease = high NPV
prevalence is directly related to pretest probability
o sensitivity & specificity to not vary with
pretest probability

#1 Rx major depression: SSRI

Dx: must have depressed mood or anhedonia
with at least 4 symptoms of SIGECAPS
for patients with advanced cancer, also consider
adjustment disorder w/ depressive features
o symptoms must occur within 3 months
---------------------------------------------------------------Antipsychotic extrapyramidal effects
(related to degree of D2 blockade)
a/w high-potency typical antipsychotic, acute dystonic
onset after 4 hours to 4 days,
sudden, sustained contraction of neck,
mouth, tongue, EOM, opisthotonus
Rx: benztropine (anticholinergic) or
diphenhydramine (antihistamine)
subjective restlessness,
onset can occur at anytime
Rx: benzodiazepine (lorazepam) or
beta-blocker (propranolol)
onset within 4 days to 4 months;
tremor, rigidity, bradykinesia
Rx: benztropine or amantadine
onset within 1 6 months;
dyskinesia of mouth/face, extremities;
lip smacking, puckering, biting,
grunting, tongue protrusion
no effective treatment
--------------------------------------------------------------- atypical antipsychotic most likely to cause EPS:
Rx: replace with clozapine; least likely for EPS
o CBC before starting clozapine
--------------------------------------------------------------- amiodarone: Rx conversion & maintenance of
sinus rhythm for patients with a-fib
does not prevent thrombus formation
---------------------------------------------------------------Running injuries of the foot &ankle
a/w sudden in activity,
insidious, localized pain in navicular
or metatarsals; microfractures that
coalesce within cortical bone,
burning pain, worse when initiating
first steps of the day,
pain decreases with activity, but

worsens with prolong weight-bearing

burning pain or stiffness 2 to 4 cm
above posterior calcaneus
numbness/pain between 3rd & 4th toe, Morton
clicking sensation when palpating
plantar space between 3rd & 4th toes
while squeezing metatarsal joints
compression of tibial nerve at ankle
Tarsal tunnel
burning, numbness, aching of distal
plantar surface; MCC: ankle fx
--------------------------------------------------------------- placenta previa: painless, 3rd trimester bleeding
hemorrhage is fetal origin
no fetal deterioration
risk factors: prior placenta previa, prior c-section
or uterine surgery, multiparity, adv maternal age
Dx: transabdominal, then transvaginal USS
no digital vaginal exam before USS due to
risk of massive hemorrhage
Rx unstable mother, regardless of gestational age:
emergency c-section
Rx stable mother, fetus at term: scheduled c-section
Rx stable mother, fetus not at term: expectant;
amniocentesis @ 36 wks to assess lung maturity
o if lungs mature scheduled c-section
--------------------------------------------------------------- abruptio placenta: hypertonic, uterine tenderness
premature separation due to hemorrhage in
decidua basalis; hemorrhage is maternal origin
MC risk factor: HTN
--------------------------------------------------------------- vasa previa: painless, antepartum hemorrhage
upon ROM with rapid deterioration of fetal tracing
(sinusoidal tracing); no maternal symptoms
hemorrhage is fetal origin
fetal death by exsanguination
Dx: antenatal transvaginal Doppler USS
Rx: emergency c-section
--------------------------------------------------------------- uterine rupture: sudden onset intense pain,
vaginal bleeding, hyperventilation, tachycardia
hemorrhage is maternal origin
fetal deterioration, palpable fetal parts
--------------------------------------------------------------- cord prolapse occurs with rupture of membranes

deep, recurring variable decelerations; painless

--------------------------------------------------------------- placenta acreta: implantation of villi into
myometrium; abdominal pain & vaginal bleeding
risk factor: prior c-section when placenta is next
to uterine scar (low-lying anterior)
--------------------------------------------------------------- uterine atony: painless postpartum hemorrhage
--------------------------------------------------------------- PEP after a bite wound from wild carnivore
o MCC raccoons; exposure to saliva
rabies post-exposure prophylaxis: rabies Ig &
rabies vaccine immediately (passive & active)
hydrophobia & aerophobia: encephalitic rabies
ascending flaccid paralysis
--------------------------------------------------------------- post-menopausal female with vaginal dryness,
pruritus, dysuria; pale, dry vaginal mucosa,
diminished labial fat pad, scarce pubic hair:
atrophic vaginitis
Dx: Hx & physical findings
Rx: vaginal estrogen (moderate/severe cases),
moisturizers/lubricants (mild)
--------------------------------------------------------------- Rx vulvar lichen planus & lichen sclerosis:
high-potency corticosteroid cream
--------------------------------------------------------------- risk stratification of stroke using CHADS2 for
all a-fib to assess for long-term anticoagulation
anti-thrombotic therapy with warfarin (or
dabigatran, rivaroxaban, apixaban) is the most
effective at risk of systemic embolization with
nonvalvular a-fib
ASA is less effective in preventing
thromboembolic events
ASA + clopidogrel is better than ASA alone, but
inferior to warfarin
--------------------------------------------------------------- tinnitus, fever, hyperventilation: ASA overdose
o mixed anion gap metabolic acidosis &
respiratory alkalosis; no osmolar gap
Rx: sodium bicarbonate
---------------------------------------------------------------Complications in DES exposed daughters

clear cell adenocarcinoma of vagina & cervix

structural abnormalities of reproductive tract
--------------------------------------------------------------- endometrial adenocarcinoma risk factors:
prolonged estrogen stimulation (early menarche,
late menopause, obesity, chronic tamoxifen use)
--------------------------------------------------------------- #2 highly malignant bone tumor, common with
children in lower extremity: Ewings sarcoma
white males, < age 20 yr
joint pain & swelling for weeks or months
MC sites: metaphysis & diaphysis of femur; also
tibia & humerus
commonly mets to lungs & lymph nodes
XR: central lytic lesion was endosteal scalloping;
onion-skin periosteal reaction, followed with
moth-eaten or mottled appearance
DDx: osteomyelitis (fevers, leukocytosis, local
joint pain, swelling, anemia, ESR)
--------------------------------------------------------------- asbestos exposure risk of pulmonary fibrosis
& malignancy (x6)
MC malignancy is bronchogenic carcinoma
smoking synergistically lung cancer risk
symptoms develop 20 yrs after initial exposure
cough, sputum, & wheezing not typically present
progressive dyspnea, bibasilar end-inspiratory
crackles & clubbing
CXR: bibasilar reticulonodular infiltrates,
honeycombing, B/L pleural thickening
o pleural plaques
--------------------------------------------------------------- asbestos is the only risk factor for malignant
pleural mesothelioma
CXR: unilateral pleural abnormality with a large
pleural effusion
--------------------------------------------------------------- pulsus paradoxus is a frequent finding of cardiac
tamponade, but also severe asthma or COPD
--------------------------------------------------------------- Proteus is the most likely cause of UTI in those
with alkaline urine, due to its secretion of urease,
forming struvite stones, a source of bacteria
formation of ammonium increases urine pH

chronic indwelling urinary catheters are a

source of urease-producing bacteria (Proteus)
--------------------------------------------------------------- elderly patients with anemia, renal failure,
hypercalcemia, back pain, recurrent infections:
multiple myeloma
total serum protein, normal albumin
ESR > 100, +Bence Jones proteins
Dx: serum immunoelectrophoresis shows M-spike
due to IgG production by plasma cells
--------------------------------------------------------------- internal carotid artery dissection is a potential
cause of stroke in children
o delayed stroke symptoms after trauma
Hx of trauma to the soft palate with a foreign body
--------------------------------------------------------------- acute bronchitis commonly cause new onset
blood-tinged sputum; MCC is viral URI
mild wheezing & ronchi that clear with coughing
epithelial sloughing makes yellow/purulent sputum
Rx: supportive, observation
if recurrent/active bleeding > 30 mL, risk factors
for malignancy, or abnormal CXR
o Dx: high-resolution chest CT
--------------------------------------------------------------- pulmonary airway disease (chronic bronchitis,
bronchogenic carcinoma, bronchiectasis) is
MCC of hemoptysis in adults with a Hx of
chronic bronchitis: chronic productive cough
for 3 months in 2 successive years; a/w smoking
bronchiectasis: irreversible dilation & destruction
of bronchi results in chronic productive cough &
inadequate mucus clearance
o high-resolution CT: dilated bronchi &
bronchial thickening
o complication: hemoptysis
o Rx: bronchial artery embolization
a/w Hx of recurrent URI & chronic production of
mucopurulent sputum with airway drainage
crackles, ronchi, & wheezing are common
---------------------------------------------------------------Common causes of hemoptysis
chronic bronchitis, PE,
bronchiectasis, Mallory-Weiss,

lung cancer
MS/acute pulmonary edema
TB, lung abscess
AVMs, severe thrombocytopenia
Wegeners, Goodpastures,
SLE, vasculitis
---------------------------------------------------------------Diabetic autonomic neuropathy
tachycardia, postural hypotension,
impaired exercise tolerance
peripheral dry skin, pruritus, retinopathy,
foot ulcers, poor would healing
Charcot arthropathy ( fx risk)
gastroparesis, delayed gastric emptying
esophageal dysmotility, dyspepsia
erectile dysfunction, decreased libido
neurogenic bladder, urinary retention,
overflow incontinence, high PVR,
--------------------------------------------------------------- foot ulcers are graded from 0 - 5
Management of diabetic foot ulcers
o off-loading
o debridement
o wound dressing
o revascularization
o amputation
--------------------------------------------------------------- Hx of cyanotic congenital heart disease &
recurrent sinusitis predisposes to brain abscess
o direct spread from sinuses to frontal lobe
cyanotic heart disease hematogenous spread
fever, headache, focal neurologic deficits, seizure
indolent process
--------------------------------------------------------------- urinary diverticulum: outpouchings of the
bladder or urethra into adjacent tissue
MC in women
post-void dribbling, dysuria, dyspareunia
urinary stasis leads to recurrent cystitis/UTI
--------------------------------------------------------------- post-op adhesions cause mechanical SBO
congenital adhesions: Ladds bands

DDx: acute cholecystitis, acute pancreatitis,

PUD, Crohns, SMA syndrome
--------------------------------------------------------------- prodromal fever, irritability, skin tenderness,
followed by generalized erythema & superficial
flaccid blisters; + Nikolsky sign: Staphylococcal
scalded skin syndrome
scaling & desquamation (5 days), then resolution
within 1 2 wks
children age < 10 yrs
superficial flaccid blisters with flexural accentuation,
perioral crusting, & facial edema
--------------------------------------------------------------- erythema multiforme: targetoid papule or plaque,
acrofacial distribution, involves palms & soles
a/w HSV, coccidiomycosis, Mycoplasma
--------------------------------------------------------------- use dependence: enhanced pharmacologic effects
during faster HR (Class IC & IV antiarrhythmics)
flecainide (class IC): Rx a-fib for maintenance
of sinus rhythm with structurally normal hearts
o slowest rate of drug binding & dissociation
from Na+ channel receptors
o normally does not prolong QRS or QT
o faster HR causes progressive impulse
conduction, leading to wide QRS
Rx: supraventricular arrhythmia
--------------------------------------------------------------- non-dihydropyridine CCB (verapamil, diltiazem)
displays use dependence by prolonging AV node
refractory period, thus PR interval
--------------------------------------------------------------- Digoxin: inhibits ATPase-dependent Na+/K+
pump, thus intracellular Na+
o results in decreased Na+/Ca++ exchanger,
thus intracellular Ca++
enhances vagal tone & slows AV node conduction
Rx: systolic dysfunction (+inotrope)
--------------------------------------------------------------- excisional biopsy with narrow margins & depth
through SC fat is preferred for Dx of melanoma
tumors > 1 mm in depth should have a sentinel
lymph node study
depth is the most important prognostic factor

mild TBI with GCS 13 15, vomiting, headache,

seizure, LOC < 5 min, focal neurologic finding,
altered mental status: CT without contrast &
observation 4 6 hr
hospitalization unnecessary unless CT is abnormal
provide detailed return precautions upon discharge
--------------------------------------------------------------- minor head trauma: GCS = 15 with non-severe
mechanism, no vomiting, no headache, no LOC,
no signs of skull fx: no head CT
serious TBI: GCS < 13, prolonged LOC,
neurologic deficits, signs of basilar skull fx:
requires neuroimaging, inpatient monitoring
(neuro exam q2h), & neuro consult
---------------------------------------------------------------DDx of stridor in infants/children
age 6 mo 6 yrs
(laryngotracheo parainfluenza virus
barky cough, inspiratory stridor
fever, rhinorrhea, congestion
Rx: nebulized racemic epinephrine
stridor, dysphagia, excess drooling,
high fever, tachypnea, tachycardia
muffled hot potato voice
lateral XR: thick aryepiglottic folds
age 4 8 months
stridor worsens when supine,
improves when prone
foreign body
age 6 mo 4 yr
acute onset inspiratory stridor,
focal monophonic wheezing,
moderate/severe respiratory distress
Vascular ring
age < 1 yr; difficulty feeding
wheezing, cough, dysphagia
improves with neck extension,
a/w cardiac abnormalities

vascular ring: does not improve with corticosteroids,

racemic epinephrine, or bronchodilators; requires
high index of suspicion
o Dx: barium contrast esophagogram,
bronchoscopy, CT or MRA
o Rx: surgical correction

dry, rough skin with horny plates over extensor

surfaces: ichthyosis vulgaris
lizard skin; worsens in winter
--------------------------------------------------------------- medulloblastoma: pediatric tumor
nocturnal or morning headaches, ataxia
a/w posterior vermis syndrome: truncal dystaxia
--------------------------------------------------------------- method to improve communication of relevant
info during patient transfers: sign-out checklist
--------------------------------------------------------------- exercise-induced bronchoconstriction Rx:
short-acting -agonist (albuterol) 10 20 min prior
alt Rx: montelukast or inhaled steroids daily
--------------------------------------------------------------- cirrhosis & ascites with fever or mental status
change: spontaneous bacterial peritonitis (SBP)
hypotension, hypothermia, or paralytic ileus
indicates severe infection
MCC: E. coli & Klebsiella
Dx/Rx: paracentesis (performed before ABX)
Dx = PMN count > 250, +culture
SAAG > 1.1 g/dL (indicates portal HTN)
Rx: empiric 3rd gen cephalosporin (cefotaxime)
--------------------------------------------------------------- Riluzole (glutamate inhibitor) Rx: ALS
corticosteroids: Rx acute exacerbations of MS
--------------------------------------------------------------- hepatic adenoma: benign tumor common in
young/mid-aged women; chronic OCP use
solitary mass in right hepatic lobe
Bx: sheets of enlarged hepatocytes containing
glycogen & lipid deposits
Rx: surgical resection if symptomatic
complications: intra-tumor hemorrhage &
malignant transformation ( AFP)
--------------------------------------------------------------- abdominal fat pad Bx for suspected amyloidosis
--------------------------------------------------------------- IgM spike on electrophoresis, hyperviscocity
due to excess IgM: Waldenstroms
anemia, lymphadenopathy, hepatosplenomegaly

DDx: MM (involve IgG or IgA), MGUS (mild

symptoms or asymptomatic)
--------------------------------------------------------------- serum protein with normal albumin (gamma gap)
o DDx: multiple myeloma, amyloidosis,
Waldenstroms, MGUS
monoclonal gammopathy uncertain significance
(MGUS) can be differentiated from MM by
absence of renal insufficiency, hypercalcemia,
anemia, & lytic bone lesions
o MGUS is asymptomatic; 1% per year risk
of progression to MM
Dx: metastatic skeletal bone survey to exclude
lytic bone lesions that suggest MM
--------------------------------------------------------------- single photon emission CT (SPECT) scan is useful
for evaluating CAD; indicates inducible ischemia
when a reversible defect is noted on stress & at rest
Rx: antiplatelets (ASA)
--------------------------------------------------------------- metformin can cause lactic acidosis if given to
patients predisposed to hypoxia (CVD, CKD)
--------------------------------------------------------------- male infant, recurrent pneumonia & otitis media
after age 6 9 months: Brutons
XR defect in B-cell tyrosine kinase
all serum Igs & B-cells levels decreased
recurrent pyogenic infections (S. pnemo, H. infl)
maternal IgG maintained for first 6 months
--------------------------------------------------------------- CVID: serum Igs decreased; similar to Brutons
less severe symptoms & later onset (age 15 35 yrs)
normal circulating B cells
--------------------------------------------------------------- neonate with hypocalcemic seizures: DiGeorge
--------------------------------------------------------------- mortality benefits in CHF: ACE-I, -blockers,
ARB, spironolactone
digoxin decreases hospitalizations in CHF
dobutamine: temporary Rx for severe
decompensated CHF to improve contractility, but
risk for arrhythmia
--------------------------------------------------------------- Friedrich ataxia: MC spinocerebellar ataxia
AR, median survival rarely beyond 20 yrs

gait ataxia, frequent falls, dysarthria

concentric cardiac hypertrophy, scoliosis,
hammer toes
MCC death: cardiomyopathy
---------------------------------------------------------------Causes of AUB in premenopausal women
o structural: fibroids, adenomyosis,
endometrial polyp, malignancy
o non-structural: coagulopathy, infection
o ovulatory dysFx: prolactinoma, PCOS,
thyroid disorder, eating disorder, weight loss
#1 Dx: exclude pregnancy
Dx: endometrial Bx
--------------------------------------------------------------- postmenopausal women with AUB are at high risk
for endometrial cancer
Dx: transvaginal USS, then endometrial Bx

endometrial biopsy is indicated for evaluating

abnormal uterine bleeding for.
all women 45 & all postmenopausal bleeding
women < 45 with persistent symptoms or risk
factors for endometrial cancer
unopposed estrogen exposure (obesity, PCOS)
prolonged amenorrhea with anovulation
---------------------------------------------------------------Risk factors
Endometrial carcinoma
Breast cancer
advancing age
family Hx
unopposed estrogen
chronic tamoxifen
early menarche
late menopause
prolonged HRT
chronic anovulation
---------------------------------------------------------------Endometrial biopsy for AUB
hyperplasia without atypia (< 3% cancer risk)
Rx: progestin therapy to oppose estrogen
F/U in 3 months to assess response
hyperplasia with atypia (30% cancer risk)
if considering pregnancy progestin
if no pregnancy plans hysterectomy

--------------------------------------------------------------- endometrial ablation is contraindicated with

endometrial hyperplasia; prevents future
evaluation of the endometrium by biopsy
--------------------------------------------------------------- peripheral artery aneurysm: pulsatile mass that
compresses adjacent structures, results in
thrombosis & ischemia
anterior thigh pain 2/2 femoral nerve compression
popliteal & femoral artery aneurysm are a/w AAA
#1 MCC: C. trachomatis
#2 MCC: N. gonorrhea (urethritis & PID)
o 50% asymptomatic
o friable cervix with easy bleeding,
mucopurulent discharge
Rx uncomplicated gonococcal cervicitis/urethritis:
ceftriaxone + azithromycin or doxycycline,
which covers resistant gonococci & simultaneous
Rx C. trachomatis
do not delay empiric Rx to confirm Dx
Dx: nucleic acid amplification testing
--------------------------------------------------------------- amiodarone causes pulmonary toxicity
related to cumulative dose
avoid in patients with pre-existing lung disease
2/2 decreased pulmonary reserve
--------------------------------------------------------------- IM epinephrine can prevent/reverse progression
of anaphylaxis to anaphylactic shock
2-agonist effect: bronchodilation & systemic
release of inflammatory mediators
1-agonist effect: vasoconstriction raises BP &
upper airway edema
bee stings: refer for venom immunotherapy
--------------------------------------------------------------- ASA/salicylate intoxication leads to
respiratory alkalosis by stimulating respiratory
center, & anion gap metabolic acidosis by
uncoupling oxidative phosphorylation, leads to
anaerobic metabolism
triad: fever, tinnitus, tachypnea
ABG: low PaCO2, low HCO3, normal pH
mixed respiratory alkalosis & metabolic acidosis

--------------------------------------------------------------- acute Hep B markers: HBsAg & IgM anti-HBc

o both are elevated during window period
HBsAg: first to appear 4 -8 wk after infection
HBcAg is not detectable
--------------------------------------------------------------- fever, lethargy, signs of heart failure after a viral
prodrome in a child: viral myocarditis
MCC: Coxackie B, Adenovirus
myocyte necrosis impairs systolic/diastolic function
heart failure signs: dyspnea, syncope, N/V,
tachycardia, hepatomegaly
CXR: cardiomegaly, pulmonary edema
echo: diffuse hypokinesis
Dx: myocardial biopsy shows inflammatory
infiltrate of myocardium with myocyte necrosis
Rx: diuretics, inotropes, ICU
--------------------------------------------------------------- Pagets disease of bone is typically asymptomatic,
with incidentally ALP
o normal Ca++, phosphorous, & GGT
symptomatics present with pain a/w long bone fx
resulting in secondary arthritis of hip or knee
defective osteoid formation at sites of high bone
turnover; abnormal bone remodeling
Dx: elevated ALP; also nuclear bone scan to
determine extent of skeletal involvement
Rx: bisphosphonates only if symptomatic
highest risk for hearing loss & osteosarcoma
DDx: prostate ca with bone mets, MM, statins,
biliary obstruction, osteoporosis
---------------------------------------------------------------Indications for treating Pagets disease of bone
symptomatic bone & joint pain
hypercalcemia of immobilization
neuro-compressive symptoms
high-output cardiac failure
involvement of weight-bearing bones
symptomatic pseudofractures
--------------------------------------------------------------- sudden worsening of asthma & nasal congestion
30 min 3 hr after NSAIDs ingestion

ASA-exacerbated respiratory disease (AERD):

non-IgE mediated reaction due to ASA-induced
prostaglandin/leukotriene imbalance
o arachidonic acid is diverted to production of
leukotrienes via 5-lipoxygenase pathway
development of asthma & chronic rhinosinusitis
with nasal polyps, bronchospasm & nasal
congestion following ASA or NSAID ingestion:
pseudoallergic drug reaction
Rx: montelukast, avoid NSAIDs
--------------------------------------------------------------- volume overload & ascites are complications of
decompensated liver cirrhosis
Rx: loop diuretics; A/E: hypokalemia,
metabolic alkalosis, prerenal azotemia
--------------------------------------------------------------- pulmonary HTN: long-standing primary
pulmonary or cardiac disease
o dyspnea on exertion, fatigue, LE edema
pulmonary edema: fluid accumulation in air spaces
& parenchyma of the lungs, leading to impaired gas
exchange, due to either LV failure to adequately
remove blood from the pulmonary circulation
("cardiogenic "), or injury to the lung parenchyma or
vasculature of the lung ("noncardiogenic ")
---------------------------------------------------------------Infectious etiology of genital ulcers
multiple, grouped shallow ulcers
(genital herpes) with erythematous base,
tender lymph nodes,
recurrence is common
H. ducreyi
single/multiple deep ulcers with
irregular/ragged border, friable base,
gray/yellow exudate,
matted & tender lymph nodes

T. pallidum
(10 syphilis)
C. trachomatis

single, indurated, well-circumscribed

papule/chancre that ulcerates
punched-out, clean base,
painless inguinal lymphadenopathy
painless, small shallow ulcers,
large & painful buboes
ulcers with red, beefy base
no lymphadenopathy


does not resolve with ABX

vulvar pain, malaise, dysuria, painful labial ulcers

a/w inguinal lymphadenopathy: genital herpes
due to HSV
non-tender pedunculated lesions (genital warts)
due to HPV; can progress to SCC if untreated
primary syphilis Dx: dark field microscopy
o high rate of false negatives with RPR, FTA-ABS
serologic testing
--------------------------------------------------------------- familial colonic polyposis (FAP): 100% cancer risk
AD inheritance, APC gene mutation
Rx: elective proctocolectomy
--------------------------------------------------------------- EEG: symmetrical 3 Hz spike-and-wave activity
on a normal background; provoked/simulated by
hyperventilation: absence seizure (petit mal)
MCC: age 4 8 yrs
daydreaming episodes, no post-ictal state
Rx: valproate or ethosuximide
--------------------------------------------------------------- complex partial seizures: brief episodes of impaired
consciousness, postictal confusion, staring spells,
failure to respond to stimuli, automatisms
(swallowing, lip smacking, hand picking movements)
EEG: normal or brief discharges; hyperventilation
cannot simulate complex partial seizures
--------------------------------------------------------------- Lennox-Gastaut syndrome: childhood seizures
of multiple types, mental retardation, age < 7 yrs
EEG: slow spike-and-wave
--------------------------------------------------------------- H. pylori with MALT lymphoma w/o metastasis
Rx: omeprazole + clarithromycin + amoxicillin
o Rx: CHOP chemotherapy if ABX fails
(cyclophosphamide, adriamycin, vincristine,
--------------------------------------------------------------- Toxic megacolon is a complication of UC
UC: multiple bloody BMs, fever, weight loss
megacolon: total or segmental nonobstructive
colonic dilation, severe bloody diarrhea, fever,
tachycardia, leukocytosis

also volume depletion, altered mental status,

hypotension, electrolyte abnormalities
XR: dilated right or transverse colon (> 6 cm)
Dx: XR, +anemia, fever > 380C, pulse > 120,
WBC > 10,000
medical emergency!!
Rx: IV fluids, ABX, bowel rest
o IV steroids if IBD-induced
--------------------------------------------------------------- right-sided colon cancer presents with anemia
left-sided colon cancer presents with obstruction
both are a/w change in bowel habits
--------------------------------------------------------------- intestinal lymphoma: diffuse infiltrate by
atypical lymphocytes
occult blood in stool, abdo pain, weight loss, N/V
--------------------------------------------------------------- clinical evidence of PE should be anticoagulated
before undergoing diagnostic evaluation
presence of DVT features should have Dx
confirmed before starting anticoagulation
Wells criteria for
pretest probability of PE
+3 points
o clinical signs of DVT
o alternate Dx less likely than PE
+1.5 points
o previous PE or DVT
o HR > 100
o recent surgery or immobilization
+1 point
o hemoptysis
o cancer
Total score
< 2 low risk
2 6 moderate risk
> 7 high risk

evaluation of DVT: assess pretest probability

using Modified Wells Criteria
o if DVT not likely D-dimer testing
low D-dimer DVT unlikely
high D-dimer compression USS

if DVT likely compression USS

negative USS DVT unlikely
positive USS anticoagulate
DDx of DVT: venous insufficiency, cellulitis,
ruptured Baker cyst, post-thrombotic syndrome
--------------------------------------------------------------- tachypnea, weight loss, polydipsia, polyuria: DKA
Dx: fingerstick glucose
--------------------------------------------------------------- atlantoaxial instability should be suspected in
Down syndrome presenting with UMN findings
behavioral changes, urinary incontinence,
torticollis, dizziness, vertigo, diplopia
Rx: surgical fusion
---------------------------------------------------------------DDx of metabolic alkalosis
low urine chloride
o vomiting, NG aspiration, laxative abuse
o volume depletion, decreased oral intake
o prior diuretic use**
high urine chloride
o hypovolemic/euvolemic current diuretic use*
o hypervolemic excess mineralocorticoid
(primary hyperaldosteronism, Cushings,
ectopic ACTH, severe hypokalemia)
saline-resistant type: high urine chloride
o Rx underlying disorder
saline-responsive type: low urine chloride
o Rx: isotonic saline corrects hypochloremia &
promotes urinary HCO3- excretion
loop diuretics would worsen metabolic alkalosis,
hypokalemia, & volume depletion
--------------------------------------------------------------- blood type & Ab screen @ first prenatal visit
HIV screen @ first prenatal visit; rescreen @ 3rd
trimester if high-risk
asymptomatic bacteriuria screen @ 1st trimester
routine GBS rectovaginal screen @ 35 37 wk,
results valid for 5 weeks
---------------------------------------------------------------Rh alloimmunization/sensitization
anti-D antibodies that form after prior pregnancy
or blood transfusion to Rh+ fetus/blood
antepartum prophylaxis not need if father is Rho

prophylactic anti-D Ig for unsensitized Rh- mom

o @ 28 30 wk gestation
repeat within 72 hr of delivery of Rh+ infant
or spontaneous, threatened, or induced abortion
o ectopic or hydatidiform pregnancy
o after CVS or amniocentesis
o abdominal trauma, 2nd or 3rd trimester bleed
o external cephalic version
Kleihaur-Betke test: calculates anti-D Ig dose;
performed if placental abruption occurs in pregos
--------------------------------------------------------------- OCPs can cause HTN
o switch to an alternate birth control method
if HTN persists Dx: essential HTN
initial Rx: diet & exercise
Rx: low-dose thiazide
--------------------------------------------------------------- hypertrophic cardiomyopathy (HCM):
asymmetric LVH leads to outflow tract
AD inheritance, MC in African-Americans
crescendo-decrescendo systolic murmur @ LLSB
due to interventricular septal hypertrophy &
systolic anterior motion (SAM) of mitral leaflet
dual upstroke carotid pulse
Rx: -blocker (prolongs diastole); or diltiazem
Effect of maneuvers on HCM
preload = intensity (Valsalva, standing, nitro)
preload/afterload = murmur intensity
(hand grip, squatting, passive leg raise)
--------------------------------------------------------------- no detailed metabolic evaluation needed for a
first renal stone
Management of nephrolithiasis
Dx: abdominal CT without contrast
Rx: NSAIDs & narcotics are equally effective
o narcotics can exacerbate N/V
< 5 mm can pass spontaneously
o conservative Rx: fluid intake > 2 L/day
urology referral for anuria, urosepsis, ARF
--------------------------------------------------------------- uric acid stones are radiolucent, seen on USS or CT
MC in patients with low urine pH
Rx: hydration, urine alkalization, low protein diet

Rx: potassium citrate to alkalinize urine

o citrate inhibits stones & crystallization
o Rx recurrent stones due to citrate deficiency
allopurinol can be added if hyperuricosuria
--------------------------------------------------------------- mucormycosis due to Rhizopus: direct extension
of rhinosinusitis via paranasal sinuses
MC in immunocompromised & uncontrolled DM
fever, bloody nasal discharge, nasal congestion
also eye involvement: chemosis, proptosis, diplopia
necrotic nasal turbinates shows hyphae on KOH
Rx: surgical debridement & IV amphotericin B
complication: blindness, cavernous sinus thrombosis,
coma & death if untreated
--------------------------------------------------------------- MTX: purine antimetabolite, DMARD
A/E: oral ulcers, stomatitis, hepatotoxicity, rash,
pulmonary toxicity, bone marrow suppression,
alopecia, macrocytic anemia
folic acid supplementation reduces A/Es
--------------------------------------------------------------- -thalassemia major: impaired -globin
production, leads to excess -globin chains
chronic hemolysis, transfusion-dependent anemia
-thalassemia minor: one normal -globin allele
o mainly asymptomatic, mild anemia
o high RBC count, low MCV, Hb > 10
Rx: no therapy required
o can present similar to iron deficiency anemia
iron deficiency: low RBC count,
becomes microcytic when Hb < 10










target cells

target cells

normal/ iron normal/ iron
& ferritin
& ferritin
does not
does not
to iron
Hb A2
thalassemia trait: often found incidentally on
universal screening for anemia at age 1 yr
low MCV, total RBC count, normal RDW
o rarely require Rx, but Dx for genetic counseling
o iron Rx can cause hemochromatosis
iron deficiency: RDW, total RBC count
--------------------------------------------------------------- folic acid supplementation: megaloblastic anemia,
hereditary spherocytosis, PND, sickle cell disease,
-thalassemia major, on MTX
--------------------------------------------------------------- prednisone: Rx autoimmune hemolytic anemia
--------------------------------------------------------------- TNF- inhibitors: anti-cytokine
o infliximab, etanercept
Rx: chronic RA
A/E: neutropenia, latent TB reactivation, CHF,
demyelination, risk of malignancy
--------------------------------------------------------------- renal vein thrombosis is a/w nephrotic syndrome
membranous glomerulopathy
due to loss of anti-thrombin III in urine
--------------------------------------------------------------- conversion disorder: sudden onset of neurologic
symptoms incompatible with neuro exam
unexplained weakness, non-epileptic seizures,
paralysis, ataxia, aphonia, blindness, or paresthesia
triggered by stress or emotions
not feigned or intentional; la belle indifference
#1 Rx: education, encouragement, support

#2 Rx: CBT
--------------------------------------------------------------- somatic symptom disorder: 1 persistent physical
symptom; excessive anxiety, concern & energy
devoted to symptoms; persists 6 months
physiologic symptoms: pain, heartburn, fatigue
Rx: regularly scheduled appointments focusing
on psychological distress; emphasize reassurance
--------------------------------------------------------------- depression with comorbid medical conditions,
including terminal illness
short life expectancy Rx: rapid psychostimulants
(methylphenidate, modafinil)
long life expectancy Rx: SSRI (takes longer to
reach therapeutic effect)
--------------------------------------------------------------- preterm labor: uterine contractions @ < 37 wks
gestation; cervical dilation &/or effacement
preterm labor @ < 34 wks should receive
o tocolytic (CCB, -blockers, NSAIDs)
o Mg-sulfate for neuroprotection
o corticosteroids for lung maturity
--------------------------------------------------------------- crampy lower abdominal & back pain during
menses, normal exam: primary dysmenorrhea
o Rx: NSAIDs & OCPs
pain 1 to 2 days before menstruation, dyspareunia,
dysmenorrhea, infertility: endometriosis
heavy menses with clots, constipation, urinary
frequency, pelvic pain; irregular/enlarged uterus:
dysmenorrhea, menorrhagia, pelvic pain; bulky,
globular & tender uterus: adenomyosis
dull & ill-defined pelvic pain that worsens with
standing & relieved with menses, dyspareunia:
pelvic congestion
---------------------------------------------------------------DDx of acute pelvic pain
recurrent mild, unilateral mid-cycle
pain 2/2 normal follicular enlargement
prior to ovulation
crampy abdominal pain, amenorrhea,
vaginal bleed, +-hCG
acute onset unilateral abdominal pain,
N/V, tender adnexal mass,

pelvic USS: enlarged, edematous

ovary with blood flow
sudden onset U/L abdominal pain
ovarian cyst
after strenuous or sexual activity,
pelvic USS: free fluid near cyst
fever/chills, new vaginal discharge,
dysuria, cervical motion tenderness,
transvaginal USS: r/o tubo-ovarian
uncomplicated ovarian cyst rupture: no fever,
hypotension, tachycardia, or hemoperitoneum
o Rx: analgesics as outpatient
--------------------------------------------------------------- situational syncope: 2/2 autonomic dysregulation
(LOC after urination or during coughing fits)
--------------------------------------------------------------- postexposure HIV prophylaxis: immediately start
with 3-drug antiviral therapy for 4 weeks following
high-risk occupational exposure to blood or body
fluids from HIV-infected individuals
Rx: tenofovir, emtricitabine, + raltegravir
HIV testing immediately to establish baseline
status; repeat @ 6 weeks, 3 months, & 6 months
--------------------------------------------------------------- Strep pneumoniae: MCC of community-acquired
pneumonia & nursing homes
--------------------------------------------------------------- pivoting/twisting injury or knee struck from
lateral side with foot planted: MCL tear
immediate swelling of knee joint 2/2 effusion
Rx: bracing & early ambulation
o surgery is rarely needed
--------------------------------------------------------------- high index of suspicion for physical/sexual abuse
in children with sudden behavioral problems,
unstable economic backgrounds, or parents with a
Hx of drug/alcohol abuse
--------------------------------------------------------------- vertigo, ear fullness, tinnitus, & hearing loss:
Menieres disease
endolymph accumulation in inner ear
horizontal nystagmus during acute attacks
#1 Rx: environmental & dietary modifications
low-salt diet; avoid caffeine, nicotine, alcohol

inflammation of pericolic fat, thickened bowel wall,

soft tissue mass (phlegmons), pericolic fluid
suggesting abscess: diverticulitis
Dx: abdominal CT
--------------------------------------------------------------- calcium oxalate crystals are a frequent finding
in urinary sediment, not clinically significant
unless symptoms suggest acute nephrolithiasis
--------------------------------------------------------------- persistent PTX & significant air leak following
chest tube placement in a patient with sustained
blunt chest trauma: tracheobronchial rupture
pneumomediastinum & subcut. emphysema
confirm Dx: high-resolution CT, bronchoscopy,
or surgical exploration
--------------------------------------------------------------- painless blisters on back of hand, hypertrichosis,
hyperpigmentation: porphyria cutanea tarda
uroporphyrinogen decarboxylase deficiency
a/w Hep C
triggers: alcohol, estrogens
Dx: elevated urine porphyrin
Rx: phlebotomy, hydroxychloroquine,
---------------------------------------------------------------Prenatal testing for fetal aneuploidy
cff DNA
high sensitivity &
( 10 wks)
specificity for
not diagnostic
1st trimester
not diagnostic
(9 13 wks)
2nd trimester
quad screen
not diagnostic
(15 20 wks)
early definitive
pain, vaginal
(10 13 wks) karyotypic Dx
spotting, risk of
pregnancy loss
amniocentesi definitive
pain, risk of bleed
karyotypic Dx
& amniotic fluid
(15 20 wks)
2nd trimester
fetal growth,
cannot identify all
anatomy, placenta abnormalities;

(18 20 wks)


soft markers

pregos age 35 at increased risk of aneuploidy

should be offered cell-free fetal DNA
o abnormal cffDNA should be confirmed by
fetal karyotyping with CVS (1st trimester) or
amniocentesis (2nd trimester)
low risk of aneuploidy: 1st trimester combined test
o PAPP, -hCG, USS nuchal translucency
2nd trimester (18 20 wks) Quad screen
o maternal AFP, -hCG, estriol, inhibin A
o AFP & estriol, with -hCG & inhibin A is
a/w Downs
next: transabdominal USS to evaluate fetal
anatomy & growth; abnormal markers risk
o next: amniocentesis to confirm abnormal
quad screen
--------------------------------------------------------------- aminoglycosides cause ototoxicity (hearing loss)
by damaging cochlear cells
gentamicin causes selective vestibular injury
(vestibulopathy) without significant ototocity
oscillopsia: sensation of objects moving around
in the visual field when looking in any direction;
leads to gait disturbance
Dx: head thrust test (inability to maintain eyes
on a target)
--------------------------------------------------------------- myasthenia gravis: diplopia, jaw fatigue after
prolonged chewing, dysarthria with talking
normal reflexes
hallmark: resolution of weakness with rest
Dx: EMG & ACh Rc antibody test
also chest CT to screen/exclude for thymoma
--------------------------------------------------------------- Rx options for myasthenia gravis
o pyridostigmine: symptomatic relief only
(A/E: cramps, fasciculations, weakness)
o atropine: anticholinergic; prevents
muscarinic A/E of anticholinesterases
o immunosuppressives: induce remission
(prednisone, azathioprine, cyclosporine)
o thymectomy: induces remission
o plasmapheresis: Rx myasthenia crisis

edrophonium: short-acting anticholinesterase;

Dx only
--------------------------------------------------------------- atropine: Rx to prevent muscarinic side effects
of AChE inhibitor with myasthenia gravis
--------------------------------------------------------------- incentive spirometry is the most effective at
preventing post-op pulmonary complications
--------------------------------------------------------------- PAPP-A is produced by trophoblast
1st trimester screen with PAPP-A + -hCG along
with USS nuchal translucency to detect Downs
o Downs produces less PAPP-A
--------------------------------------------------------------- well-appearing infant with intermittent cyanosis
& distress during feeing, relieved by crying:
choanal atresia
Dx: head CT
--------------------------------------------------------------- CHARGE syndrome: Coloboma, Heart defects,
Atresia of choanae, Renal anomalies, Growth
impairment, Ear abnormalities
--------------------------------------------------------------- dermatitis herpetiformis is a/w Celiacs
intensely pruritic papules, vesicles over elbows,
knees, buttocks, posterior neck, scalp
IF: granular IgA deposits along dermal papillae
+anti-endomysial antibodies
Rx: dapsone (heals within hours)
--------------------------------------------------------------- benign paroxysmal positional vertigo (BPPV):
Ca++ crystals in semicircular canals (canaliths)
MCC of vertigo
brief, recurrent episodes of room spinning with
head movements or position change
no neurologic or auditory symptoms
Dx: Dix-Hallpike maneuver cause nystagmus
Rx: Epley maneuver
--------------------------------------------------------------- lateral cerebellar infarction: dizziness, ataxia,
weakness, swaying TOWARD the lesion side
--------------------------------------------------------------- hypercalcemia, renal insufficiency, metabolic
alkalosis: milk-alkali syndrome
normal phosphate & ALP levels

--------------------------------------------------------------- methamphetamine: CNS stimulant

HTN, tachycardia, agitation, aggressiveness
acne or facial sores due to skin picking
--------------------------------------------------------------- drug-induced hypersensitivity reaction, Type I:
drug-specific IgE occupy receptors on mast cells
& basophils; immediate onset
o Rx: antihistamines for urticarial & pruritus
o Rx: epinephrine & corticosteroids for
anaphylaxis with systemic symptoms
ABX-induced rash due to infectious mononucleosis
2/2 EBV develops after 24 hr
--------------------------------------------------------------- confusion, lethargy, fatigue, anorexia, polyuria,
constipation, CXR suggestive of lung cancer:
hypercalcemia of malignancy
2/2 PTHrP production
a/w squa-Ca++-mous cell lung cancer
--------------------------------------------------------------- tremor is often first manifestation of Parkinsons,
can present asymmetrically
Rx: trihexyphenidyl (anticholinergic) for
younger patients if tremor is the primary symptom
--------------------------------------------------------------- all suspected BPH: U/A & serum creatinine
Cr suggests bladder outlet obstruction
Dx: renal USS
Rx: urinary catheter, tamsulosin, finasteride
o TURP for refractory symptoms
--------------------------------------------------------------- Charcot joint: neurogenic arthropathy
a/w Vit B12 deficiency, diabetes
proprioception, pain & temp sensation
unknowingly traumatizes weight-bearing joints,
results in secondary DJD & joint deformities
XR: loss of cartilage, osteophytes, loose bodies
Rx: underlying disease, mechanical devices to
decreased further trauma
--------------------------------------------------------------- patchy neurological deficits, painful loss of vision,
central visual field defect, normal fundoscopy: MS
optic neuritis, Uhthoff phenomenon, Lhermitte sign
scanning speech

CSF: normal pressure & total protein, elevated IgG

& oligoclonal bands (not diagnostic)
Dx: MRI show cerebral or cerebellar plaques as
hypo/hyperdense lesions involving white matter
--------------------------------------------------------------- contraindication for use of succinylcholine for
rapid-sequence intubation: hyperkalemia
also burn & crush injury (rhabdomyolysis),
prolonged demyelination (Guillain-Barre, tumor
lysis syndrome)
succinylcholine causes significant K+ release &
life-threatening arrhythmias
safe alternatives: vecuronium, rocuronium
--------------------------------------------------------------- CBT: reduces automatic negative thoughts &
avoidance behaviors that cause distress
uses: depression, anxiety, PTSD, OCD,
somatoform disorders, eating disorders
--------------------------------------------------------------- psychodynamic psychotherapy focuses on the
role that unconscious conflict causes symptoms;
emphasize ways in which passive experiences
shape the present situations
--------------------------------------------------------------- chorioamnionitis: maternal fever PLUS 1:
uterine tenderness, maternal or fetal tachycardia,
malodorous amniotic fluid, or purulent discharge
risk factor: PROM (> 18 hr)
MCC: polymicrobial
Dx: IV ABX & oxytocin to accelerate labor
o c-section for normal OB indications
--------------------------------------------------------------- cor pulmonale: isolated RHF 2/2 pulmonary HTN;
exertional syncope, exertional angina, JVD, ascites
RV heave, dependent pitting edema, hepatomegaly
Dx: right heart catheterization show RV dysFx,
pulmonary HTN, & absence of left heart disease
--------------------------------------------------------------- DDx of anterior mediastinal mass: 4 Ts =
thymoma, teratoma, thyroid, terrible lymphoma
bronchogenic cysts: middle mediastinum
all neurogenic tumors: posterior mediastinum

meningocele, enteric cysts, lymphoma,

esophageal tumors, diaphragmatic hernias,
aortic aneurysms
--------------------------------------------------------------- seminomas: -hCG only
non-seminomatous germ cell tumors
o yolk sac tumors, choriocarcinoma,
embryonal carcinoma
o AFP, -hCG
---------------------------------------------------------------Neonatal bowel obstruction
if stable, initial test: abdominal XR to rule out
pneumoperitoneum due to bowel perforation,
which would require emergency surgery
next test: water-soluble contrast enema
microcolon is caused by viscous meconium
accumulation in terminal ileum due to CF
o Rx: Gastrografin hyperosmolar enema
narrow rectosigmoid & dilated megacolon
transition zone: Hirschsprung disease
o next test: rectal biopsy (absent ganglion cells)
--------------------------------------------------------------- CXR: widened mediastinum, left-sided hemothorax,
right-sided mediastinal deviation, disruption of
normal aortic contour
rapid deceleration blunt chest trauma are high risk
for aortic injury with contained aortic rupture
confirm Dx: CT angiogram
--------------------------------------------------------------- pneumomediastinum & pleural effusion:
esophageal rupture
Dx: water-soluble contrast esophagography
--------------------------------------------------------------- sudden onset dyspnea, colicky abdominal pain,
rapid-onset for edema of the face, extremities, &
genitals without urticaria: hereditary angioedema
complement C1 inhibitor deficiency results in
elevated bradykinin; normal C1q levels, C4
episodes following infection, dental procedures,
or trauma
--------------------------------------------------------------- MCC of acquired isolated angioedema: ACE-I
low C1q levels
can occur at anytime

also, ACE-I can precipitate ARF in patients with

B/L renal artery stenosis
--------------------------------------------------------------- child with nocturnal headaches, morning vomiting,
with coexisting otitis & mastoiditis: temporal
brain abscess
intracranial pressure increases in supine position
& stimulates medullary vomiting center
Dx: solitary ring-enhancing lesion on CT with
contrast or MRI
Rx: high-dose corticosteroids
--------------------------------------------------------------- 3 phases of viral hepatitis: prodromal, enteric,
Hep A
Hep B
Hep C
30 days
40 50
contaminated sexual,
food or water, parenteral,
risk factors recent travel

acute onset malaise, anorexia, N/V, mild abdo pain,

aversion to smoking: Hep A
hepatosplenomegaly, AST/ALT spike
Rx: supportive; close contacts: Hep A Ig
--------------------------------------------------------------- dysphagia, salivation, mouth burns, severe pain,
white tongue: caustic poisoning
does not cause altered mental status
complications: peritonitis, mediastinitis
--------------------------------------------------------------- hyperthermia, mydriasis, delirium, dry, mouth,
urinary retention, decreased bowel sounds:
anticholinergic toxicity
o Rx: physostigmine
CNS depression, arrhythmias, hypotension,
anticholinergic signs: TCA poisoning
o Rx: sodium bicarbonate
anticholinergic symptoms, drowsiness, confusion:
diphenhydramine toxicity
o Rx: physostigmine

headache, vomiting, abdo pain, phosphorus skin,

bitter almond odor: cyanide toxicity
o Rx: sodium thiosulfate
tinnitus, N/V, fever, acid-base abnormalities:
salicylate intoxication
o Rx: sodium bicarbonate to alkalinize urine
HTN, hyperthermia, tachycardia, diaphoresis,
mydriasis, hyperreflexia: serotonin syndrome
o Rx: benzo (lorazepam)
horizontal nystagmus, cerebellar ataxia, confusion:
phenytoin toxicity
tremor, hyperreflexia, ataxia, seizure: lithium tox.
o Rx: hemodialysis
--------------------------------------------------------------- undiagnosed pleural effusion is best evaluated
with thoracocentesis
Dx: diagnostic thoracocentesis
o if clear evidence of CHF trial of diuretic
transudate or exudate?
transudative effusion rules out malignancy
lung carcinoma, breast carcinoma, & lymphoma:
MCC malignant exudative pleural effusion
--------------------------------------------------------------- artificial heart valves or severely calcified valves
cause microangiopathic hemolytic anemia
LDH, haptoglobin, indirect bilirubin,
reticulocytosis, schistocytes
chronic hemolysis leads to iron loss &
microcytic anemia
--------------------------------------------------------------- autoimmune hemolysis: +direct Coombs,
--------------------------------------------------------------- AL amyloidosis (primary): MM, Waldenstrom
AA amyloidosis (secondary to chronic inflmmation):
RA, TB, Crohns, lymphoma, vasculitis
--------------------------------------------------------------- rheumatoid arthritis predisposes to AA amyloidosis
causes nephrotic syndrome
enlarged kidneys, hepatomegaly
renal Bx: amyloid deposits stain with Congo red
& apple-green birefringence

elderly, memory impairment, social withdrawal,

depressed mood: pseudodementia
poor effort with cognitive testing
distressed by impaired memory
(Alzheimers are indifferent & confabulate)
Rx: SSRI improves depression & cognition
--------------------------------------------------------------- crescent formation on light microscopy: RPGN
hyalinosis of afferent & efferent arterioles:
diabetic nephropathy
linear deposits & anti-IgM: Goodpastures
granular deposits: immune complex GN
(postinfectious GN, lupus nephritis, IgA neph)
--------------------------------------------------------------- unexplained chronic & severe abdo pain, weight
loss, food aversion: chronic mesenteric ischemia
chronic occlusion of visceral arteries leads to
worsening postprandial pain & food avoidance
evidence of atherosclerotic disease (HTN,
CAD, DM type II, hypercholesterolemia, PVD)
nonspecific physical exam, XR, CT scan
Dx: angiography or Doppler USS
--------------------------------------------------------------- acute aortic dissection can cause hemopericardium,
progress to cardiac tamponade & cardiogenic shock
Dx: TEE (hemodynamically stable)
Rx: IV labetalol
Rx: pericardiocentesis (hemodynamically unstable)
--------------------------------------------------------------- sharp, pleuritic chest pain, pericardial friction rub,
uremia (BUN > 60): uremic pericarditis
do not have classic EKG changes
Rx: hemodialysis
--------------------------------------------------------------- brain infarct: hypodense on CT scan
IC hemorrhage: hyperdense on CT scan
o Rx: stop warfarin & ASA, give FFP & Vit K
--------------------------------------------------------------- after blunt chest trauma, hemorrhagic shock a/w
decreased breath sounds & dullness to percussion
over one hemithorax & C/L tracheal deviation:
massive hemothorax
MCC: traumatic laceration of lung parenchyma or
damage to intercostal/internal mammary artery

DDx: tension PTX (hyperressonance), pulmonary

contusion (no hemorrhagic shock)

--------------------------------------------------------------- case-control study: determines outcome first

then compares past associated risk factors
retrospectively assess outcomes with risk factors
obtained by interviews, health records, lab reports
used to measure odds ratio
--------------------------------------------------------------- retrospective cohort: reviews prior records for
risk factor exposure then determine incidence
o both risk factors & outcome occur in the past
--------------------------------------------------------------- prospective cohort study: chose subjects based on
risk factors, then compare disease incidence
allows for calculation of relative risk
better ability to prove causation than case control
& cross-sectional studies
--------------------------------------------------------------- cross-sectional study: current risk factor
exposures compare disease prevalence
assess exposure & outcome simultaneously
shows an association, but not causation
--------------------------------------------------------------- informed consents obtained from either parent
of a minor prior to performing a procedure

exception is emergency conditions, transfusions,

& surgery
--------------------------------------------------------------- alopecia, skin lesions, abnormal taste, impaired
wound healing: zinc deficiency
2/2 chronic TPN or malabsorption
found in animal protein, whole grains, beans, nuts
digested in the jejunum
--------------------------------------------------------------- selenium deficiency: cardiomyopathy
--------------------------------------------------------------- fever, focal spinal tenderness, neurologic dysFx:
spinal epidural abscess
risk factors: IVDA, immunocompromised,
infectious hematogenous spread, vertebral body
osteomyelitis, steroid injections, epidural anesthesia
MCC: S. aureus
Dx: spine MRI with gadolinium, ESR, CRP, CTguided aspiration & culture
Rx: ABX, surgical decompression & drainage
complications: cord compression, cauda equina
---------------------------------------------------------------Common skin infections
fiery red, tender, painful plaque
with demarcated edges; limited to
(S. pyogenes)
epidermis & superficial dermis
folliculitis: purulence in hair follicle Cellulitis
in areas of heavy friction/sweating
furuncles: folliculitis extending into S. aureus
dermis, leads to abscess
carbuncle: severe infection due to
aggregation of multiple furuncles
erythema, edema, tenderness
flat subcut. lesions, less demarcated (non-purulent)
regional lymphadenopathy
Group A Strep

risk factors: venous insufficiency, skin disruption,

Rx: oral ABX; or IV ABX if systemic involvement
(hypotension, tachycardia)
o nafcillin: IV anti-staphylococcal
--------------------------------------------------------------- flail chest Rx: pain control, supplement O2, PPV
---------------------------------------------------------------DDx of depressed mood

o 2 wks, 4/9 SIGECAPS
o significant functional impairment
o no lifetime Hx of mania
Adjustment disorder with depressed mood
o onset within 3 months of identifiable stressor
o marked stress & significant impairment
o does not meet other DSM-5 criteria
Normal stress response
o not excessive or out of proportion to severity
of stressor
o no functional impairment
--------------------------------------------------------------- impaired social & occupational functioning is a
DSM-5 requirement for all psychiatric disorders
---------------------------------------------------------------Herpes simplex (HSV) keratitis
pain, photophobia, blurred vision, tearing
dendritic ulcers is MC presentation
recurrence due to excessive sun exposure
complication: corneal blindness
--------------------------------------------------------------- dendriform corneal ulcers & vesicular rash in V1
trigeminal distribution: herpes zoster (VZV)
MC in elderly; or a presenting sign of HIV
vesicular rash in CN V1 cutaneous branch
periorbital burning & itching, fever, malaise
conjunctivitis & dendriform corneal ulcers
Dx: high-dose acyclovir within 72 hrs
--------------------------------------------------------------- HIV retinopathy: benign, cotton-wool spots
which remit spontaneously
--------------------------------------------------------------- bacterial keratitis: MC in contact lens wearers
hazy cornea + central ulcer; adjacent stromal abscess
MCC: Pseudomonas
--------------------------------------------------------------- Todd paralysis: post-ictal hemiparesis,
restoration of motor function within 24 hr
--------------------------------------------------------------- hydatid cysts caused by Echinococcus spp affect
the liver & lungs
MC in sheep breeders & exposure to dogs

--------------------------------------------------------------- T. solium: neurocysticercosis

consuming T. solium eggs in human feces
not contracted by eating infected pork
multiple, small fluid-filled cysts in brain parenchyma
--------------------------------------------------------------- Enterobius vermicularis (pinworm) infection
Rx: albendazole or pyrantel pamoate; including
all household contacts
--------------------------------------------------------------- risk factors for gallstones: fat, fertile, female, 40,
Native American, DM, rapid weight loss, OCPs
Dx: abdominal USS
Rx #1: lap chole
Rx #2 (poor surgical candidates): ursodeoxycholic
acid (bile acid, dissolves gallstones) high recurrence
--------------------------------------------------------------- HIDA scan: visualizes bile duct obstruction, GB
disease, & bile leaks
ERCP Rx: therapeutic intervention for bile duct
obstruction or cholangitis
PTC: visualize interahepatic & extrahepatic
biliary tree; invasive
---------------------------------------------------------------Indications for aortic valve replacement
all symptomatic aortic stenosis (AS)
SAD: syncope, angina, dyspnea
severe AS undergoing CABG or valvular surgery
asymptomatics with severe AS & poor LV systolic
function, LVH > 15 mm, valve area < 0.6 cm2, or
abnormal response to exercise
--------------------------------------------------------------- only left-sided murmurs on expiration
--------------------------------------------------------------- cholesterol embolism is a complication of
cardiac catheterization & vascular procedures
blue toe syndrome, livedo reticularis,
Hollenhorst plaques in the retinal artery, AKI,
cerebral infarction, intestinal ischemia
Rx: supportive, statins prevent recurrence
--------------------------------------------------------------- acute, unilateral cervical lymphadenitis in children:
S. aureus
enlarged, tender & erythematous lymph node

Isotretinoin: must not be taken by reproductive age

women unless 2 effective forms of contraception are
used for at least 1 month prior to initiating, during,
& 1 month after treatment
pregnancy test 1 wk before starting &
periodically during therapy
--------------------------------------------------------------- hemolytic anemia, jaundice, splenomegaly; or
infant with persistent jaundice despite photo-Rx:
hereditary spherocytosis
AD inheritance, northern European descent
ankyrin gene mutation spectrin deficiency &
extravascular hemolysis
jaundice, dark urine, acute cholecystitis due to
pigmented gallstones
MCHC, RDW, negative Coombs
Dx: acidified glycerol lysis test
o & eosin-5-maleimide binding test
Rx: folate, blood transfusions, splenectomy
o chronic hemolysis consumes folate
complications: pigmented gallstones, aplastic crises
2/2 parvovirus B19
--------------------------------------------------------------- Tularemia: Francisella tularensis (rabbits)
U/L cervical lymphadenopathy, fever/chill, headache
--------------------------------------------------------------- Toxic shock syndrome due to S. aureus exotoxin
a/w tampons, nasal packing, post-surgery infection
fever, marked hypotension, altered mentation,
myalgia, multi-organ injury
diffuse erythematous macular rash on the trunk,
spreads to extremities (includes palms/soles),
desquamation 1 2 wk after onset
--------------------------------------------------------------- meningococcemia: petechial rash ecchymosis,
bullae, vesicles gangrenous necrosis
fever, N/V, myalgias, meningeal signs
--------------------------------------------------------------- lightheadedness, diffuse abdo pain, adnexal &
cervical motion tenderness, hemodynamic instability:
ectopic pregnancy
Hx of syncope, hypotension, tachycardia:
ruptured ectopic pregnancy
Dx: -hCG & transvaginal USS

o hemodynamic instability requires surgical eval.

--------------------------------------------------------------- Hepatic metabolism of bilirubin
1. bilirubin uptake from bloodstream
2. storage within hepatocyte
3. conjugation with glucuronic acid
4. biliary excretion
--------------------------------------------------------------- Dubin-Johnson: conjugated hyperbilirubinemia,
dark granular pigment in hepatocytes (black liver)
o normal urinary coproporphyrin
o elevated coproporphyrin I
o normal AST, ALT, & ALP
o no Rx needed, benign, good prognosis
Rotor syndrome: defect of hepatic storage of
conjugated bilirubin with leakage into plasma
o conjugated bilirubinemia; +urine bilirubin
o dark urine; normal AST, ALT, & ALP
o no Rx, benign, absence of black liver
Crigler-Najjar Type I: severe jaundice,
kernicterus, neurologic impairment & death
o unconjugated bilirubinemia
if given IV phenobarbital bilirubin unchanged
o Rx: liver transplant
Crigler-Najjar Type II: less severe than Type I
o survival into adulthood
o if given IV phenobarbital bilirubin is reduced
o no Rx in mild cases
Gilberts: familial disorder of reduced bilirubin
glucuronidation; unconjugated bilirubin
o triggers: fasting, fat-free diet, illness, stress
o normal LFTs, CBC, blood smear, reticulocytes
Alloimmune hemolytic disease (erythroblastosis
fetalis): unconjugated, +Coombs
o Rh disease, ABO incompatibility
physiologic jaundice: unconjugated, appears
after 24 hr of life, resolves within 1 wk
breast milk jaundice: unconjugated, appears
after 2nd wk of life, benign
--------------------------------------------------------------- hemolysis leads to unconjugated hyperbilirubin
& +urine urobilinogen assay
o urine bilirubin assay is negative since there
is no hepatic dysfunction

--------------------------------------------------------------- liver steatosis: 2/2 long-term OCP usage

--------------------------------------------------------------- hypoalbuminemia can total serum Ca++, but
ionized Ca++ is hormonally regulated & stable
o serum Ca++ by 0.8 mg/dL for every 1 g/dL
in serum albumin
--------------------------------------------------------------- lymphocytic infiltration of salivary glands in
Sjogren syndrome causes enlarged & firm
submandibular glands
--------------------------------------------------------------- CHF causes preferential vasoconstriction of
efferent renal arterioles, thus increased
intraglomerular pressure to maintain GFR
o also ADH secretion to maintain C.O.
--------------------------------------------------------------- salmon-colored, hypopigmented & hyperpigmented
macules on the upper trunk: Tinea versicolor
MCC: Malassezia globosa
exposure to hot & humid weather
KOH: large, blunt hyphae & thick-walled
budding spores (spaghetti & meatballs)
Rx: selenium sulfide, ketoconazole, terbinafine
--------------------------------------------------------------- ring-shaped lesions with enlarging raised, scaly
border & central clearing, or patchy scales on the
trunk: Tinea corporis (ringworm)
scalp = Tinea capitis (a/w hair loss)
Rx: terbinafine or itraconazole
--------------------------------------------------------------- ABI 0.9 is abnormal
--------------------------------------------------------------- ASA: antiplatelet; early Rx of acute ischemic stroke
--------------------------------------------------------------- recombinant tPA (alteplase): Rx acute ischemic
stroke; initiated within 3 4.5 hr of onset
Dx: head CT r/o intracranial hemorrhage
C/I: unknown duration, severe & persistent HTN,
small deficits, rapid recovery of deficits
--------------------------------------------------------------- acute mitral regurgitation can occur due to
papillary muscle displacement during acute MI
abrupt & excessive volume overload

elevated LA & LV filling pressures results in

acute pulmonary edema
does not change chamber size or compliance
--------------------------------------------------------------- moderately obese middle-aged male, fatigability,
daytime somnolence, morning headaches, snoring,
mild HTN: sleep apnea syndrome
hypoxemia-induced in EPO causes polycythemia
Rx: weight reduction, avoid sedative & alcohol,
avoid sleeping supine
polycythemia improves with OSA Rx
complications: pulmonary HTN, RV failure
--------------------------------------------------------------- OSA alone causes nocturnal hypoventilation,
resulting in transient hypoxia & hypercarbia that
resolves during wakefulness
o morning headaches, impotence, arterial HTN
o normal ABG
obesity hypoventilation syndrome (Pickwickian):
due to obesity & untreated OSA
chronic hypercapnic respiratory failure, hypoxia,
secondary erythrocytosis, pulmonary HTN, &
cor pulmonale
chronic respiratory acidosis compensatory
metabolic alkalosis
Cl reabsorption due to HCO3 retention
--------------------------------------------------------------- obesity hypoventilation syndrome: obesity
impedes chest & abdomen expansion in breathing
BMI > 30; daytime hypersomnolence
obesity reduces chest wall & lung compliance,
thus tidal volume, TLC, & FRC
persistent hypoventilation
awake daytime hypercapnea: PaCO2 > 45
increases respiratory work, respiratory drive due
to decreased chemosensitivity to hypercapnia
renal HCO3 retention compensates for
respiratory acidosis, which blunts the ventilatory
response to CO2 hypoventilation
normal A-a gradient
#1 Rx: nocturnal positive-pressure ventilation
o also: weight loss, bariatric surgery
o avoid sedatives

initial evaluation of suspected BPH: urinalysis

to assess for UTI & hematuria
cytoscopy if U/A shows hematuria
PSA screen for prostate cancer if life
expectancy > 10 yrs
--------------------------------------------------------------- severe persistent HTN: > 185/110 is a C/I to
Rx: labetalol or nicardipine
--------------------------------------------------------------- intravascular hemolysis: RBC structural damage
o haptoglobin, LDH
extravascular hemolysis: RBCs destroyed by
phagocytes in spleen RES (AIHA, HS, G6PD def.)
o less Hb release, slight elevation of LDH,
normal haptoglobin
--------------------------------------------------------------- autoimmune hemolytic anemia, G6PD
deficiency & hereditary spherocytosis all cause
extravascular hemolytic anemia & +spherocytes
o AIHA: negative family Hx, +Coombs
o HS: +family Hx, negative Coombs
o G6PD deficiency: Heinz bodies, neg Coombs
--------------------------------------------------------------- decreased passive & active ROM, more stiffness
than pain: adhesive capsulitis (frozen shoulder)
inability to lift arm above head; due to fibrosis
risk factors: idiopathic, rotator cuff tendinopathy,
subacromial bursitis, paralytic stroke, DM,
humoral head fracture
--------------------------------------------------------------- factors that aggravate prerenal azotemia:
decreased fluid intake, ACE-I, NSAIDs
decreased effective renal blood flow activates the
RAA axis, which constrict glomerular arterioles
(efferent > afferent) to maintain intraglomerular
pressure & GFR
continued volume depletion GFR
persistent untreated renal hypoperfusion leads to
intrinsic renal failure due to ischemia
o tubules undergo acute ischemic necrosis &
reabsorption of solutes is impaired
o BUN/Cr ratio falls (< 20:1)

compartment syndrome: pain out of proportion

to injury, pain with passive ROM, paresthesia
sensory loss & motor weakness present later
arterial pulses are present
Dx: measure compartment pressures
Rx: urgent fasciotomy
--------------------------------------------------------------- Kawasaki disease (mucocutaneous lymph node
syndrome) is a clinical diagnosis
o common in age < 5
o fever 5 days
o B/L non-exudative conjunctivitis
o cervical lymphadenopathy > 1.5 cm
o mucositis (injected/fissured lips or
strawberry tongue)
o swelling/erythema of palms/soles
o polymorphous rash
Rx: ASA & IV immunoglobulin within 10 days
of fever to prevent cardiac complications, but
usually self-limited (Reye syndrome risk with
ASA; life-threatening hepatic encephalopathy)
complications: coronary artery aneurysms,
leading to MI & ischemia
o perform a baseline echocardiography in all
suspected cases; repeat to monitor changes
--------------------------------------------------------------- congenital syphilis: rhinorrhea, cataracts,
sensorineural hearing loss; no cardiac defects
congenital CMV: unilateral deafness, IUGR,
chorioretinitis; no cardiac defects
congenital toxoplasmosis: chorioretinitis,
hydrocephalus, intracranial calcifications,
sensorineural hearing loss; no cardiac defects
---------------------------------------------------------------Rubella (German measles, RNA togavirus)
features congenital: sensorineural deafness, cardiac
defects (PDA), glaucoma/cataracts,
microcephaly, thrombocytopenic blueberry
muffin rash purpura
children: low-grade fever, coryza,
conjunctivitis, cervical lymphadenopathy,
Forschheimer spots (petechiae on soft palate)
transient (< 3 days) cephalo-caudal
blanching maculopapular rash in centrifugal

adults: PLUS arthralgias/arthritis

mild disease 2 3 wks after inhalation of
respiratory droplets
PCR, anti-rubella IgM & IgG
supportive, acetaminophen
live attenuated rubella vaccine (MMR)
first trimester infection results in spontaneous
abortion & congenital rubella; teratogenic
---------------------------------------------------------------Measles (rubeola)
respiratory droplets (hours)
manifest 1 3 wks after exposure
prodrome fever, malaise, anorexia;
cough, coryza, conjunctivitis, &
Koplik spots, followed by
blanching, red-brown maculopapular rash with
cephalocaudal/centrifugal spread; spares palms/soles
PCR, anti-measles IgM & IgG
live, attenuated vaccine
supportive, anti-pyretics, hydration
Vitamin A ( morbidity/mortality)
complications otitis media, pneumonia,
gastroenteritis, encephalitis
(subacute sclerosing panencephalitis)

known/suspected cases: immediate isolation with

negative air pressure, N95 mask
Koplik spots: tiny, white lesions in conjunctiva
& buccal mucosa
--------------------------------------------------------------- complication of untreated Strep pharyngitis:
Scarlet fever
preceding Group A Strep infection (tonsillitis,
pharyngitis) with tonsillar gray/white exudates
produces erythrogenic exotoxins
incubation: 1 7 days
prodromal fever, headache, vomiting, sore throat,
circumoral pallor, then 12 48 hr later
fine pink blanching papules on neck, axilla, groin;
sandpaper-like texture; spares palms/soles
Dx: throat culture
Rx: rapid response to PCN V; or amoxicillin
complications: rheumatic fever
DDx: Kawasakis (B/L conjunctival injection)

--------------------------------------------------------------- Viridans group Streptococci (S. mutans) causing

native-valve IE are susceptible to PCN
IV ABX is preferred for initial Rx
empiric Rx: IV vancomycin
Rx: IV aqueous PCN G or IV ceftriaxone
PCN-allergic: vancomycin
--------------------------------------------------------------- ALL: lymphoblasts lack peroxidase positive
granules but contain cytoplasmic aggregates of
PAS positive material
positive TdT: expressed only by pre-B & pre-T
recurrent infection, lymphadenopathy, splenomegaly
Dx: > 25% lymphoblasts
--------------------------------------------------------------- myeloblasts contain peroxidase positive material
--------------------------------------------------------------- mass involving mandible or abdominal viscera,
high mitotic index, starry sky appearance:
Burkitt lymphoma
Rx: high-dose chemotherapy
--------------------------------------------------------------- abdominal pain, constipation, polydipsia
a single elevated Ca++ must be confirmed with a
second serum Ca++ to confirm hypercalcemia
next: measure PTH levels
elevated PTH measure urinary Ca++
o high urine Ca++ 10 & 30 hyperPTH
o low urine Ca++ familial hypercalcemic
suppressed PTH measure PTHrP, 25(OH)D,
& 1,25(OH)D
o PTHrP malignant tumor
o 25(OH)D Vit D toxicity
o 1,25(OH)D CXR for lymphoma, sarcoid
o all normal hyperthyroidism, MM,
acromegaly, milk-alkali syndrome
--------------------------------------------------------------- antipsychotics cause hyperprolactinemia by
blocking DA activity of tuberoinfundibular path,
projects from hypothalamus to pituitary
o amenorrhea, galactorrhea, gynecomastia,
sexual dysfunction

therapeutic effects of antipsychotics work on the

mesolimbic pathway, projects from ventral
tegmental area (VTA) to limbic system
decrease DA activity in the nigrostriatal path
causes EPS effects of antipsychotics, extend
from the substantia nigra to basal ganglia
o DA activity causes chorea & tics
--------------------------------------------------------------- chorioretinitis: posterior uveitis
--------------------------------------------------------------- shortened PR, widened QRS, delta waves: WPW
due to an anterograde accessory AV pathway,
allow early depolarization of the ventricle
causes pre-excitation & risk of tachyarrhythmia
retrograde conduction can result in SVT
--------------------------------------------------------------- Hx of caustic ingestion pyloric stricture
abdominal succussion splash
Dx: upper endoscopy
--------------------------------------------------------------- odorless vaginal spotting/bleeding in a newborn:
effects of maternal estrogen
Rx: reassurance
--------------------------------------------------------------- initial management of children with speech delay:
audiology evaluation
--------------------------------------------------------------- massive hemoptysis: > 600 mL/24 hr or 100 mL/hr
complication: asphyxiation
Management of ongoing hemoptysis
establish an adequate patent airway & ventilation
ensure hemodynamic stability
place bleeding lung in the dependent position
bronchoscopy to localize bleed site
--------------------------------------------------------------- radioiodine therapy causes permanent
hypothyroidism with Graves since the entire
thyroid gland is hyperfunctional
toxic adenoma & multinodular goiters remain
euthyroid after radioiodine; only destroys
autonomous areas
--------------------------------------------------------------- ABO incompatibility occur in group O mother
with a group A or B baby

Abs to ABO antigens cause mild disease in

most newborns compared to Rh incompatibility
can occur in the first pregnancy
--------------------------------------------------------------- MCC of postpartum hemorrhage within 24 hr
of delivery: uterine atony
soft, boggy, poorly contracted uterus
risk factors: multiple gestation, polyhydramnios,
macrosomia, prolonged labor
Rx: fundal or bimanual uterine massage,
crystalloid infusion, oxytocin
alternative Rx: uterine packing
--------------------------------------------------------------- Henoch-Schonlein purpura are at risk for
ileo-ileal intussusception
o does not reduce spontaneously compared to
ileocolic intussusceptions
Rx: surgical
--------------------------------------------------------------- statin A/E: hepatotoxicity & myopathy
ASA & NSAIDs A/E: allergic angioedema
--------------------------------------------------------------- VSD is common in Edwards (trisomy 18)
--------------------------------------------------------------- liver Bx is required for HCV staging
Candidates for chronic Hep C therapy
age > 18
detectable HCV RNA in serum
liver Bx with bridging fibrosis
compensated liver disease (no ascites)
stable lab studies
willingness for Rx & compliance
no contraindications (ongoing alcohol/drug abuse,
major uncontrolled depression)
Rx: peginterferon & ribavirin
o HCV genotype 1 also receive protease
inhibitor: telaprevir or boceprevir
--------------------------------------------------------------- recurrent, predictable, self-limited episodes of
vomiting without apparent cause in a child:
cyclic vomiting syndrome
no symptoms between episodes
a/w family Hx of migraines
resolution in 5 10 yrs

DDx: bulimia, GERD, malrotation, Munchausen,

mesenteric adenitis, viral gastroenteritis
--------------------------------------------------------------- severe bilious emesis & hypovolemic shock
upper GI series to Dx intestinal malrotation
--------------------------------------------------------------- transient proteinuria is MCC of isolated
proteinuria in children
2/2 fever, exercise, seizure, stress, volume depletion
repeat urine dipstick on 2 subsequent occasions
to r/o persistent proteinuria
--------------------------------------------------------------- diarrhea, weight loss, anemia, mild DM or
hyperglycemia, necrotic migratory erythema:
necrotic migratory erythema: papule/plaques that
coalesce to form a large, painful blister &/or
crusting with central clearing; perineum, face
Dx: glucagon > 500 pg/mL
DDx: gastrinoma, late-onset Type I DM,
thyrotoxicosis, carcinoid syndrome
--------------------------------------------------------------- MCC of pneumonia in HIV: Strep pneumo
CXR: pleural effusion
also susceptible to other encapsulated spp
---------------------------------------------------------------Causes of fetal growth restriction (weight < 10th %)
asymmetric vascular disease (HTN, preeclampsia, DM)
antiphospholipid Ab syndrome
autoimmune disease (SLE)
cyanotic cardiac disease
substance abuse (tobacco, alcohol, cocaine)
genetics (aneuploidy)
congenital heart disease
intrauterine infection (malaria, CMV,
rubella, toxoplasmosis, varicella)

impaired blood flow due to suboptimal maternal

factors result in asymmetric growth, as fetal blood
flow redistributes to vital organs (brain, heart) &
appears late in pregnancy
---------------------------------------------------------------Natural history of diabetic nephropathy (DN)
hyperfiltration (0 5 yr after onset)
o glomerular hypertrophy, GFR

incipient DN (5 15 yrs)
o microangiopathy 2/2 advanced glycation end
(AGE) products
o mesangial expansion, glomerular sclerosis,
glomerular BM thickening,
microalbuminuria, arteriolar hyalinosis, HTN
overt DN (15+ yrs)
o mesangial nodules (Kimmelstiel-Wilson),
tubulointerstitial fibrosis, nephrotic syndrome,
--------------------------------------------------------------- air in the biliary tract: gallstone ileus
--------------------------------------------------------------- porcelain gallbladder results from deposition of
Ca++ salts 2/2 chronic cholecystitis
incidental finding, a/w risk of GB carcinoma
definitive Rx: cholecystectomy
--------------------------------------------------------------- ASD, VSD, PDA, & dextrocardia are acyanotic
congenital heart diseases
---------------------------------------------------------------Congenital cyanotic heart diseases
MCC in the neonatal period,
cyanosis within 24 hr, single S2
of great
CXR: narrow mediastinum
Rx: prostaglandins keep PDA open
MCC after the neonatal period,
harsh pulmonary stenosis murmur,
VSD murmur, single S2,
CXR: RVH, boot-shaped heart
single S2, minimal pulmonary flow
VSD murmur, hypoplastic RV
newborn with left-axis deviation
single S2, systolic ejection murmur, Truncus
increased pulmonary flow, edema
severe cyanosis, pulmonary edema,
respiratory distress
RA & RV enlargement
CXR: snowman sign
venous return
--------------------------------------------------------------- fever, muscle rigidity, autonomic instability,
diaphoresis, confusion, elevated CPK: NMS
MCC: haloperidol; occurs within 2 weeks

#1 Rx: discontinue drug, ICU, aggressive cooling,

antipyretics, fluids & electrolytes, alkaline diuresis
Rx: dantrolene (muscle relaxant) or bromocriptine
(DA agonist) or amantadine (DA properties)
complication: rhabdomyolysis
--------------------------------------------------------------- management of placenta previa depends on
gestational age & bleeding severity
active, uncontrolled antepartum hemorrhage with
unstable vital signs & non-reassuring fetal HR,
regardless of gestational age c-section
o induction of labor will aggravate bleeding
by triggering uterine contractions
prior c-section increases risk for placenta accreta
--------------------------------------------------------------- Fibromuscular dysplasia: causes arterial stenosis,
aneurysm, or dissection; MCC of secondary HTN
o renal artery involvement resistant HTN
o cerebrovascular arteries TIA, stroke,
amaurosis fugax, Horners
o non-specific: headache, dizziness, tinnitus
--------------------------------------------------------------- increased intragastric pressure during vomiting
causing tears in submucosal arteries of distal
esophagus & proximal stomach: Mallory-Weiss
rupture of dilated submucosal veins at GE junction:
esophageal varices
--------------------------------------------------------------- complication of IE: cerebral septic emboli
DDx: carotid thrombosis, drug-induced vascular
spasm, migraine, lacunar stroke
--------------------------------------------------------------- post-ictal lactic acidosis occurs following a
tonic-clonic seizure
transient anion gap metabolic acidosis
resolves without Rx within 60 90 min
following resolution of seizure activity
Rx: repeat labs after 2 hrs
--------------------------------------------------------------- painless hematuria, sterile pyuria, WBC casts:
analgesic nephropathy
females chronically using combined analgesics
asymptomatic; incidental increase in Cr
painless hematuria due to papillary ischemia from
analgesia-induced vasoconstriction of vas recta

papillary necrosis & tubulointerstitial nephritis

with focal glomerulosclerosis
results in CKD & ESRD
severe cases: nephrotic range proteinuria
CT: small kidneys, B/L papillary calcifications
--------------------------------------------------------------- simple renal cyst: thin wall, no solid component,
no contrast enhancement on CT, no septae
o incidental finding; no Rx, no follow-up
malignant cystic mass: irregular septae walls,
multilocular, heterogeneous (solid & cystic),
contrast enhancement on CT
--------------------------------------------------------------- HTN, low plasma renin, hypokalemia,: primary
--------------------------------------------------------------- COPD exacerbation with cor pulmonale
(peripheral edema, hepatomegaly, clear lungs,
JVD, pulmonary HTN)
#1 Rx: bronchodilators, glucocorticoids
Rx: furosemide is used to lower RV filling &
reduce peripheral edema
o caution: C.O. reduction & prerenal azotemia
---------------------------------------------------------------Medication side effects
levodopa/carbidopa early: hallucination, agitation,
(DA precursor
dizziness, headache, confusion
late: dyskinesia, dystonia
dry mouth, blurry vision,
constipation, urinary retention
livedo reticularis, ankle edema
somnolence, hypotension,
confusion, hallucination
(DA agonist)
dyskinesia, hallucinations,
(COMT inhibitor)
confusion, orthostatic
insomnia, confusion
(MAO-B inhibitor)
--------------------------------------------------------------- trihexyphenidyl: anti-muscarinic used for
Parkinsons & drug-induced EPS
red as a beet, dry as a bone, hot as a hare,
blind as a bat, mad as a hatter, full as a flask

flushing, anhidrosis, hyperthermia, mydriasis,

delirium, urinary retention/constipation
--------------------------------------------------------------- BPH: affects central portion; @ transitional zone
prostate cancer: lateral lobe of prostate; firm
--------------------------------------------------------------- initial BPH workup: one-time PSA measurement
--------------------------------------------------------------- prostate Bx: suspected prostate cancer with
abnormal prostate exam, or persistently elevated
PSA > 4 ng/dL
--------------------------------------------------------------- initial evaluation of essential HTN should assess
possible secondary causes
o U/A for occult hematuria & protein/Cr ratio
o chemistry panel
o lipid profile (risk stratification for CAD)
o baseline EKG
--------------------------------------------------------------- unexplained elevation of serum CK & myopathy:
fatigue, myalgia, proximal muscle weakness,
sluggish ankle reflexes, normal ESR
Dx: TSH, T4
DDx: polymyositis (normal DTRs, ESR)
---------------------------------------------------------------Major stroke types
local artery obstruction,
symptoms fluctuate, stuttering progress (thrombotic)
Hx of a-fib, endocarditis, carotid bruit,
abrupt onset,
maximal symptoms at the start
focal neurologic deficits early,
progress over minutes to hours, then
features of increased ICP (vomiting,
headache, bradycardia)
ruptured berry aneurysm or AVM,
severe headache at onset,
meningeal irritation,
focal deficits are uncommon**

ADPKD: risk of berry aneurysm, results in SAH

--------------------------------------------------------------- hypertensive intracranial hemorrhage MC in
basal ganglia, thalamus, pons, & cerebellum

focal deficits initially (hemiplegia, hemiparesis,

hemisensory disturbances), then ICH symptoms
(vomiting, headache, bradycardia)
Dx: brain CT
--------------------------------------------------------------- lacunar stroke: occluded single penetrating branch
of a large cerebral artery; MC basal ganglia
unilateral pure motor impairment
no cortical signs (aphasia, hemianopsia)
main cause: HTN, which induces microatheroma
& lipohyalinotic thickening
o small vessel hyalinosis
MC site: posterior limb of internal capsule
symptoms over a short period, slow progression
over 24 36 hr; limited neurologic deficits
pure motor, pure sensory, or ataxic hemiparesis;
or dysarthria-clumsy hand syndrome
pure sensory stroke (VPL nucleus of thalamus)
---------------------------------------------------------------Brain lesions
pure motor hemiparesis,
posterior limb
pure sensory stroke, clumsy-hand,
of int. capsule
no visual field abnormalities
(lacunar infarct)
C/L somatosensory & motor deficit
@ face & upper limbs,
conjugate eye deviate toward infarct, MCA occlusion
homonymous hemianopia,
aphasia (dominant hemisphere),
hemineglect (non-dominant parietal)
C/L somatosensory & motor deficit
in lower extremities,
ACA occlusion
abulia (lack of will or initiative),
dyspraxia, urinary incontinence
homonymous hemianopia,
alexia without agraphia (dominant),
PCA occlusion
visual hallucinations,
3rd nerve palsy, C/L motor deficits
alternate syndrome:
C/L hemiplegia,
system lesion
I/L cranial nerve deficits

anterior vasculature: internal carotid artery,

posterior circulation: paired vertebral arteries
form the basilar artery, then divide into PCAs

causes of BUN/Cr: prerenal azotemia

(dehydration), GI bleeding, systemic steroids
o GI bleeding results in bacterial breakdown of
Hb in the GIT with resultant urea absorption
--------------------------------------------------------------- Kallmann syndrome: XR disordered migration
of fetal GnRH & olfactory neurons
hypogonadotropic hypogonadism & anosmia
normal genotype & internal reproductive organs
primary amenorrhea, low FSH & LH
absent breast development, small phallus
no body hair, short stature
Rx: hormone replacement
--------------------------------------------------------------- bilious vomiting, abdominal distension, gassless
colon, triple bubble sign: jejunal atresia
risk factors: prenatal cocaine or tobacco exposure
DDx: necrotizing enterocolitis, pyloric stenosis,
duodenal atresia, Hirschsprungs
---------------------------------------------------------------Antepartum fetal surveillance
o NST: Nonstress test; #1 test
o BPP: Biophysical profile; #2 test
o CST: Contraction Stress test; #2 test
o umbilical artery Doppler velocimetry
--------------------------------------------------------------- NST is performed when there is loss of perception
of fetal movements or in high-risk pregnancies at
32-34 wks gestation; fetal heart tones by Doppler
reactive: within 20 min, 2 accelerations at
least 15 beats/min > baseline, lasting 15 seconds
high negative predictive value
abnormal result yields a low PPV
MCC of non-reactive NST: fetal sleep cycle (20 min)
o Rx: vibroacoustic stimulation
weekly NST for 3rd trimester pregos requiring

ongoing antenatal surveillance

non-reactive NST requires BPP or CST

--------------------------------------------------------------- Biophysical profile (BPP): assess fetal well-being
o amniotic fluid volume
o fetal movement
o fetal tone

o fetal breathing movements

if abnormal NST amniotic fluid volume & fetal
activity are assessed with real-time USS, 30 min
score 8 10 = normal
score 6 = equivocal
score 4 = delivery!
--------------------------------------------------------------- contraction stress test (CST): infusion of oxytocin
sufficient to result in 3 contractions every 10 min
normal CST suggests a low likelihood of stillbirth
within 1 wk of the test; F/U testing in 1 wk
late decelerations is an indication for delivery
--------------------------------------------------------------- umbilical artery Doppler velocimetry:
evaluation of IUGR only
--------------------------------------------------------------- Dx of intrauterine fetal demise: real-time USS
occurs @ >20 wks, before onset of labor
fetal heart tone not heard by Doppler
autopsy of fetus & placenta should be performed
in the first episode of intrauterine fetal demise
also perform maternal coagulation profile
--------------------------------------------------------------- ovulation occurs on day 14
fertilization is possible 24 hr after ovulation
pregnancy = embryo implants @ 6 12 days
after fertilization; -hCG produced by blastocyst
can be detected on a pregnancy test
---------------------------------------------------------------Combined estrogen/progestin OCPs
early A/E: nausea, bloating, breast tenderness;
improves with use; does not cause weight gain
MC A/E: breakthrough bleeding due to lower
estrogen dose
endometrial & ovarian cancer risk
o risk of iron deficiency anemia
o venous thromboembolism
o hepatic adenoma (chronic OCP use)
o amenorrhea
risk of cervical cancer

o rare: stroke, MI
women who smoke, with uncontrolled HTN,
end-organ damage, or age > 35 should consider
contraception without estrogen
---------------------------------------------------------------Emergency contraception
time frame
inflammatory rxn is
0 120 hr
toxic to sperm,
(5 days)
impairs implantation
ulipristal anti-progestin,
0 120 hr
delays ovulation
(5 days)
levonorg progestin,
0 72 hr
delays ovulation
(3 days)
(Plan B)
0 72 hr)
delays ovulation

copper IUD & OCPs are also precoital methods

copper IUD is the most effective emergency
contraceptive method, regardless of parity or age
o C/I: acute cervicitis & PID
--------------------------------------------------------------- DPMA & etonogestrel subdermal implants are
systemic progestin-based precoital contraceptives
that inhibit GnRH secretion, thus FSH/LH
--------------------------------------------------------------- newborns with suspected DiGeorge must be
assessed for life-threatening hypocalcemia
(tetany, seizures, arrhythmias)
o Conotruncal defects (truncus arteriosus)
o Abnormal facies
o Thymic aplasia/hypoplasia
o Cleft palate
o Hypocalcemia
T-cell lymphopenia risk for bacterial, viral, &
fungal infections
--------------------------------------------------------------- appendicitis begins as vague periumbilical visceral
pain caused by stretching of the appendiceal wall
peritoneum becomes inflamed & localize to RLQ
---------------------------------------------------------------Neonatal rashes
asymptomatic, blanching Erythema

erythematous macules,
in 2 wks
papules, or pustules
vesicular clusters on skin,
eyes, mucous membranes, neonatal
CNS infection (seizures), HSV
multi-organ disease
fever, ranges from
vesicular clusters to
disseminated disease
fever, irritability, diffuse
(SSSS)Staph oxacillin,
erythema; blistering &
scalded skin nafcillin,
exfoliation, +Nikolsky
--------------------------------------------------------------- hoarseness, barking cough, respiratory distress:
croup (laryngotracheitis)
o age < 3 yrs; due to Parainfluenza
o lateral XR: subglottic narrowing
--------------------------------------------------------------- exertional dyspnea, heart pounding sensation,
widened pulse pressure: aortic regurgitation
MMC in developing countries: rheumatic fever
MCC in developed countries: aortic root dilation
or congenital bicuspid valve
---------------------------------------------------------------Features of TCA overdose
drowsiness, delirium, coma,
seizure, respiratory depression
sinus bradycardia, hypotension,
(MCC death)
prolonged PR/QRS/QT,
ventricular tachycardia, v-fib
dry mouth, blurred vision,
mydriasis, flushing, hyperthermia,
urinary retention
TCAs inhibit fast Na+ channels, thus conduction
velocity, duration of repolarization, & prolongs
absolute refractory period
--------------------------------------------------------------- TCA overdose decreases myocardial conduction
velocity, leading to QRS prolongation & risk of
ventricular arrhythmia or seizure
QRS complex duration is the best
prognostic indicator of TCA overdose
supportive Rx: supplemental O2, IV fluids,
activated charcoal if within 2 hrs of ingestion

Rx: sodium bicarbonate narrows the QRS

complex & incidence of ventricular arrhythmia
o indicated when QRS > 100 msec
o pH decreases TCA avidity for Na+ channels
sodium load alleviates depressant action on
myocardial fast sodium channels
--------------------------------------------------------------- B/L hydronephrosis, B/L hydroureters, bladder
distension: posterior urethral valves (PUV)
diagnosed prenatally; can present later in life as
recurrent UTIs & renal failure; only boys
Potter sequence
o urinary tract anomaly oliguria in utero
oligohydramnios pulmonary hypoplasia,
flat facies, & limb deformities
Dx: voiding cystourethrogram & cytoscopy
--------------------------------------------------------------- hypercalcemia of malignancy can be due to
tumor production of PTHrP, osteolytic metastasis,
tumor production of 1,25(OH) vitamin D, or
increased IL-6 levels, IL-3, TNF-
PTH is suppressed; Ca++ > 13 mg/dL
N/V, polyuria, polydipsia, constipation, fatigue,
poor appetite, Hx of smoking
--------------------------------------------------------------- pain, swollen eyelid, visual acuity, hypopyon,
conjunctivitis, corneal edema: post-operative
MC within 6 wk; due to infection of the vitreous
hypopyon = pus in anterior eye chamber
---------------------------------------------------------------Classification & management of asthma
intermittent daytime symptoms 2 days/wk,
nighttime awakenings 2x/month,
-agonist use 2x/wk
normal baseline FEV1 & FEV1/FVC
no limitations of daily activities
Rx: short-acting -agonist (albuterol) PRN
symptoms 2x/wk, but not daily,
nighttime awakenings 3 4x/month,
normal PFTs, minor limitations
Rx: add low-dose inhaled corticosteroid
daily symptoms, weekly nighttime
awakenings, FEV1 60 80% of predicted
Rx: add long-acting inhaled 2-agonist


symptoms throughout, frequent nighttime

awakenings, extreme limitations, FEV1
<60% predicted
Rx: add high-dose inhaled corticosteroid
or oral prednisone
---------------------------------------------------------------Management of asthma exacerbation
mild/moderate asthma exacerbation
o O2, until saturation 90%
o inhaled short-acting -agonists (SABA)
if no response: oral systemic corticosteroids
moderate/severe asthma exacerbation
o O2, until saturation 90%
o inhaled high-dose SABA
PLUS ipratropium nebulizer
o oral systemic corticosteroids
impending or actual respiratory arrest
o mechanical ventilation with intubation on
100% O2; admit to ICU
o nebulized SABA + ipratropium
IV corticosteroids
o if no improvement: Mg++-sulfate
adding ipratropium to SABA causes greater
bronchodilation than either alone
systemic corticosteroids take several hours to
exert its effects
--------------------------------------------------------------- asthmatic child with altered mental status,
unresponsive to Rx, poor air entry on exam,
hypoxemia & CO2 retention: acute asthma
elevated or normal pCO2 suggest decreased
respiratory drive due to respiratory muscle fatigue
& impending respiratory failure
Rx: intubation & mechanical ventilation
o inhaled SABA + inhaled ipratropium, &
systemic corticosteroids; admit to ICU
--------------------------------------------------------------- prevalence is directly related to pre-test probability
if a test result is negative, probability of
having the disease = 1 NPV
false positive ratio = 1 specificity
false negative ratio = 1 sensitivity

---------------------------------------------------------------Features of crystal-induced AKI

etiologie IV acyclovir, sulfonamides, MTX,
ethylene glycol, protease inhibitors
creatinine within 24 48 hr,
intratubular obstruction & direct toxicity
U/A: hematuria, pyuria, crystals
risk with volume depletion or CKD
discontinue drug & volume repletion,
concurrent volume repletion with drug can
prevent kidney injury
AIN occurs 7 10 days after drug exposure
o skin rash, eosinophilia, eosinophiluria, pyuria
--------------------------------------------------------------- MC renal malignancy in childhood: Wilms tumor
(aka nephroblastoma); asymptomatic
--------------------------------------------------------------- excess tearing, burning, mild pain, conjunctival &
eyelid edema, vision is not affected: conjunctivitis
blurry vision, moderate pain, conjunctival injection,
miosis: uveitis
significant pain, photophobia, miosis, vision loss:
anterior uveitis (iritis)
proptosis, ophthalmoplegia, chemosis, vision loss:
cavernous sinus thrombosis
pain with eye movement, proptosis, diplopia,
impaired EOM: orbital cellulitis
corneal vesicles, opacification, dendritic ulcers:
viral keratitis (HSV or varicella)
---------------------------------------------------------------Differentiation of conjunctivitis

stuck shut
watery, scant
stringy mucus
burning, sandy,
gritty feeling
follicular or

stuck shut
purulent, thick,

stuck shut
watery, scant
stringy mucus
intense itching,
Hx of allergy
edema (chemosis)
self-limited, 24 hr

intense itching, hyperemia, tearing, edema of

conjunctiva & eyelids, subsides in 24 hr: allergic
viral pink eye presents similar to allergic, but
lasts several days; a/w URI, MCC adenovirus

Conjunctivitis Rx
topical erythromycin ointment,
fluoroquinolone drops (contact lens)
cool, moist compress
OTC antihistamine/decongestant drops
--------------------------------------------------------------- hyperestrogenism in cirrhosis: gynecomastia,
testicular atrophy, body hair, spider angiomas,
palmar erythema
---------------------------------------------------------------liver functions
synthesis of clotting factors, cholesterols, protein
metabolism of drugs & steroids, detoxification
excretion of bile
--------------------------------------------------------------- portal HTN leads to esophageal varices,
hemorrhoids, & caput medusae
--------------------------------------------------------------- asterixis is a neurologic sign a/w poor hepatic
function & hyperammonemia
a/w CO2 retention, hepatic encephalopathy, &
uremic encephalopathy
uremic encephalopathy Rx: urgent hemodialysis
hepatic encephalopathy Rx: lactulose
---------------------------------------------------------------Bacterial meningitis
risk group
empiric ABX
age 2 50 yrs
vanco & 3rd gen
meningitidis, S. cephalosporin
age > 50 yrs
S. pneumo,


Listeria, G- rod

ampicillin, &
3rd gen
ampicillin, &

alternative to ampicillin: TMP-SMX for Listeria

--------------------------------------------------------------- empiric Rx for bacterial meningitis for
immunocompromised: vancomycin, ampicillin,
+ cefepime with dexamethasone
o adding corticosteroids prevent complications
of meningitis due to S. pneumoniae
if there is delay in performing LP, empiric Rx
must be given after obtaining blood cultures
--------------------------------------------------------------- Rx dehydration: IV Na+-containing crystalloid
(0.9% NS)
can unmask subclinical heart failure in elderly
--------------------------------------------------------------- colloid solutions contain albumin
Rx: burns, hypoproteinemia
--------------------------------------------------------------- post-op cholestasis is a benign condition after
prolonged surgery characterized by
hypotension, extensive blood loss into tissues, &
massive blood replacement
--------------------------------------------------------------- liver has dual blood supply: hepatic arteries &
portal veins
--------------------------------------------------------------- raising the cut-off point of a test
o specificity & sensitivity
--------------------------------------------------------------- CKD causes decreased renal production of Vit D,
leading to hypocalcemia, hyperphosphatemia, &
secondary hyperPTH
circulating PTH increases with declining GFR,
correlates with severity of renal failure
hyperphosphatemia directly stimulates parathyroids
to synthesize & release PTH
DDx: Vit D deficiency (low/normal phosphate,
normal serum Ca++)

--------------------------------------------------------------- diabetic, severe ear pain, granulation tissue in ear

canal, otorrhea,: malignant otitis externa MCC
is P. aeruginosa
MC in elderly with poorly controlled diabetes
aggravated by chewing, difficulty eating
worsens despite topical ABX
Dx: CT or MRI
Rx: systemic anti-pseudomonals (ciprofloxacin)
risk factor: immunosuppressed conditions
complications: osteomyelitis of skull base & CN
damage (facial drooping)
--------------------------------------------------------------- anxiety restricted to social & performance, also
fear of scrutiny & embarrassment: social phobia
DDx: specific phobia, panic disorder, GAD
---------------------------------------------------------------Specific phobia
marked anxiety > 6 months
no fear of scrutiny by others
#1 Rx: behavior therapy
#2 Rx: short-acting benzo (limited role)
--------------------------------------------------------------- anemia, bone disease, & HTN persist with dialysis,
but controlled with renal transplantation
transplant patients have return or normal
endocrine, sexual, & reproductive functions
--------------------------------------------------------------- bupropion inhibits re-uptake of NE, DA, 5-HT
C/I to use of bupropion: Hx of anorexia/bulimia
since development of electrolyte abnormalities
can precipitate seizures
--------------------------------------------------------------- acute pancreatitis can cause an acute abdomen
Rx: analgesics, IV fluids, NPO
Px: self-limited, subsides in 4 7 days
--------------------------------------------------------------- medial meniscus is injured during forceful torsion
of the knee with foot planted
delayed evidence of effusion
swelling & pain within 24 hrs
limited ROM, popping, catching, locking
(inability to extend the knee)
joint line tenderness

evaluation: positive McMurrays & Apleys

--------------------------------------------------------------- ACL tear from forceful hyperextension
swelling & effusion immediately
Dx: positive Lachmans
--------------------------------------------------------------- theophylline has a narrow therapeutic window
o CNS (headache, insomnia, seizure), N/V,
cardiac toxicity (palpitations, arrhythmia)
Dx: measure serum levels
--------------------------------------------------------------- HIV patient with altered mental status
primary CNS lymphoma: MCC is EBV
MRI: solitary, weakly ring-enhancing
periventricular mass
--------------------------------------------------------------- multiple, ring-enhancing lesions in basal ganglia:
o @ cortical grey-white matter interface
multiple, non-enhancing lesions, no mass effect:
solitary, periventricular ring-enhancing lesion:
primary CNS lymphoma
solitary ring-enhancing lesion, bacterial infection,
sinusitis, immunocompetent: brain abscess
o direct extension from contiguous infection
(sinusitis, mastoiditis, otitis media)
o MCC: Viridans strep (S. mutans), anaerobes
--------------------------------------------------------------- brain abscesses from hematogenous spread
from lung infection or endocarditis
o MCC is S. aureus
--------------------------------------------------------------- fatigue, memory loss, constipation, weight gain,
dry skin: amiodarone-induced hypothyroidism
monitor thyroid & hepatic function
pulmonary symptoms require CXR & PFTs
corneal deposits does not necessitate disuse


Major side effects of amiodarone

sinus bradycardia, heart block
QT prolongation, TdP


chronic interstitial pneumonitis,

pulmonary fibrosis
hypothyroid (MC), hyperthyroid
transaminases, hepatitis
optic neuropathy,
corneal deposits
blue-gray discoloration (face)
peripheral neuropathy
--------------------------------------------------------------- Dofetilide A/E: risk of TdP
Procainamide A/E: drug-induced lupus,
agranulocytosis, QT prolongation
--------------------------------------------------------------- quinidine A/E: diarrhea, tinnitus, QT prolongation,
TdP, hemolytic anemia & thrombocytopenia
hydralazine A/E: peripheral edema, salt & fluid
retention, palpitations, orthostatic hypotension,
drug-induced lupus
metoprolol A/E: worsening of heart failure,
bradyarrhythmia, bronchoconstriction, fatigue,
depression, weight gain, sexual dysfunction
---------------------------------------------------------------Antihypertensive in pregnancy
**methyldopa (slow) spironolactone
direct renin inhibitor
--------------------------------------------------------------- labetalol & hydralazine: Rx pre-eclamptic
hypertensive emergencies (BP 160/110)
o not methyldopa (slow onset)
--------------------------------------------------------------- severe antepartum hemorrhage first requires
hemodynamic resuscitation, then emergency USS
o vaginal exam is C/I for risk of aggravating
possible placenta previa bleeding
--------------------------------------------------------------- healthy infants can lose up to 7% of birth weight
in the first 5 days of life
no Rx required; continue exclusive breastfeeding
F/U @ age 10 14 days for weight gain

infants losing > 7%: formula supplementation

--------------------------------------------------------------- # of wet diapers = age in days for 1st wk
6 diapers/day after the 1st wk is normal
pink stains or brick dust in neonatal diapers
= uric acid crystals, common in first few weeks
--------------------------------------------------------------- dysthymia (persistent depressive disorder)
depressed mood 2 yrs (1 yr in childhood)
o MDE symptoms may occur concurrently or
--------------------------------------------------------------- hairy cell leukemia: bone marrow is fibrotic,
leading to dry taps of aspirates
pancytopenia & splenomegaly
+tartrate resistant acid phosphatase (TRAP)
Rx: cladibine (2-CdA)
--------------------------------------------------------------- Hep B vaccination decreases HCC incidence,
especially if from Asia & Africa; MCC due to
vertical transmission
--------------------------------------------------------------- hemodynamically unstable with penetrating
abdominal trauma exploratory laparotomy
any penetrating wound below the 4th IC space is
considered to involve the abdomen
--------------------------------------------------------------- detrusor instability, bladder irritation from neoplasm,
interstitial cystitis results in urge incontinence
o sudden, infrequent loss of moderate to large
amounts of urine, nocturia & frequency
--------------------------------------------------------------- diabetic neuropathy causes overflow incontinence
loss of small amounts of urine from overdistended
bladder; residual volume
--------------------------------------------------------------- cerebellar astrocytoma: #1 MC posterior fossa
tumor, MC site is lateral hemispheres
medulloblastomas MC arise from the vermis
o #2 MC posterior fossa tumor; infratentorial
posterior vermis syndrome: truncal dystaxia
o highly radiosensitive
--------------------------------------------------------------- idiopathic thrombocytopenic purpura (ITP) is
a Dx of exclusion

antecedent viral infection, mucocutaneous bleeding

isolated thrombocytopenia < 100,000
inhibition of megakaryocyte PLT production due to
IgG autoantibodies against PLT membrane
glycoproteins & PLT destruction

Management of ITP
no bleeding: observe
bleeding: IV Ig or glucocorticoids
PLT > 30,000, no bleeding: observe
PLT < 30,000 or bleeding: IV Ig or

r/o pseudothrombocytopenia due to PLT clumping

by EDTA, abciximab, or inadequate coagulation
isolated thrombocytopenia can be the initial
presentation of chronic HIV
also test for HIV & Hep C
DDx: Bernard-Soulier, aplastic anemia, DIC,
dilutional thrombocytopenia, TTP, HUS
--------------------------------------------------------------- chronic GI disease (steatorrhea, Celiac) can cause
Vit D deficiency due to malabsorption
results in hypocalcemia, hypophosphatemia, &
secondary hyperPTH
bone pain, muscle weakness, abnormal gait
--------------------------------------------------------------- CREST syndrome: calcinosis cutis, Raynauds,
esophageal dysmotility, sclerodactyly, telangiectasias
calcinosis cutis: localized dystrophic Ca++ skin
depositions; subcutaneous pink/white nodules
on upper extremities
Raynauds: fingers progress through white, blue,
& hyperemic stages
sclerodactyly: fibrosis of skin distal to MCP joint
telangiectasias: mat-like patches on face & palms
---------------------------------------------------------------Clinical features of cystic fibrosis
bronchiectasis, recurrent pneumonia,
chronic rhinosinusitis, nasal polyps
meconium ileus, steatorrhea,
fat-soluble vitamin malabsorption
(night blindness, rickets, neuropathy,
exocrine pancreatic insufficiency


infertility ( 95% males)
growth failure, osteopenia (fractures),
clubbing, kyphoscoliosis

inspissated mucus predisposes to rhinosinusitis

fecal elastase testing (exocrine pancreas status)
Dx: sweat chloride test via quantitative
pilocarpine iontophoresis
Strep pneumo: MCC pneumonia overall
S. aureus is MCC of CF-pneumonia in age < 20 yr
Rx: IV vancomycin
P. aeruginosa is MCC of CF-pneumonia in adults
Rx: IV ceftazidime or aminoglycosides
frequent Rx with aminoglycosides can
result in sensorineural hearing loss
Rx: high-calorie diet, fat-soluble vitamin &
pancreatic enzyme replacement
--------------------------------------------------------------- male infertility 2/2 CF is due to congenital B/L
absence of vas deferens
o inspissated mucus in fetal genital tract
obstructs vas deferens development
spermatogenesis is normal, but no ejaculation
(obstructive azoospermia)
--------------------------------------------------------------- diarrhea, dermatitis, dementia, death: pellagra
o niacin (Vit B3) deficiency
scaly dermatitis on sun-exposed areas become
thick & hyperpigmented, resembles a sunburn
abdominal pain, watery diarrhea, glossitis, anorexia
irritability, aggressiveness, poor concentration
a/w bowel disease (UC) that interfere with vitamin
absorption, immigrants on corn-based diets,
alcoholics, carcinoid syndrome, Hartnups
DDx: SLE (no diarrhea), seborrheic dermatitis,
acute intermittent porphyria (no photosensitivity)
--------------------------------------------------------------- cheilosis, glossitis, seborrheic dermatitis, pharyngitis,
oral erythema: riboflavin (Vit B2) deficiency
--------------------------------------------------------------- irritability, depression, dermatitis, stomatitis,
homocysteine : pyridoxine (Vit B6) deficiency

diabetics have risk of atherosclerotic CV disease

Indications for statins
all diabetics age 40 75 regardless of baseline
lipid levels statin
o CHD risk for any baseline lipid levels
clinical CVD: ACS, MI, angina, TIA, stroke
LDL 190 (no recommended LDL goal)
10-year atherosclerotic CVD risk 7.5%
--------------------------------------------------------------- hemorrhagic pancreatitis: life-threatening illness,
retroperitoneal hemorrhage & pancreatic necrosis
bluish discoloration of the flanks (Grey Turner
sign) or periumbilical region (Cullen sign) due to
blood accumulation intra-abdominal fascial planes
--------------------------------------------------------------- Felty syndrome: a/w rheumatoid arthritis
o neutropenia, recurrent infections, splenomegaly
--------------------------------------------------------------- constitutional growth delay: simultaneous
deceleration in length & weight before age 2 yrs;
normal growth velocity after age 2 yrs; idiopathic
MCC of short stature & delayed puberty
o family Hx of delayed puberty
catch-up growth, onset of puberty, & growth spurt
occur later than average
delayed bone age, but final adult height is normal
--------------------------------------------------------------- familial short stature: standing height > 2 SDs
below the mean for age & gender
normal height velocity, puberty, & bone age
predicted adult height appropriate to familial pattern

--------------------------------------------------------------- post-op patient with hypotension, syncope, JVD,

new-onset right BBB: massive PE
massive PE = PE complicated by hypotension
&/or acute right heart strain

syncope is common
right heart strain ventricular dysFx C.O.,
bradycardia, & cardiogenic shock
Dx: CT angiography
Rx: fibrinolysis (relative C/I: surgery within
preceding 10 days)
--------------------------------------------------------------- pancreatic pseudocyst: fibrous capsule containing
enzyme-rich fluid, tissue, & debris accumulates
within the pancreas elevated amylase
palpable epigastric mass a/w chronic pancreatitis
Rx: resolves spontaneously
--------------------------------------------------------------- diffuse infection of necrotic pancreatic tissue,
MC 1 2 wks after acute pancreatitis episode:
infected pancreatic necrosis
Rx: surgical debridement
---------------------------------------------------------------DDx of flaccid paralysis
infant botulism foodborne
C. botulinum
C. botulinum
spore ingestion preformed
peripheral nerve
from environmt toxin
ascending flaccid
flaccid paralysis flaccid paralysis paralysis
prodrome N/V,
absent DTRx
Rx: botulism Ig Rx: anti-toxin
IV Ig or plsmphrss
previously healthy infant with B/L bulbar palsies
(ptosis, sluggish pupillary response, poor suck or
gag reflexes), symmetric hypotonia, constipation,
Rx: empiric IV botulism Ig
--------------------------------------------------------------- mucopurulent vaginal discharge, friable cervix:
#1 MCC: C. trachomatis; #2: N. gonorrhea
Dx: nucleic acid amplification
--------------------------------------------------------------- solitary pulmonary nodule on CXR: compare
with previous CXR
stable lesion, 2 3 yrs no further testing

no previous imaging chest CT

o benign features serial CT scans
o intermediate suspicion Bx or PET
o high suspicion surgical excision
2 cm, low density, speculated/irregular,
eccentric calcification favors carcinoma
high risk: age > 60, current smoker, weight loss,
previous malignancy
Bx central lesions: bronchoscopy
Bx peripheral lesions: CT-guided percutaneous Bx
--------------------------------------------------------------- uncomplicated proximal LE DVT
Management of SIADH
asymptomatic/mild fluid restriction (< 800 mL/day),
oral Na+ tablets,
unstable gait)
furosemide if urine Osm > 2x
serum Osm
hypertonic saline (3 4 hrs) to
(confusion, lethargy) Na+ > 120 mEq/L
hypertonic saline bolus until
(mental status
symptoms resolve,
change, seizure,
+/- conivaptan (ADH Rc
&/or coma)
antagonist; cause water diuresis)
Rx: anticoagulation (unfractionated or LMWH)
anticoagulation C/I: recent surgery, active bleed,
Hx of HIT, hemorrhagic stroke, bleeding diathesis
Rx: IVC filter
proximal DVT with hemodynamically unstable PE
or massive proximal DVT with severe swelling or
limb-threatening ischemia
Rx: thrombolytics
o if C/I: iliac stenting, mechanical or
surgical thrombectomy
--------------------------------------------------------------- middle-aged woman, widespread pain, fatigue,
cognitive/mood disturbance: fibromyalgia
normal lab findings, normal ESR
symptoms > 3 months
Dx: widespread pain index/symptom severity scale
#1 Rx: education, exercise, & sleep hygiene
#2 Rx: amitriptyline (TCAs)
alt Rx: pregabalin, duloxetine, milnacepran
---------------------------------------------------------------Polymyalgia rheumatica

age > 50 with B/L pain & stiffness >1 month,

morning stiffness > 1 hr, constitutional symptoms,
ESR, normal CK
active ROM of shoulder, neck, & hip
no focal tenderness or weakness
Rx: low-dose prednisone (rapid, thorough relief)
a/w giant cell arteritis
o Dx: temporal artery Bx if suspected
o Rx: high-dose prednisone
--------------------------------------------------------------- euvolemic hyponatremia due to renal Na+ losses
when normal saline bolus is given, urine Na+
excretion, while serum Na+ is unaffected
SIADH findings
o serum osmolality < 290
urine osmolality > 300 (concentrated urine)
urine Na+ > 40 mEq/L
o absence of hypovolemia (euvolemic)
o normal Cr, K+, acid-base
o normal renal, adrenal, & thyroid function
asymptomatic or mild symptoms of SIADH
respond to fluid restriction &/or Na+ tablets
severe, symptomatic hyponatremia requires
hypertonic saline
serum Na+ correction: 0.5 1 mEq/L/hr or 10
mEq/24 hr to prevent osmotic demyelination
--------------------------------------------------------------- demeclocycline: responsiveness to ADH
Rx SIADH by inhibiting ADH-mediated aquaporin
A/E: nephrotoxic
--------------------------------------------------------------- effective management of SIADH required the
infused fluid to have a higher electrolyte
concentration than urine & plasma
NS (0.9%) is only slightly higher than serum
osmolality & leads to NaCl excretion
excessive ADH causes more water retention,
thus concentrates the urine, dilutes the serum, &
worsens hyponatremia
--------------------------------------------------------------- ACE-I are recommended for patients with
proteinuria, heart failure, or CKD with HTN
C/I in B/L renal artery stenosis

--------------------------------------------------------------- cirrhosis causes signs of total body water overload

(ascites, interstitial edema) 2/2 hypoalbuminemia
edema causes relative depletion of intravascular
volume, causing kidney to maximally retain water,
resulting in low urine Na+
--------------------------------------------------------------- sodium bicarbonate: Rx severe metabolic acidosis,
hyperkalemia, & TCA overdose
--------------------------------------------------------------- chronic phenytoin can cause megaloblastic anemia
due to impaired absorption of folic acid
also primidone, phenobarbital, TMP, MTX
--------------------------------------------------------------- low-dose prednisone: Rx polymyalgia rheumatica
high-dose prednisone: Rx giant cell arteritis
MTX: Rx rheumatoid arthritis
hydroxychloroquine: Rx SLE for skin & joint
--------------------------------------------------------------- mittelschmerz: mid-cycle pain is due to ovulation
unilateral abdo pain, 2 wks after LMP
regular menstrual periods, not on OCPs
--------------------------------------------------------------- nephrotic syndrome can cause dyslipidemia,
increasing risk for accelerated atherosclerosis
& intrinsic hypercoagulability (venous)
complications: stroke, MI
--------------------------------------------------------------- Metabolic syndrome (at least 3/5)
o abdomen (men: > 40 in, women > 35 in)
o fasting glucose > 100 mg/dL
o BP > 130/80 mmHg
o triglycerides > 150 mg/dL
o HDL (men < 40, women < 50)
pathogenesis: insulin resistance (results in
increased insulin secretion to compensate)
o endothelial dependent vasodilatation is
impaired in insulin resistance
--------------------------------------------------------------- blood at urethral meatus, inability to void, &
high-riding prostate: posterior urethral injury
Dx: retrograde urethrogram prior to Foley
o Foley catheter will predispose to abscess,
hematoma, or urethral damage

perineal or scrotal hematomas are a/w pelvic fx

immunocompetent: asymptomatic or mild
pulmonary disease
immunocompromised: pneumonia, pancytopenia,
adenopathy, hepatosplenomegaly, mucocutaneous
Dx: urine or serum antigen
Rx (mild): oral itraconazole
Rx: (severe): amphotericin B, then oral itraconazole
--------------------------------------------------------------- short-acting benzos (alprazolam) is a/w seizures
& confusion following abrupt discontinuation
dose-dependent A/E of bupropion use: seizures
--------------------------------------------------------------- AAA screening: 1x abdominal USS for male
active or former smokers ager 65 75
selective screening for male never smokers
women age 65 - 75 who have ever smoked
o insufficient evidence
surgical Rx AAA 5.5 cm
--------------------------------------------------------------- acute onset back pain & profound hypotension:
evaluate for presumptive ruptured AAA
Rx: emergent surgical AAA repair
complication: AAA can rupture into retroperitoneum,
creating an aortocaval fistula with the IVC venous
congestion in the bladder fragile, distended veins
can rupture gross hematuria
DDx: renal colic, mesenteric ischemia,
pancreatitis, diverticulitis, biliary disease
--------------------------------------------------------------- symptoms of impending eclampsia: persistent
frontal/occipital headache, visual disturbance,
altered mental status, RUQ or epigastric pain, SOB
tonic-clonic (grand mal) seizures last 3 4 min
& self-limited
fetal bradycardia is common during seizures;
resolves once patient is stabilized
Rx: Mg++ sulfate prevents seizure recurrence;
continued through labor & postpartum period
Rx: labor induction/augmentation if no evidence
of fetal distress
o c-section reserved for typical OC reasons

--------------------------------------------------------------- chronic Rx with supra-physiologic doses of

glucocorticoids (Rx giant cell arteritis) is a/w
hyperglycemia, bone loss, chronic myopathy
glucocorticoid-induced myopathy progresses
over weeks to month after Rx initiation
painless proximal weakness, no tenderness
normal CK & ESR, no inflammation
DDx: MS, Myasthenia, polymyalgia rheumatica
---------------------------------------------------------------DDx of myopathy
glucocorticoid progressive proximal
nrml nrml
weakness, mainly LE,
no pain or tenderness
pain & tenderness,

w/without weakness,
pain, cramps, weakness nrml

of proximal muscles,
delayed DTRs,
hypothyroid features
pain & stiffness

decreased ROM at hip
& shoulders
rapid response to
proximal weakness,

pain & tenderness,
rash, arthritis
--------------------------------------------------------------- Management of blunt abdominal trauma in
hemodynamically unstable: FAST exam
o positive laparotomy
o negative abdominal CT
o inconclusive DPL
--------------------------------------------------------------- hearing tests for children with behavioral concerns,
poor language & social skills, inattentive
MCC: conductive hearing loss due to recurrent
ear infections
--------------------------------------------------------------- SGA infant: weight < 10th percentile
complications: hypoxia, polycythemia,
hypoglycemia, hypothermia, hypocalcemia

o polycythemia is 2/2 hypoxia

--------------------------------------------------------------- preseptal cellulitis: anterior to orbital septum
orbital cellulitis: posterior to orbital septum
eyelid edema & erythema
fever, leukocytosis
+/+/ophthalmoplegia, diplopia
pain with eye movement
decreased visual acuity
Dx: orbital CT scan
Rx preseptal: outpatient, oral ABX
Rx orbital: inpatient, IV ABX
complication: cavernous sinus thrombosis
--------------------------------------------------------------- circumferential full-thickness burns of extremity
o Rx: IV fluids, analgesia, topical ABX, &
wound dressing
eschar: firm necrotic tissue on exposed tissue
following burn wounds
o compromises blood & lymph circulation
compartment syndrome: deep pain out of
proportion to injury, pulselessness, paresthesia
Dx: Doppler USS to document peripheral pulses
& tissue compartment pressure
Rx: escharotomy for edema & constriction of
vascular supply or peripheral pulses
o evaluate for signs of adequate perfusion
fasciotomy: Rx compartment syndrome
--------------------------------------------------------------- decreased appetite, behavioral changes, erythema
of turbinates in nasal septum: cocaine abuse
--------------------------------------------------------------- primary dysmenorrhea: lower abdo cramping
with menses, in absence of other pathology
o MC onset during adolescence
cramping in 1st few days of menses, due to
release of prostaglandins from sloughing
endometrium causes uterine contractions
normal physical exam

Anti-diabetic medications
1 2%
initial therapeutic agent
weight neutral
low risk of hypoglycemia
A/E: lactic acidosis
C/I: renal insufficiency
1 2%
added for metformin failure
weight gain, hypoglycemia
1 - 1.5% 2nd line to metformin/sulfon.
low risk of hypoglycemia
can use in renal insufficiency
A/E: weight gain, edema,
CHF, bone fx, bladder cancer
1 - 3.5% basal insulin added in
metformin failure, A1c >8.5%
weight gain, hypoglycemia
.5 - .8% weight neutral
low risk of hypoglycemia
can use in renal insufficiency
0.5 - 1% 2nd agent to metformin
(GLP-1 Rc
weight loss**
low hypoglycemia risk
A/E: acute pancreatitis
--------------------------------------------------------------- secondary dysmenorrhea: age 20s 30s,
previous Hx of non-painful menses
MCC: endometriosis, adenomyosis, fibroids,
pelvic infection
--------------------------------------------------------------- chronic corticosteroids & chronic alcohol are
a/w avascular necrosis
progressive hip pain, normal ROM; normal XR
--------------------------------------------------------------- hemodynamic compromise 3 7 days post-MI:
MR due to papillary rupture, LV free wall rupture,
or interventricular septum rupture
--------------------------------------------------------------- young patient with a fleshy, immobile mass on
the midline hard palate: torus platinus
o benign, congenital lesion
--------------------------------------------------------------- elevated ALP indicates cholestasis
Dx: RUQ USS; intrahepatic or extrahepatic
cause of biliary obstruction

o biliary dilatation: extrahepatic cholestasis

--------------------------------------------------------------- polyuria, polydipsia, mild hypernatremia (> 145)
& serum hypertonicity: diabetes insipidus
nephrogenic DI: intact thirst mechanism
o serum Na+ ~ 145
central DI: no intact thirst mechanism
o serum Na+ > 150
o desmopressin: #1 Rx for central DI
---------------------------------------------------------------10 polydipsia
central DI
nephrogenic DI
H2O intake
ADH release
ADH resistance
idiopathic, trauma chronic lithium,
pituitary surgery,
female on
antipsychotics encephalopathy
polyuria, low urine osmolality (dilute urine)
Na+ < 137
Na+ > 150,
Na+ 142 150,
thirst impairment
intact thirst mech
--------------------------------------------------------------- diuretic: hypoK+, hyperglycemia, hyperuricemia
o stimulates ADH concentrated urine
--------------------------------------------------------------- demeclocycline: Rx SIADH by inhibiting the
ADH-mediated aquaporin insertion
--------------------------------------------------------------- tolvaptan: V2 vasopressin Rc antagonist, causes
selective free water loss
Rx severe hypervolemic/euvolemic hyponatremia
--------------------------------------------------------------- hypersensitivity pneumonitis: inflammation of
lung parenchyma due to antigen exposure
cough, dyspnea, fever, malaise within 4 6 hr
chronic: weight loss, clubbing, honeycomb lung
CXR: ground-glass opacity, haziness
Rx: avoidance of antigen
complications: pulmonary fibrosis
--------------------------------------------------------------- SSRIs take 4 6 wks for benefits
o should be continued if no significant A/E
initial change: dosage
next: prescribe another SSRI
--------------------------------------------------------------- PTU A/E: hepatic failure (black box)

methimazole A/E: 1st trimester teratogen

patients with sore throat & fever stop med &
check WBC for agranulocytosis (WBC < 1,000)
Rx: IV ABX (anti-pseudomonals)
30 - 40% on anti-thyroidal after 1 yr go into
permanent remission
--------------------------------------------------------------- hyperactive DTRs post-surgery: hypocalcemia
MCC: volume expansion & hypoalbuminemia
in patients requiring multiple transfusions
caused by citrate binding to ionized Ca++
--------------------------------------------------------------- severe hypoMg++ can mimic hypocalcemia
PTH secretion & peripheral PTH resistance
serum phosphate level is normal
--------------------------------------------------------------- severe hyperMg++: loss of DTRs, paralysis,
apnea, cardiac arrest
--------------------------------------------------------------- sensorineural hearing loss due to aging:
o B/L high-frequency hearing loss
o difficulty hearing in noisy, crowded spaces
--------------------------------------------------------------- chronic conductive hearing loss a/w overgrowth
of stapes bone: otosclerosis
o low-frequency hearing loss
o women age 30s 40s
--------------------------------------------------------------- steatorrhea can be due to pancreatic insufficiency
(chronic pancreatitis, CF), impaired bile salt
absorption (Crohns), impaired intestinal surface
epithelium (Celiacs), or Whipples
MCC of chronic pancreatitis: alcohol abuse
generalized seizure: diffuse brain involvement
partial seizure: arise from a discrete focus; can
be preceded by an aura (burning smell)
o simple partial: no loss of consciousness
o complex partial: a/w LOC & automatisms
(chewing, picking, lip smacking)
partial with secondary generalization:
tonic-clonic manifestations (muscle aches,
CK, loss of bowel/bladder control)

--------------------------------------------------------------- clavicle fractures require a neurovascular exam;

proximity of subclavian artery & brachial plexus
bruit heard under the clavicle requires angiogram
middle 1/3 fx Rx: brace/sling, ice, rest
distal 1/3 fx Rx: ORIF to prevent non union
--------------------------------------------------------------- MCC of aortic stenosis
o senile calcific aortic stenosis (MC age > 70)
bicuspid aortic valve (MC age < 70)
o rheumatic heart disease
DDx: hypertrophic cardiomyopathy (heard @
LLSB, does not radiate to carotids)
--------------------------------------------------------------- young female immigrant with a-fib & symptoms
of pulmonary edema: mitral stenosis 2/2
rheumatic heart disease
females become symptomatic during pregnancy due
to increased blood volume
--------------------------------------------------------------- lateral epicondylitis: pain with supination,
passive wrist flexion, or resisted wrist extension
point tenderness distal to lateral epicondyle
extensor carpi radialis brevis tendon degeneration
DDx: radial tunnel syndrome
--------------------------------------------------------------- medial epicondylitis: pain with passive wrist
extension or resisted wrist flexion
--------------------------------------------------------------- ASA & -blockers can trigger bronchoconstriction
in asthmatics (acute dyspnea, prolonged expiration)
o especially with chronic rhinitis & nasal polyps
cardioselective -blockers (metoprolol, atenolol)
act on -1; safe for mild/moderate asthmatics
--------------------------------------------------------------- stress incontinence Rx: Kegel exercise, urethropexy
Dx: urethral hypermobility (> 300 urethrovesical
angle with increased intra-abdominal pressure)
--------------------------------------------------------------- oxybutynin: Rx urge incontinence
bethanechol & -blockers: Rx overflow incont.
--------------------------------------------------------------- most predictive sign of opioid intoxication:
bradypnea (respiratory depression)

obtunded, bowel sounds, miosis,

hypotension, hypothermia
---------------------------------------------------------------GBS prophylaxis for unknown GBS status
delivery @ < 37 wks
membrane rupture > 18 hr
GBS bacteriuria during current pregnancy
prior Hx of newborn with GBS sepsis
--------------------------------------------------------------- presence of a VSD requires an echo to determine
location & size, also r/o other defects
small VSDs close spontaneously by age 2 yrs
--------------------------------------------------------------- V-fib (reentrant ventricular arrhythmias) is MCC of
sudden cardiac arrest, immediately post-MI
o re-entry is the predominant mechanism
causes syncope
---------------------------------------------------------------Neonatal displaced clavicle fracture
fetal macrosomia, shoulder dystocia,
instrumentation delivery
features crying with passive motion, crepitus,
asymmetric Moro reflex
reassurance, gentle handling, analgesics,
spontaneous healing in 7 10 days,
place affected arm in long-sleeved garment
& pin to chest with elbow flexed 900
--------------------------------------------------------------- fat necrosis of the breast: fixed mass with skin
or nipple retraction, appears solid on USS
coarse calcification on mammography
(breast malignancy: microcalcifications)
fat globules & foamy histiocytes/macrophages
Rx: routine F/U, no intervention, self-limited
--------------------------------------------------------------- ALT is predominant in the liver, more specific
for hepatocyte injury
screen Hx for hepatitis risk factors: drugs, alcohol,
travel outside US, transfusions, sexual practices
repeat LFTs: if chronically elevated transaminases
(> 6 months); evaluate for Hep B & C, fatty liver, &

pallor, fatigue, bloody diarrhea, scattered petechial

rash, oliguria: HUS
hemolytic anemia, thrombocytopenia, ARF
MCC: E. coli O157:H7; also S. pneumo (causes
pneumonia or meningitis instead of diarrhea)
progressive renal involvement: oliguria,
microscopic hematuria, hyaline casts
results in fluid overload (pulmonary edema, CHF)
Rx: supportive, plasmapheresis, dialysis
DDx: Henoch-Schonlein (normal PLT count),
ITP, post-strep GN, RMSF
--------------------------------------------------------------- Chikunguna fever: mosquito-borne viral illness
incubation: 3 7 days
flu-like illness, symmetric polyarthralgia,
maculopapular rash, cervical lymphadenopathy,
peripheral edema
lymphopenia, thrombocytopenia
Rx: supportive, resolves in 7 10 days
--------------------------------------------------------------- initial hematuria: urethral damage
terminal hematuria: bladder or prostate damage
o Dx: cystoscopy (r/o bladder ca)
total hematuria: kidney, glomerular, or ureter
--------------------------------------------------------------- conjunctivitis, urethritis, arthritis: reactive arthritis
1 4 wks after GI/GU infection (urethritis)
asymmetric oligoarthritis, conjunctivitis,
mucocutaneous oral lesions (stomatitis)
Chlamydia infection can cause reactive arthritis
--------------------------------------------------------------- infant with failure to thrive, lymphadenopathy,
diarrhea, thrush, maternal IVDA: HIV infection
high risk mother: HIV antibody test @ 1st & 3rd
trimesters; Ab detection can take up to 3 months,
occurs after the infectious window period
infants (birth 18 months) Dx: PCR testing
--------------------------------------------------------------- diabetic foot ulcers result from neuropathy,
microvascular insufficiency, immunosuppression
a/w Charcot joint deformities
MC site: plantar surface of 1st metatarsal head,
under bony prominences

best assessment for risk of diabetic foot ulcers:

monofilament testing
--------------------------------------------------------------- venous insufficiency ulcers: stasis dermatitis @
medial aspect above medial malleolus
arterial ulcers: tissue necrosis @ tip of toes
--------------------------------------------------------------- factorial design study: randomization to 2 or more
interventions with assignment to 2 or more
variables studied independently
effect of two or more independent variables upon a
single dependent variable
--------------------------------------------------------------- trichotillomania: recurrent hair pulling, results
in hair loss, distress, & functional impairment
o shared features & comorbidity with OCD
DDx: alopecia acreta, body dysmorphic disorder,
--------------------------------------------------------------- fever, productive cough, RLL infiltrate, extremely
WBC with lymphocyte predominance: CLL
atypical lymphocytes with smudge cells
MC in elderly age > 70
risk of recurrent infections
presence of thrombocytopenia = poor prognosis
Dx: flow cytometry
--------------------------------------------------------------- Howell-Jolly bodies: nuclear remnants of RBCs
generally removed by a functional spleen
single, round, blue inclusions on Wright stain
suggests functional asplenia or splenectomy
a/w sickle cell anemia
--------------------------------------------------------------- Heinz bodies: aggregates of denatured Hb
o Hb is oxidized & become insoluble precipitants
a/w G6PD deficiency & thalassemia
phagocytes extract Heinz bodies bite cells
--------------------------------------------------------------- basophilic stippling: ribosomal precipitates
appear as blue granules in RBC cytoplasm
thalassemia, lead/heavy metal poisoning, alcoholism

chronic alcoholics present with hypoK+, hypoMg+

+, & hypophosphatemia
Mg++ regulates K+ uptake & intracellular levels
hypoMg++ causes refractory hypoK+ despite
K+ supplementation
--------------------------------------------------------------- hypoalbuminemia in alcoholics can result in
o Ca++ is largely albumin-bound
--------------------------------------------------------------- vaccines for chronic liver disease
o Tdap 1x substitute (Td every 10 yrs)
o influenza annually (IM inactivated)
PPSV23 1x, then PCV13/PPSV23 @ age 65
o Hep A & B
--------------------------------------------------------------- all sexually active women age 24 should be
screened for C. trachomatis & N. gonorrhea by
nucleic amplification testing
--------------------------------------------------------------- screen for chlamydia: all sexually active women
age 24 or > 25 if new/multi partners, Hx of STD
or incarceration
MCC of urethritis, cervicitis, vaginitis
asymptomatic in 80% of women
intracellular organisms (-wet mount, -Gram stain)
Dx: nucleic acid amplification
Rx: azithromycin (single dose) or doxycycline;
also treat partners
complications: PID, infertility
--------------------------------------------------------------- gonorrhea screen: high-risk sexually active
women, age < 24 yrs, new/multi sexual partners,
Hx of STIs; including pregos in this category
--------------------------------------------------------------- febrile neutropenia: absolute neutrophil count <
1500 (severe < 500); medical emergency!
no obvious focus of infection; normal CXR & U/A
MCC is P. aeruginosa
Rx: empiric anti-pseudomonal
(cefepime, meropenem, piperacillin-tazobactam)
Dx: blood & urine cultures
--------------------------------------------------------------- communicating hydrocele: processus vaginalis
fails to obliteration

non-communicating: fluid within tunica vaginalis

most spontaneously disappear by age 1 yr
Rx: reassurance & observation for 1 yr
unresolved communicating hydrocele surgical
removal due to risk of inguinal hernia
--------------------------------------------------------------- sick sinus syndrome: impaired SA node automaticity
o 2/2 degeneration or fibrosis of SA node
fatigue, lightheadedness, palpitations, syncope
EKG: tachycardia-bradycardia syndrome,
sinus pause/arrest, SA exit block
--------------------------------------------------------------- painless, hard testicular mass + suggestive USS:
radical orchiectomy (testis & cord)
o kill first, investigate later
o determine cancer type to guide treatment
highest cure rate of all cancers
--------------------------------------------------------------- burst fracture of vertebra, loss of motor function
below lesion, loss of pain/temp B/L below lesion,
intact proprioception: anterior cord syndrome
B/L loss of vibratory & proprioception, weakness,
paresthesias, urinary incontinence or retention:
posterior cord syndrome (MS)
burning pain & weakness in upper extremities from
forced hyperextension neck injury with pre-existing
degenerative cervical changes: central cord
o localized deficit in pain & temp
I/L motor weakness, spasticity, loss of vibration &
proprioception, C/L loss of pain & temp 2 levels
below lesion: Brown-Sequard
paraplegia, variable sensory loss, urinary & fecal
incontinence, saddle anesthesia: Cauda equina
--------------------------------------------------------------- Cauda equina syndrome: sacral nerve root
compression 2/2 herniation, spinal stenosis,
metastasis, tumors, infection, iatrogenic injury
provides sensory innervation to saddle area,
motor to sphincters, PNS to bowel & bladder
LMN signs, hyporeflexia
gradual, severe back pain with U/L radiculopathy,
saddle numbness, asymmetric weakness
---------------------------------------------------------------Cauda equina
Conus medullaris

LMN signs
UMN & LMN signs
B/L radicular pain
sudden severe back pain
saddle anesthesia
perianal anesthesia
asymmetric motor weak symmetric motor weak
late-onset bowel/bladder early-onset bowel/bladder
Rx: MRI, IV glucocorticoids, neurosurg consult
--------------------------------------------------------------- acute mechanical back pain w/o neuro deficits,
pain radiation, +Straight-leg raise: disc herniation
unilateral radicular pain in dermatome distribution
Rx: early mobilization, relaxants, NSAIDs
o 4 6 wks
return to daily activities ASAP
o bed rest, exercise program, & PT not helpful
severe pain may result in urinary retention due
to inability to Valsalva in those with BPH
---------------------------------------------------------------Opportunistic infections in HIV
P. jirovecii
CD4 < 200
TMP-SMX (10)
CD4 < 100
TMP-SMX (10)
CD4 < 50
azithromycin (10)
CD4 < 150
optimal approach to preventing opportunistic
infections: anti-retrovirals, vaccination
primary prophylaxis (CD4 < 200)
o TMP-SMX & azithromycin
secondary prophylaxis: after an infection to
prevent relapse or recurrence; regardless of CD4
o acyclovir/valacyclovir for HSV
o fluconazole for Cryptococcus
--------------------------------------------------------------- sudden onset back pain, pallor, dark urine,
jaundice, bite cells: G6PD deficiency
X-linked; MC in A-A, Asian, Mediterranean
hemolytic anemia after oxidative stress/injury
( indirect bilirubin, LDH, haptoglobin)
precipitated by infection, meds (TMP-SMX, sulfa,
antimalarial, nitrofurantoin), fava beans
G6PD activity assay can be normal during attack
as G6PD deficient RBCs are hemolyzed early
+Prussian blue stain = hemosiderin
PBS: bite cells with Heinz bodies

G6PD catalyzes reduction of NADP to NADPH;

NADPH is necessary to reduce glutathione, which
protects RBCs from oxidation by oxidizing agents
(bacterial toxins, meds)
o without G6PD, Hb become oxidized &
denatured into Heinz bodies hemolysis
Rx: supportive; manage underlying cause
--------------------------------------------------------------- arteriovenous fistula causes high-output cardiac
failure by shunting blood from arterial to venous
increase preload
o also systemic vascular resistance
circulation is unable to meet O2 demands of
peripheral tissues
MCC: trauma, iatrogenic (femoral catheterization),
atherosclerosis (aortocaval fistula)
wide pulse pressure, brisk carotid upstroke,
systolic murmur, flushed extremity, LVH
Dx: Doppler USS
---------------------------------------------------------------Primary humoral deficiencies
/absent B-cells
agammaglobulinemi all Ig
normal B-cells
all Ig
IgA deficiency
normal B-cells
IgA only
normal B-cells
IgG & IgA, IgM

all result in recurrent sinopulmonary infections

with encapsulated spp, viruses, opportunistics
hyper-IgM syndrome prevents class switching
due to CD40 ligand deficiency
o lymphoid hyperplasia
o Giardia & sinopulmonary infections
IgA def: recurrent respiratory, GI, GU infections
& anaphylactic transfusion reaction
o episodic diarrhea: Giardia
--------------------------------------------------------------- diabetic foot ulcers allow contiguous spread of
infection, resulting in osteomyelitis

episodic vision loss, diplopia, sensory deficits,

motor weakness, gait/balance disturbance: MS
relapsing-remitting pattern
optic neuritis, internuclear ophthalmoplegia
MRI: multiple, B/L, asymmetric hyperintense
lesions in periventricular white matter
acute exacerbation Rx: high-dose IV
o plasma exchange if no response
--------------------------------------------------------------- M. tuberculosis occurs when droplets of bacilli
reach the alveolar space & replicate; accumulation
of macrophage & neutrophils, with bacilli
proliferation form a tubercle
tubercle + lymphadenopathy = Gohn complex
cell-mediated immune response forms a
granuloma, resulting in latent TB
--------------------------------------------------------------- initial menstrual cycles at menarche are anovulatory
2/2 immature hypothalamic-pituitary-ovarian axis
causes irregular cycles &/or menorrhagia
some cyclic bleeding due to breakthrough
--------------------------------------------------------------- acute low back pain
o no red flags, sciatica or cord compression
Rx: conservative therapy 4 6 wks
back XR & ESR if no improvement
o red flags or sciatica: back XR & ESR
MRI if results abnormal
cord compression signs/symptoms: MRI
red flags: age > 50, nighttime pain, constitutional
symptoms (fever, weight loss), unrelieved by rest,
not exacerbated with movement or palpation,
neurologic symptoms, Hx of malignancy, IVDA
cord compression signs: back pain, paralysis,
hyperreflexia, urinary & fecal incontinence
--------------------------------------------------------------- atelectasis: common post-op complication
peak severity: 2nd post-op day
MC due to airway obstruction from retained airway
secretion, lung compliance, post-operative pain,
& medications interfering with deep breathing
results from shallow breathing & weak cough
V/Q mismatch evident

ABG: hypoxemia, hypocapnia, resp. alkalosis

Rx: pain control, breathing exercises, directed
coughing, early mobilization, incentive spirometry
---------------------------------------------------------------Preventing post-op pulmonary complications
smoking cessation at least 8 wks prior
o COPD symptom control
o Rx respiratory infections
o education on lung expansion maneuvers
o incentive spirometry, deep breathing exercises
o CPAP, chest PT
---------------------------------------------------------------Rome criteria for irritable bowel syndrome
recurrent abdo pain/discomfort, 3 days/month
for the last 3 months + 2
o improves with bowel movement
o change in stool frequency
o change in stool form
diarrhea- or constipation-predominant, or mixed
no extensive workup if no alarm features, & no
family Hx or IBD or CRC
colonoscopy: normal colonic mucosa
--------------------------------------------------------------- severe vulvar itching with numerous excoriations,
& skin is thin, dry, & white; post-menopause:
lichen sclerosis
porcelain-white polygonal macules & papules
with atrophic, cigarette paper quality
premalignant lesion SCC
Dx: vulvar punch biopsy (r/o vulvar SCC)
Rx: high-potency topical corticosteroids
--------------------------------------------------------------- clusters of small teardrop-shaped growths at
vestibule of the vulva: HPV genital warts
(condyloma acuminata)
clusters of smooth, pink/skin-colored lesions
Rx: trichloroacetic acid (complete resolution) or
DDx: condyloma lata (20 syphilis; flat & velvety),
vulva ca (single, fleshy lesion), lichen sclerosis,
vulvar lichen planus

itchy, painful, erosive purple lesions on the vulva:

vulvar lichen planus
MC in middle-aged women
---------------------------------------------------------------Down syndrome comorbidities
AV septal defect, VSD, ASD
duodenal atresia, Hirschsprung
intellectual disability
early-onset Alzheimers
acute leukemia
hypothyroidism, Type I DM
atlanto-axial instability
--------------------------------------------------------------- Small intestinal bacterial overgrowth: native
& non-native bacteria causing excess
fermentation, inflammation, & malabsorption
causes: anatomic or dysmotility disorders
(strictures, fistulas, systemic sclerosis, diabetes,
immunodeficiency, chronic pancreatitis, cirrhosis)
bloating, flatulence, abdominal pain, diarrhea,
weight loss, malabsorption
Dx: endoscopy with jejunal aspirate
Rx: ABX, trial of metoclopramide, diet changes
DDx: IBD, IBS, lactose intolerance, SBO
--------------------------------------------------------------- post-op DVT prophylaxis: LMWH
---------------------------------------------------------------Breastfeeding failure
Breast milk jaundice
1st week of life
3 -5 days, peak @ 2 wks
lactation failure,
-glucuronidase in
breast milk deconjugate
intestinal bilirubin, &
bilirubin elimination, &
enterohepatic circulation
enterohepatic circulation
sub-optimal feeding,
adequate breastfeeding
dehydration signs,
normal exam,
inadequate stooling
no dehydration
Rx: feeding 15 minutes per
side every 2 -3 hrs

causes of lactation failure: inadequate milk supply,

infrequent feedings, cracked/clogged nipples,
engorgement, poor latching

inadequate stooling results in bilirubin elimination

& enterohepatic circulation
yellow-seedy stool = normal
brick-red urate crystals in diaper = dehydration
--------------------------------------------------------------- all newborns have mild unconjugated
hyperbilirubinemia due to high Hb turnover &
immature hepatic UDGT activity
---------------------------------------------------------------Biliary atresia
jaundice, acholic stool, dark urine,
conjugated hyperbilirubinemia &
hepatomegaly in first 2 months of life
USS: absent/abnormal GB
hepatobiliary scintigraphy: failure of
tracer excretion into small bowel
cholangiogram: biliary obstruction;
done intraoperatively (gold std)
liver Bx: expanded portal tracts with
bile duct obstruction & proliferation;
portal tract edema, fibrosis, inflammtn
hepatoportoenterostomy (Kasai),
liver transplant inevitable
MC indication for pediatric liver transplant
--------------------------------------------------------------- cerebellar ataxia @ vermis (truncal ataxia) or
hemisphere (I/L ataxia): staggering, swaying,
impaired tandem gait & titubation (nodding)
TOWARD the affected side
---------------------------------------------------------------Acute Lymphoblastic Leukemia (ALL)
MC childhood cancer
peak age: 2 5 yrs; M > F
bone pain, pallor (anemia),
nontender lymphadenopathy,
bone marrow Bx
shows > 25% lymphoblasts
--------------------------------------------------------------- aphthous ulcers, granulomatous inflammation,
weight loss, vague abdominal pain: Crohns

confounding: the exposure-disease relationship

is obscured by the effect of an extraneous factor
that is associated with both exposure & disease
Methods to control confounding
matching: used in case-control studies; selecting
matched known or suspected variables (age, race),
both groups having a similar distribution
o stratified analysis
restriction: limited specific characteristics
randomization: used in clinical trials, minimizes
selection bias
o controls known, unknown, & difficult-tomeasure confounders
--------------------------------------------------------------- effect modification: an external variable that
positively or negatively impacts the effect of a
risk factor on the disease of interest
distinguished from confounding by performing a
stratified analysis on the variable of interest
o if the variable is a cofounder no significant
association in risk between stratified groups
as the confounding effect is removed
o if the variable is an effect modifier strong
association exists between stratified groups
example: family Hx increases the risk of breast ca
in patients taking OCPs
--------------------------------------------------------------- observer bias: investigators decision is adversely
affected by knowledge of exposure status
recall bias: inaccurate recall by participants
o MC with case-control studies
--------------------------------------------------------------- Tumor lysis syndrome: oncologic emergency
releases K+, phosphate & uric acid into circulation
o Ca++, K+, phosphate, uric acid
MCC: massive lymphoma or leukemia, chemoRx
Rx: allopurinol reduces acute urate nephropathy
--------------------------------------------------------------- eye exposure to acid: full recovery likely
alkaline exposure: corneal damage likely
--------------------------------------------------------------- parkinsonism, orthostatic hypotension, impotence,
incontinence: multiple system atrophy
(Shy-Drager syndrome)
parkinsonism + autonomic & neurologic dysFx

--------------------------------------------------------------- hyperkalemia can cause ascending muscle

weakness with flaccid paralysis
initial evaluation: EKG
next: exclude acute treatable secondary causes
(CKD, hyperglycemia, tumor lysis syndrome)
next: review current/recent meds (non-selective
-blockers, triamterene, ACE-I/ARB, NSAIDs)
--------------------------------------------------------------- steppage gait: unilateral foot drop 2/2 weakness
of foot dorsiflexion; exaggerated hip/knee flexion
L5 radiculopathy: back pain radiates to foot,
weak foot inversion & plantar flexion
common peroneal neuropathy: lateral fibula
compression, paresthesia & sensory loss over foot
dorsum; normal inversion & plantar flexion
Dx: electromyography or NCV
--------------------------------------------------------------- normocytic anemia, splenomegaly, reticulocytosis,
indirect bilirubin, LDH, haptoglobin:
autoimmune hemolytic anemia
MCC: infectious mono, CLL, SLE, PCN
spherocytes (not schistocytes)
confirm Dx: +direct Coomb show IgG or C3 on
RBC surface
Rx: high-dose glucocorticoids if symptomatic
o splenectomy or immunosuppressives for
refractory cases
DDx: sickle cell, microangiopathic hemolytic
anemia (DIC)
--------------------------------------------------------------- renin is produced in juxtaglomerular cells in
response to hypoperfusion
renin cleaves angiotensinogen angiotensin I,
converted to angiotensin II by ACE in the lung
angiotensin II is a potent vasoconstrictor & also
promotes aldosterone production in adrenal cortex
aldosterone Rc antagonist: induce natriuresis
angiotensin II Rc blocker: cause natriuresis &
aldosterone production
direct renin inhibitor (aliskiren): angiotensin I/II
& aldosterone

--------------------------------------------------------------- loop diuretics induce natriuresis, but the decreased

blood volume stimulates renin, angiotensin II, &
---------------------------------------------------------------Causes of Vit K deficiency
fat malabsorption, fat-soluble vitamin deficiency
hepatocellular disease
--------------------------------------------------------------- fever, migratory polyarthralgia, & pustular rash on
trunk & extremities, with Hx of high-risk sexual
behavior: disseminated gonococcal infection
MC STD causing septic arthritis
Dx: nucleic acid amplification
DDx of fever, rash, arthritis: IE, parvovirus B19,
secondary syphilis, toxic shock syndrome

Disseminated gonococcal infection

septic arthritis without skin lesions

triad: tenosynovitis, dermatitis,

migratory asymmetric polyarthritis
without purulent arthritis
synovial fluid: > 50,000 (septic),
urethral, cervical, or rectal cultures,
HIV & syphilis screen
IV ceftriaxone,
joint drainage for purulent arthritis,
empiric azithromycin for Chlamydia,
treat sexual partners
purulent arthritis in a sexually active individual
is gonococcal arthritis until proven otherwise
--------------------------------------------------------------- causes of high-output cardiac failure: anemia,
thyrotoxicosis, bone Pagets, thiamine deficiency
---------------------------------------------------------------Bacterial meningitis in children age > 1 month
S. pneumoniae & N. meningitidis
features fever, vomiting/poor feeding,
lethargy, irritability, seizures,
bulging anterior fontanelle
nuchal rigidity, +Kernig, +Brudzinski
CBC, electrolytes, blood cultures, LP
IV vancomycin & ceftriaxone
(newborns 28 days: cefotaxime)
PLUS dexamethasone for HiB meningitis
(reduces risk of sensorineural hearing loss)
Rx: LP first, then prompt empiric ABX
o ABX can sterilize CSF hindering definitive Dx
ceftriaxone displaces bilirubin from albumin &
increases risk for kernicterus in newborns
herniation is rare in infants, thus head CT is
reserved only for comatose, focal neuro signs, or
Hx of neurosurgical procedures
--------------------------------------------------------------- milk production at delivery
o sudden in estrogen & progesterone which
normally interferes with actions of prolactin
o suckling stimulatory effects on prolactin
& oxytocin release
suppression of breast milk: tight-fitting bra, avoid
nipple stimulation, ice packs, analgesics
do not use DA agonists (bromocriptine)

toxic adenoma presents as thyroid toxicosis

o RIU uptake only in the nodule
Graves: diffuse RIU uptake, infiltrative
ophthalmopathy, pretibial myxedema
multinodular goiter: patchy RIU uptake
painless thyroiditis: reduced RIU uptake
--------------------------------------------------------------- all diastolic, continuous, & loud systolic murmurs
require transthoracic echo
--------------------------------------------------------------- primary tumors of the GIT, lungs, & breast are
MCC of liver metastasis (multiple liver masses)
o Dx: colonoscopy
solitary mass in the setting of chronic liver disease:
o Dx: AFP & USS (poorly defined mass)
liver abscess: DDx amebic vs. pyogenic
o Dx: serology
encapsulated, calcified cyst with fluid & budding
cells; immigrant or exposure to sheep & dogs
o hydatid cyst (Echinococcus)
benign epithelial liver tumor, solitary mass in
right hepatic lobe, young female, chronic OCPs
o hepatic adenoma
exposure to vinyl chloride gas, thorium dioxide
arsenic,; vascular spaces with malignant cells
o angiosarcoma of the liver
--------------------------------------------------------------- Prinzmetal angina is a/w Raynauds & migraines
precipitated by emotional stress, hyperventilation,
exercise, cold, cocaine use
greatest risk factor: smoking
Rx: CCB or nitrates
o non-selective -blockers (2) & ASA
promote vasoconstriction
--------------------------------------------------------------- protease inhibitors (indinavir) commonly cause
crystal-induced nephropathy
o periodic monitoring of U/A & serum Cr
NRTI: a/w lactic acidosis
nevirapine: a/w liver failure

intermittent chest pain, dysphagia, young female:

diffuse esophageal spasm
a/w emotional factors & functional GI disorders
relieved by nitrates & CCBs
barium swallow: corkscrew or normal
Dx: manometry simultaneous high amplitude
contractions & normal LES
Rx: anti-spasmodics, diet, psych counseling
DDx: Zenker, achalasia, scleroderma, infectious
esophagitis (candida, HSV, CMV)
--------------------------------------------------------------- scleroderma can present with loss of distal
peristalsis of esophagus
fibrosis & atrophy of esophageal smooth muscle
LES is incompetent reflux stricture
--------------------------------------------------------------- CVD is MCC of morbidity & mortality in PAD
& intermittent claudication
5-yr risk of nonfatal MI & stroke
PAD is a CAD risk equivalent
#1 Rx: supervised graded exercise program
o goal: reproduce claudication symptoms
o reduces symptoms & improve distance
#2 Rx: low-dose ASA & statin reduces
atherosclerotic CV mortality
#3 Rx: add cilostazol for persistent symptoms
#4 Rx: percutaneous or surgical revascularization
for persistent symptoms
--------------------------------------------------------------- aminoglycosides: Rx multi-drug resistant
pyelonephritis or serious G-negative infections
aminoglycosides (amikacin) are nephrotoxic
o can cause acute renal failure in setting of CKD
o monitor drug levels & renal function
--------------------------------------------------------------- Nafcillin is used for Rx MSSA
o MCC of AIN (eosinophils & WBC casts)
--------------------------------------------------------------- daytime drowsiness & cataplexy (sudden loss of
muscle tone triggered by strong emotions), sleep
paralysis, hypnagogic/hypnopompic hallucination:
#1 Rx: modafinil (psychostimulant)
alt Rx: methylphenidate, amphetamines

--------------------------------------------------------------- primipexole (DA agonist): Rx RLS & Parkinson

--------------------------------------------------------------- circumstantial thought: deviates from original
subject, but eventually return
tangential thought: drift away, never returns
flight of ideas: loosely associated thoughts
that move from topic to topic
loose association: lack of logical connection
between thoughts or ideas; severe tangentiality
--------------------------------------------------------------- signs of deliberate scald injury in toddlers
o linear demarcation, no splash marks
o extensive burns to back/buttocks
o sparing of flexural creases, zebra pattern
--------------------------------------------------------------- positive pressure mechanical ventilation
acutely intrathoracic pressure, thus venous
return, ventricular preload, & C.O.
can cause circulatory collapse in
hypovolemic shock if intravascular volume
is not replaced before mechanical ventilation
--------------------------------------------------------------- flexible bronchoscopy: Rx life-threatening
hemoptysis, locate & treat bleeding source
--------------------------------------------------------------- MCC of dyspepsia: GERD, NSAIDs, GI cancer,
functional dyspepsia, H. pylori
dyspepsia + alarm symptoms upper endoscopy
o alarm symptoms for gastric or esophageal
cancer: age > 55, weight loss, dysphagia,
persistent vomiting, early satiety, anemia,
gross/occult bleed
dyspepsia, no alarm symptoms
o GERD symptoms PPI or H2 blocker
o NSAID-induced dyspepsia PPI
o if no GERD, no NSAID use H. pylori test
(breath test or stool assay, not serology)
o if no improvement upper endoscopy
--------------------------------------------------------------- GERD can present as chronic cough or hoarseness
Rx: H2 antagonist (ranitidine) or PPI
--------------------------------------------------------------- atypical antipsychotics (olanzapine, clozapine)
is a/w weight gain, hyperglycemia, dyslipidemia

o monitor BMI, fasting glucose & lipids

--------------------------------------------------------------- monitor renal & thyroid function: lithium
o a/w nephrogenic DI, interstitial nephritis,
monitor CBC weekly: clozapine
o a/w agranulocytosis, lowers seizure threshold
1st gen anti-psychotics & risperidone are a/w
o galactorrhea, amenorrhea, decreased libido
--------------------------------------------------------------- clomaphine citrate (estrogen analogue)
improves GnRH & FSH release in PCOS
metformin also improves ovulation
--------------------------------------------------------------- unvaccinated or unknown vaccination Hx with
exposure to blood from Hep B infected patients
require post-exposure prophylaxis (PEP)
o Rx: HBV Ig + HBV vaccine (within 24 hr)
known vaccinated workers do not require PEP,
but recommend a HBV booster vaccine
--------------------------------------------------------------- anti-Jo antibodies = polymyositis
--------------------------------------------------------------- MC foreign body ingestion: coins in esophagus
Rx: observe for 24 hrs if asymptomatic
o Rx: flexible endoscopy if symptomatic or
time of ingestion is unknown
ingested batteries, sharp objects, & magnets
require preemptive removal
o Rx: endoscopy or laparotomy
--------------------------------------------------------------- child with sudden onset stridor, dyspnea wheezing,
coughing,: tracheobronchial foreign body
Rx: rigid bronchoscopy
--------------------------------------------------------------- situs inversus, recurrent sinusitis, bronchiectasis:
AR disorder of dysmotile cilia; dextrocardia
--------------------------------------------------------------- normal: air conduction is 2x > bone conduction
bone conduction > air conduction on Rinne test
suggests conductive hearing loss

Weber test to confirm Dx

otosclerosis causes conductive hearing loss in
females age 20s 30s; autoimmune process

Interpretation of Rinne & Weber tests

Rinne result
Weber result
air > bone
conduction B/L
BC > AC affected
hearing loss
AC > BC unaffected toward
affected ear
Sensorineura AC > BC both ears
lateralize to
l hearing loss (diminished AC &
unaffected ear,
BC in both)
away from
affected ear
sensorineural hearing loss: involves inner ear,
cochlea, or auditory nerve
o MCC ototoxic ABX, Menieres
conductive hearing loss: decreased movement
of small ear bones, otitis media, otosclerosis
---------------------------------------------------------------Manifestations of sarcoidosis
non-caseating granulomatous inflammation
B/L hilar adenopathy,
interstitial infiltrates
anterior uveitis
reticuloendothelia peripheral lymphadenopathy,
acute polyarthritis (ankles)
chronic arthritis
central DI, hypercalcemia
o erythema nodosum
(painful shin lesions)
o hilar adenopathy
o migratory polyarthralgia
o fever

mostly asymptomatic
cough, dyspnea, fever, malaise, weight loss
elevated ACE & hypercalcemia
Dx: mediastinoscopy/bronchoscopy tissue Bx
Rx: systemic corticosteroids if symptomatic

fever, localized back pain, neurologic deficits

(motor weakness, paresthesia, bowel/bladder):
spinal epidural abscess
radicular pain below the knee, +straight leg test,
pain improves with rest: herniated disk
chronic back pain, fatigue, weight loss, anemia,
hypercalcemia, elevated Cr: MM
low back pain radiates to buttocks & thighs,
neuro deficits, worse with walking or standing:
lumbar spinal stenosis
low back pain, claudication of hip muscles,
impotence: iliac artery thrombosis
age > 50, pain worse at night, point tenderness,
cauda equina syndrome, Hx of malignancy:
cancer mets to bone
local tenderness to palpation after minor trauma,
in elderly with Hx of osteoporosis: vertebral
compression fracture
chronic progressive pain, local point tenderness,
low-grade fever, ESR/CRP, soft tissue infection:
vertebral osteomyelitis
--------------------------------------------------------------- tenderness to gentle percussion over spinous
processes of involved vertebrae, not relieved
with rest, ESR: vertebral osteomyelitis
MCC: S. aureus
MC in IVDA or recent distant infection (UTI)
initial tests: CBC, blood cultures, ESR/CRP,
spine XR
Dx: spinal MRI
confirm Dx: CT-guided aspiration & Bx
Rx: long-term IV ABX +/- surgery
complications: epidural abscess, paralysis
--------------------------------------------------------------- hyperplastic polyp: MC non-neoplastic polyp in
the colon; no CRC risk; no further work-up
hamartomatous polyp: juvenile & Peutz-Jegher
polyps; non-malignant
adenomatous polyp: premalignant potential
sessile villous adenoma, > 2.5 cm
--------------------------------------------------------------- fevers, chills, malaise, cough, dyspnea, tachypnea
& diffuse fine crackles; diffuse reticular or
ground-glass opacities on CXR: hypersensitivity
reaction or pneumonitis

--------------------------------------------------------------- sarcoidosis causes hypercalcemia by extra-renal

conversion of 25(OH) VitD to 1,25(OH) VitD in
granulomatous tissue
intestinal Ca++ absorption
---------------------------------------------------------------Approach to hypercalcemia
first: confirm by repeat testing
next: measure PTH
o high/normal PTH (PTH-dependent): 10 or 30
hyperPTH, familial hypercalcemic
hypocalciuria, Lithium, teriparatide
o suppressed PTH (PTH-independent)
measure PTHrP, 25(OH)D, 1,25(OH)D
malignancy, Vit D toxicity, sarcoidosis
--------------------------------------------------------------- fatigue, anxiety, depression, tetany
Approach to hypocalcemia
always confirm with repeat Ca++ measurement
correct serum albumin or measure ionized Ca++
evaluate Mg++, medications (Ca++ chelators,
bisphosphonates, phenytoin), recent transfusion
o correct underlying cause
next: measure serum PTH
normal/low PTH
radical neck surgery,
genetic: PTH gene, Ca+
+- sensing Rc gene

high PTH
Vit D deficiency, CKD
pancreatitis, sepsis
tumor lysis syndrome
PTH resistance

hypoMg++ causes hypoCa++ in alcoholics; due

to decreased PTH release & PTH resistance
not a/w hyperphosphatemia
--------------------------------------------------------------- total serum Ca++ varies with albumin levels
o 50% of Ca++ is albumin bound
--------------------------------------------------------------- hypophosphatemia coexists with hypoMg++ in
GI absorption & renal loss of phosphate

premenopausal: oligo/amenorrhea, infertility,
galactorrhea, hot flashes, bone density
postmenopausal: mass effect (headache, vision)
men: infertility, impotence, libido, gynecomastia
due to hypogonadotropic hypogonadism
**serum prolactin > 200 ng/mL (diagnostic)
r/o renal insufficiency & hypothyroidism
brain MRI
Rx: cabergoline, transphenoidal surgery
prolactin inhibits GnRH production & release
low LH, low/normal TSH
detected early in premenopausal due to associated
endocrine symptoms
--------------------------------------------------------------- pituitary tumor < 10 mm = microadenoma
MC prolactin-only secreting tumor
o amenorrhea & galactorrhea in women
o hypogonadism in men
Rx: cabergoline (fewer A/E) if symptomatic
--------------------------------------------------------------- non-functional pituitary adenoma: large mass
effect; low TSH & LH, mild prolactin elevation
hypogonadism & hypothyroidism
2/2 compression of thyrotrophs & gonadotrophs,
& compression of dopaminergic pathway
--------------------------------------------------------------- primary hypothyroidism can cause mild/moderate
hyperprolactinemia due to TRH-induced
lactotroph (prolactin) stimulation
--------------------------------------------------------------- child with acute bacterial sinusitis; congestion,
nasal drainage, & cough for 10 30 days without
improvement; high fever, purulent nasal drainage
MC predisposing factor: viral URI
due to impaired mucociliary clearance
Dx: clinical
Rx: augmentin
--------------------------------------------------------------- menopause symptoms are similar to hyperthyroid
Dx: measure TSH & FSH

inhibin is made by granulosa cells of ovarian

follicles causes feedback inhibition on FSH
--------------------------------------------------------------- CXR: pulmonary venous congestion, cardiomegaly,
cephalization of pulmonary vessels, Kerley B lines,
& pleural effusion: CHF
--------------------------------------------------------------- CHF exacerbation causes tachypnea as LV dysFx
results in pleural effusion, hypoxemia, hypocapnia
& respiratory alkalosis
dry cough, exertional dyspnea, bibasilar crackles
cardiomegaly, S3, S4
DDx: COPD (respiratory acidosis, hypoxia), PE (
A-a gradient)
--------------------------------------------------------------- diffuse esophageal spasm due to dysFx of
inhibitory neurons cause chest pain & dysphagia
manometry: periodic high-amplitude, non-peristaltic
---------------------------------------------------------------Features of systemic sclerosis (scleroderma)
fatigue, arthralgia
telangiectasia, sclerodactyly,
digital ulcers, calcinosis cutis
myocarditis, pericarditis
pericardial effusion
pulmonary pulmonary fibrosis, pulmonary HTN
esophageal dysmotility, dyspepsia,
dysphagia, angiodysplasia of stomach
(watermelon stomach),
malabsorption (bacterial growth)
scleroderma renal crisis
o acute oliguric renal failure with
malignant HTN
o thrombocytopenia
Rx: ACE-I o microangiopathic hemolytic anemia
lower esophagus smooth muscle atrophy &
fibrosis, causes peristalsis & LES tone
o dysphagia, heartburn, hoarseness
--------------------------------------------------------------- failure of postpartum lactation, amenorrhea,
hyponatremia, loss of sexual hair, anorexia,
weight loss, lethargy, delayed DTRs: Sheehan
prolactin deficiency

deficient anterior pituitary hormones only:

posterior pituitary (ADH, oxytocin) is unaffected
no effective Rx to restore lactation
--------------------------------------------------------------- non-pitting edema seen in Turners is due to
congenital lymphedema from dysfunctional
development of lymphatic network
o leads to webbed neck, cystic hygroma
--------------------------------------------------------------- progressive dysphagia of solids & liquids, weight
loss, regurgitation, nighttime cough: achalasia
CXR: widened mediastinum
barium studies: dilated esophagus with smooth
tapering of distal esophagus
Dx: manometry shows aperistalsis, LES tone
Dx: endoscopy to r/o malignancy
Rx: surgical pneumatic dilatation or myotomy
--------------------------------------------------------------- polymyositis: idiopathic inflammatory muscle
disease; progressive proximal muscle weakness
weakness is prominent than pain or tenderness
dysphagia due to weakness of striated muscles
in upper esophagus; regurgitation, aspiration
Dx: muscle biopsy
DDx: MG, MS, polymyalgia rheumatica,
Guillain-Barre, ACE-I (hyperkalemia)
--------------------------------------------------------------- postpartum > 8 wks with chest pain, dyspnea, &
multiple nodules on CXR: choriocarcinoma
metastatic gestational trophoblastic disease
(GT neoplasia is only locally invasive)
can occur after molar or normal prego, abortion
enlarged uterus, pelvic pain
irregular vaginal bleed > 8 wks post-partum
MC site of mets: lungs
confirm Dx: quantitative -hCG
--------------------------------------------------------------- severe headache, vomiting, B/L periorbital edema:
cavernous sinus thrombosis
2/2 uncontrolled infection of skin, sinuses, or
orbit (insect bite on the face)
CN 3, 4, 5, 6 deficits, intracranial HTN
MC is severe headache

fundoscopy: papilledema, dilated tortuous veins

Dx: MRI with venography
DDx: brain abscess, cluster headache, migraine,
preseptal cellulitis
--------------------------------------------------------------- dacryocystitis: infection of lacrimal sac
acute onset pain & redness in medial canthal,
sometimes purulent drainage
normal visual acuity
MC in infants & adults > 40
MCC: S. aureus
Rx: systemic ABX
--------------------------------------------------------------- episcleritis: between conjunctiva & sclera
o acute mild/moderate discomfort, photophobia,
watery discharge; bulbar conjunctival injection
hordeolum: abscess over upper/lower eyelid
o localized red, painful eyelid swelling
o MCC: S. aureus
o #1 Rx: warm compress
o Rx: I&D if not resolved in 48 hrs
stye: external hordeolum of Zeis or Moll gland
chalazion: chronic, granulomatous inflammation
of Meibomian gland
o hard, painless lid nodule
o Rx: incision & curettage
orbital cellulitis: posterior to orbital septum
o unilateral; abrupt onset of fever, proptosis,
restricted EOM movement, swollen eyelids
o MC predisposing factor: bacterial sinusitis
--------------------------------------------------------------- traumatic deceleration injury resulting in
vegetative state: diffuse axonal injury
CT: numerous minute punctate hemorrhages,
blurring of gray-white matter interface
---------------------------------------------------------------Interventions to lower ICP
head elevation
increase venous outflow from brain
decrease metabolic demand &
control HTN
IV mannitol
osmotic diuresis (free water)
cerebral vasoconstriction
(CO2 washout)

CSF removal

reduce volume & pressure

3 distinct brain compartments: parenchyma, CSF,

cerebral blood flow (CBF)
CBF is regulated by BP, paO2 & paCO2
paCO2 is a potent regulator of CBF
o as cerebral paCO2 , also CBF
--------------------------------------------------------------- FSH in the setting of 3 months of amenorrhea in
women < 40 = premature ovarian failure
primary hypogonadism estrogen, FSH,
LH (FSH: LH > 1.0; slower FSH clearance)
causes: chemotherapy, radiation, autoimmunity,
Turners, Fragile X
all secondary amenorrhea require a pregnancy test,
prolactin & FSH level
--------------------------------------------------------------- transudate is due to systemic factors; B/L effusion
(hypoalbuminemia, hydrostatic pressure)
o pleural fluid pH 7.4-7.55 (normal pH: 7.6)
o MCC: CHF, cirrhosis
o no further workup; Rx underlying cause
exudate is due to inflammation (pH 7.3 7.45)
results in capillary permeability
o requires further diagnostics
o MCC: infection, pneumonia, TB, malignancy,
PE, sarcoidosis, lymphoma, RA
---------------------------------------------------------------Lights criteria for exudative effusion (Excess)
at least one of the following
pleural fluid/serum protein ratio > 0.5
pleural fluid/serum LDH ratio > 0.6
pleural fluid LDH > 2/3 upper limit of normal
Next determine if effusion is
complicated: persistent bacterial invasion,
which pleural fluid glucose & LDH;
culture is negative, easily cleared with ABX
empyema: low pH < 7.2 (or glucose < 60) are
indications for chest tube drainage
o low pleural glucose also indicates exudate
(complicated parapneumonic effusion, empyema,
RA, malignancy, TB, drug-induced lupus, or
esophageal rupture)

low glucose in empyema is due to high metabolic

activity of leukocytes/bacteria in pleural fluid
--------------------------------------------------------------- fever, leukocytosis, parenchymal infiltrates:
aspiration pneumonia
--------------------------------------------------------------- GB carcinoma is Dx incidentally during or after
o sufficient Rx if confined to GB mucosa
--------------------------------------------------------------- Bacillus cereus: preformed toxin
o 1 6 hrs after contaminated rice ingestion
S. aureus: preform toxin
o dairy, salad, meat, eggs
C. perfringens: spore-forming
o meat, poultry, gravy
o watery diarrhea, 8 14 hr after ingestion
--------------------------------------------------------------- scatter plots are used for crude analysis of data;
can show a linear association, used to calculate
the correlation coefficient
0 = no association
-1 or +1 = strong correlations closer to margins
does not imply causal relationships, nor account
for cofounders
--------------------------------------------------------------- during fasting, glycogen reserves drop within the
first 12 hrs & gluconeogenesis begins
main substrates of gluconeogenesis: alanine,
glutamine, lactate, glycerol-3-phosphate
alanine & lactate are converted to pyruvate
glycerol-3-phosphate is released during
breakdown of adipose
---------------------------------------------------------------Manifestations of hemochromatosis
AR inheritance; mutated HFE gene
intestinal iron absorption & deposition
weight loss, weakness, polydipsia,
polyuria, decreased libido, ED
hyperpigmentation (bronze diabetes)
arthralgia, arthropathy,
chondrocalcinosis (pseudogout)
elevated LFTs, hepatomegaly,
cirrhosis, risk of HCC
endocrine DM, secondary hypogonadism


dilated cardiomyopathy, systolic dysFx,
conduction defect (sick sinus syndrome)
Listeria, Vibrio vulnificus, Yersinia

transferrin & serum ferritin, TIBC

o if elevated in absence of an inflammatory
condition, genetic testing should be done
--------------------------------------------------------------- cervicofacial actinomycosis presents in the
mandibular region as a slowly growing, nontender
mass with yellow pus (sulfur granules)
Actinomyces: anaerobic Gram+ branching
filamentous bacilli; not acid-fast
colonizes the oral cavity
risk factors: poor dental hygiene, irradiation,
malnutrition, immunosuppression, DM
complication: abscess, fistula, draining sinus tract
Dx: tissue culture; can take 3 wks to grow
Rx: high-dose PCN (12 wks)
--------------------------------------------------------------- skin infection, fever & purulent crusting lesions
or ulcers following puncture wound (gardening):
aerobic, Gram+ weakly acid fast, filamentous rod
subacute pneumonia that mimics TB
--------------------------------------------------------------- acute ischemic stroke due to atherosclerotic
thrombosis or emboli: ASA within 48 hr
o risk of recurrent stroke & mortality
--------------------------------------------------------------- pruritus, jaundice, steatorrhea, hepatosplenomegaly,
ALP & bilirubin, anti-mitochondrial antibodies:
primary biliary cirrhosis
nocturnal pruritus can be severe
autoimmune destruction of intrahepatic bile ducts
leads to cholestasis & cirrhosis
ability to absorb fat-soluble vitamins can lead to
a/w xanthomas & xanthelasmas
a/w Sjogrens, Raynauds, scleroderma, Celiacs
Dx: anti-mitochondrial antibodies in serum

Rx: ursodeoxycholic acid relieves symptoms &

slows disease progression
o definitive Rx: liver transplant
--------------------------------------------------------------- post-partum adrenal insufficiency can be
primary (adrenal) or secondary (pituitary)
hyperpigmentation & signs of mineralocorticoid
deficiency suggests an adrenal cause
weakness, fatigue, abdominal pain, anorexia,
mild hyponatremia, postural hypotension,
---------------------------------------------------------------Adrenal insufficiency
10 (adrenal)
20 (pituitary)
glucocorticoid Rx



severe symptoms less severe
no hyperpigment,
no hyperkalemia,
glucocorticoid > 3 wks suppress secretion of
CRH & ACTH central adrenal insufficiency
screening: morning basal cortisol, ACTH, &
cosyntropin stimulation test
basal cortisol: low
basal cortisol: low
ACTH: high
ACTH: high
cosyntropin: minimal
cosyntropin: suboptimal
10 adrenal insufficiency 20 or 30 adrenal insuff.
chronic central AI develop adrenal gland atrophy,
thus a suboptimal response to cosyntropin
--------------------------------------------------------------- weakness, fatigue, weight loss, anorexia,
depression, hypotension, hyperpigmentation,
eosinophilia, hyponatremia, hyperkalemia
Primary adrenal insufficiency (Addisons)
MCC: autoimmune adrenalitis humoral &
cell-mediated destruction of adrenal cortex
loss of glucocorticoid, mineralocorticoid, &
adrenal androgens 2/2 adrenal cortex destruction
hyperchloremic acidosis

hyperpigmentation due to increased ACTH &

melanocyte-stimulating hormone
ketoconazole can precipitate adrenal insufficiency
by inhibiting adrenal steroid synthesis
a/w other autoimmune disorders
Rx: hydrocortisone
---------------------------------------------------------------Secondary (central) adrenal insufficiency
loss of only glucocorticoid & adrenal androgen
secretion; preserved mineralocorticoid production
aldosterone is regulated by RAA system
no hypotension, hyperK+, or hyperCl- acidosis
MCC: lymphocytic hypophysitis & Sheehan
--------------------------------------------------------------- screen for Cushings: 24-hr urine free cortisol &
low-dose dexamethasone suppression test
--------------------------------------------------------------- ursodeoxycholic acid: Rx primary biliary cirrhosis
& primary sclerosing cholangitis

recurrent oral & genital ulcers, anterior uveitis,

erythema nodosum: Behcet syndrome
MC in Turkish, Asian, Middle Eastern
immune-mediated small-vessel systemic vasculitis
Dx: triple-symptom complex: recurrent aphthous
ulcers, genital ulcers, anterior uveitis
o also erythema nodosum
Rx: high dose corticosteroids
complications: aneurysm, dementia, & blindness
---------------------------------------------------------------Tamoxifen: SERM
antagonist on breast
o Rx breast cancer & prevention in other breast

agonist on endometrium
endometrial cancer risk
o uterine sarcoma risk
agonist on osteoclasts (inhibits turnover)
o risk of osteoporosis
venous thrombosis risk
---------------------------------------------------------------Raloxifene: SERM
antagonist on breast & endometrium
o breast cancer risk
does not increase risk of endometrial cancer
agonist in bone
o #1 Rx prevents osteoporosis
A/E: risk of VTE; C/I if Hx of DVT
--------------------------------------------------------------- early decelerations: due to fetal head compression
leading to a vagal response
o does not indicate fetal distress
o normal finding of active labor
variable & late decelerations indicate risk for
fetal hypoxemia & acidosis
o variable: cord compression or prolapse,
oligohydramnios; abrupt drop in fetal HR
o late: uteroplacental insufficiency
---------------------------------------------------------------Alcohol withdrawal syndrome
last drink
anxiety, tremulousness,
6 hrs
sweating, palpitations
single or multiple in short
12 48 hr
period of time
auditory, visual, tactile
12 24 hr
hallucinosis hallucination; normal vitals resolves
& intact sensorium
in 24 48
fever, HTN, tachycardia,
diaphoresis, hallucinations,
48 96 hr
--------------------------------------------------------------- polymorphic ventricular tachycardia in the setting
of congenital or acquired prolonged QT interval:
Torsades de Pointes (TdP)
can resolve spontaneously or degenerate to V-fib
Rx hemodynamically unstable: defibrillation
Rx hemodynamically stable: Mg++ sulfate

soltalol causes prolonged QT & TdP

--------------------------------------------------------------- adenosine: Rx PSVT
amiodarone: Rx hemodynamically stable atrial &
ventricular wide-complex tachycardia; also a-fib
atropine: symptomatic sinus brady, AV block
sodium bicarbonate: TCA overdose, hyperK+,
ASA overdose
--------------------------------------------------------------- small, rubbery lymph nodes < 1 cm are commonly
benign in children & young adults
o asymptomatic, soft lymph nodes can be
observed for growth or symptoms
cancerous nodes are firm & immobile, > 2 cm
hard cervical nodes in adults or smokers suggest
metastatic cancer or oropharyngeal neoplasia
---------------------------------------------------------------Peripheral facial palsy
Central facial palsy
(Bells palsy)
loss of forehead & brow
preservation of forehead
& brow movement
inability to close eye &
C/L lower face weakness
drooping eyelids
loss of nasolabial folds, drooping lower lip

Bells: CN VII neuropathy, lesion below the pons

tearing, hyperacusis, loss of taste over

anterior 2/3 of tongue
forehead muscle sparing suggests intracranial
lesion brain imaging for ischemia or tumor
o lesion above facial nucleus
o C/L hemiparesis, hemianesthesia, dysarthria
--------------------------------------------------------------- Vit K deficiency in newborns result from poor
placental transfer, absent gut flora, immature
liver function, inadequate levels in breast milk
bruising, bloody stools, intracranial hemorrhage
initially prolonged PT, followed by aPTT
Rx: Vit K replenishes in 8 10 hrs
FFP for acute hemorrhage
--------------------------------------------------------------- ACTH does not affect aldosterone production,
which is regulated by RAA system
---------------------------------------------------------------Muscular dystrophy
XR deletion of dystrophin, Xp21
AD inheritance,
CTG repeats,
DMPK gene
onset: age 2 3
age 5 15
age 12 - 30
mild weakness
facial weakness,
weakness, Gower, (*decreased
hand grip
pseudohypertroph dystrophin*)
dysphagia (asp.
foot drop
cataracts, bald,
by adolescence
death by 20 30;
death by 40 respiratory or
respiratory or
heart failure
heart failure
heart failure

DMD: absent dystrophin on immuno staining

CPK & aldolase are elevated before manifestations
--------------------------------------------------------------- medullary thyroid cancer: calcitonin secretion
follicular & papillary cancers: a/w Hurthle cells

follicular thyroid cancer: invasion of tumor

capsule & blood vessels; encapsulated
early hematogenous spread to lung, brain, bone
--------------------------------------------------------------- papillary thyroid cancer: MC thyroid malignancy
slow, infiltrative spread to thyroid gland &
regional lymph nodes; unencapsulated
Dx: psammoma bodies
FNAB: large cells with ground-glass cytoplasm,
pale nuclei with inclusion bodies & central groove
Px: excellent
---------------------------------------------------------------Neuroimaging in psychiatric disorders
autism: increased brain volume
OCD: abnormal Orbitofrontal Cortex & striaDum
pAnic disorder: decreased Amygdala volume
PTSD: decreased hippocampal volume
schizophrenia: enlarged cerebral ventricles
--------------------------------------------------------------- chemotherapy can cause rapid tumor cell lysis,
releasing uric acid (DNA by-product),
predisposing to gout attacks
Rx: allopurinol decreases uric acid production
--------------------------------------------------------------- Rx gout attacks: NSAIDs, steroids, colchicine
gout prevention: allopurinol ( production),
probenecid ( excretion)
--------------------------------------------------------------- Mesna: prevents hemorrhagic cystitis caused by
--------------------------------------------------------------- chronic liver disease immunized for Hep A & B
risk for acute hepatic failure or cirrhosis
--------------------------------------------------------------- cirrhosis causes intravascular volume depletion
& salt retention
Rx: low-salt diet decreased ascites & edema
Rx: furosemide prevents hypervolemia
--------------------------------------------------------------- child refuse to bear weight, knee pain & swelling,
high fever: septic arthritis
preceded by skin or URI; MCC is S. aureus
leukocytosis, ESR & CRP

Dx/Rx: arthrocentesis, blood & synovial cultures

before empiric IV ABX (vancomycin)
o ABX can interfere with cultures
Rx: synovial fluid aspiration & drainage
prevents long-term disability & joint destruction
DDx: transient synovitis, acute rheumatic fever,
--------------------------------------------------------------- malaria causes cyclical fever, nonspecific GI &
constitutional symptom, anemia & thrombocytopenia
cyclical fever coincides with RBC lysis
up to 2 wks after mosquito bite
Dx: thin & thick peripheral blood smears
protective: hemaglobinopathies (HbS, HbC,
thalassemia, sickle cell trait, Hx of malaria)
--------------------------------------------------------------- Dengue fever: leukopenia is common
--------------------------------------------------------------- cholestyramine: bile acid sequestrant
o fecal loss of bile salts & cholesterol
Rx: hypercholesterolemia, pruritus a/w liver failure,
bile acid diarrhea, absorb C. difficile toxins A & B
--------------------------------------------------------------- fever, jaundice, hepatomegaly, dark urine,
pruritus, acholic stools: Hep A
incubation: 30 days
--------------------------------------------------------------- headache, abdominal pain, vomiting, diarrhea,
salmon rose spots, bradycardia: typhoid fever
--------------------------------------------------------------- inhaled albuterol & systemic steroids Rx acute
asthma attacks
high-dose 2-agonists can cause hypokalemia,
resulting in weakness, arrhythmias, EKG changes
check serum electrolytes
--------------------------------------------------------------- muscle cramps, weakness, palpitations, HTN after
initiating a thiazide
HTN & hypokalemia: suspect hyperaldosteronism
test: plasma renin & aldosterone


Causes of HTN & hypokalemia


(ratio > 20)


adrenal adenoma
B/L adrenal hyperplasia
Dx: adrenal CT
diuretics, cirrhosis, CHF,
renovascular HTN,
renin-secreting tumor,
malignant HTN,
coarctation of aorta
CAH, Cushings,
glucocorticoid resistance,
exogenous mineralocorticoids

easily induced hypokalemia after starting a

thiazide suggests primary hyperaldosteronism
metabolic alkalosis (loss of H+)
mild hypernatremia only (aldosterone escape)
--------------------------------------------------------------- recurrent episodes of flash pulmonary edema
screen for renovascular HTN: abdominal CT
MCC: renal artery stenosis, fibromuscular dysplasia
--------------------------------------------------------------- acute, painless vision loss, fundoscopy: optic disk
swelling, retinal hemorrhages, dilated & tortuous
veins, & cotton wool spots: central vein occlusion
blood & thunder appearance
monocular loss of vision caused by thrombosis
Dx: fluorescein angiography
Rx: conservative, observation
DDx: angle closure glaucoma, anterior uveitis,
amaurosis fugax, optic neuritis
--------------------------------------------------------------- acute, severe eye pain, blurred vision, N/V,
steamy cornea with non-reactive, dilated pupils:
acute angle-closure glaucoma
acute, severe eye pain, unilateral vision loss,
afferent pupillary defect: optic neuritis
--------------------------------------------------------------- fever > 390C (102.20F) in any child age < 3 should
prompt evaluation for UTI
Dx tests for UTI
serum BUN/Cr, urine dipstick, U/A, urine culture

children in diapers require straight catheter for

sterile specimen
--------------------------------------------------------------- chronic productive cough of mucopurulent sputum
(> 100 mL/day), dyspnea, hemoptysis, fatigue,
weight loss, clubbing: bronchiectasis
due to damage of bronchial walls from infection
or inflammation
diffuse ronchi & wheezes, bibasilar crackles
Dx: high-resolution CT bronchial dilation,
bronchial wall thickening
Dx: sputum analysis & bronchoscopy
Rx: underlying cause, corticosteroids, macrolides,
chest PT
DDx: chronic bronchitis (less sputum, nonpurulent)
--------------------------------------------------------------- acute adrenal crisis: post-op complication in
patients with chronic glucocorticoids-induced
HPA-axis suppression (SLE, RA)
daily prednisone > 3 wks can cause central adrenal
insufficiency: ( ACTH & cortisol)
N/V, hypoglycemia, hypotension
Rx: pre-op stress-dose glucocorticoids
patients with Cushingoid features are also at risk
for HPA suppression
o Rx: short-term stress-dose of glucocorticoids
--------------------------------------------------------------- femoral nerve: hip flexion, knee extension
o innervates anterior thigh
o sensation to anterior thigh & medial leg via
saphenous branch
tibial nerve: supplies posterior thigh & leg,
plantar foot muscles
o sensation to the leg (except medial side) &
plantar foot
obturator nerve: innervated medial thigh
o thigh adduction
o sensation to medial thigh
common peroneal: supplies anterior & lateral leg
o sensation to anterolateral leg & foot dorsum
o superficial peroneal: foot eversion
o deep peroneal: sensation bwtn 1st & 2nd toe

IVDA with fever, aortic vegetation, cerebral infarct:

native valve endocarditis with cardioembolic stroke
high risk of TIA or stroke due to septic emboli
ischemic stroke: Rx underlying cause
Rx: IV ABX reduces risk of septic cardioemboli
in native valve IE
Rx: aortic valve surgery for severe cases
IV heparin is a/w risk of intracranial hemorrhage
--------------------------------------------------------------- evidence of acute pericarditis & renal failure:
uriemic pericarditis
inflammation of visceral & parietal membranes
of pericardial sac; BUN > 60
no evidence of pericarditis on EKG
definitive Rx: hemodialysis
--------------------------------------------------------------- acute viral or idiopathic pericarditis Rx: NSAIDs
& colchicine
---------------------------------------------------------------hypertensive BP 180/120 mmHg
without symptoms or end-organ damage
hypertensive headache, dyspnea, blurred vision,
+ acute, end-organ complications
(BP > 220/120) malignant HTN: exudates,
retinal hemorrhage, papilledema
hypertensive encephalopathy:
cerebral edema, neuro symptoms,
--------------------------------------------------------------- most intussusceptions before age 2 following
viral illness have no identifiable lead point
o gastroenteritis hypertrophied Peyer patches
pathological lead point should be suspected in
older children with recurrent intussusception
o MCC: Meckels
other risk factors: Henoch-Schonlein, rotavirus
--------------------------------------------------------------- ventilator-associated pneumonia occurs 48 hr
after intubation
MCC: P. aeruginosa, E. coli, Klebsiella, MRSA
Dx: CXR, lower respiratory tract culture
Rx: empiric ABX (after obtaining sample)
---------------------------------------------------------------Prostatitis overview

fever, chills, malaise,
no fever, dysuria,
myalgia, perineal pain, frequency,
cloudy urine
recurrent UTI
**mid-stream urine sample**
pyuria, tender prostate, pyuria,
+urine culture (E. coli)
+urine culture
empiric TMP-SMX for fluoroquinolones
4 6 wks
complication: prostatic abscess (CT scan)
--------------------------------------------------------------- all present with irritative voiding symptoms
(frequency, urgency, suprapubic or perineal pain)
acute bacterial prostatitis: very tender prostate

feve U/A
prostatic secretions



acute bacterial
chronic bacterial
---------------------------------------------------------------Glasgow Coma Scale
eye opening (4), verbal (5), motor (6)
not used to Dx coma
o Dx coma: impaired brainstem activity, motor
dysfunction, impaired LOC
--------------------------------------------------------------- hypoglycemic episodes can occur with pre-meal
insulin administration in diabetic gastroparesis
metoclopramide: Rx N/V & gastroparesis
o DA receptor antagonist; prokinetic & antiemetic
monitor for drug-induced EPS, dystonic reaction
rarely, NMS may occur
Rx: discontinue; benztropine or diphenhydramine
alt Rx: erythromycin (prokinetic)
--------------------------------------------------------------- fibrocystic disease of the breast: B/L tenderness
& palpable mass during luteal phase

weight loss, anorexia, fatigue, recent onset DM,

migratory superficial thrombophlebitis (Trousseau):
pancreatic adenocarcinoma
important risk factor: Hx of smoking
insidious, gnawing abdo pain, worse at night
Dx with jaundice: USS (head tumor)
Dx w/o jaundice: CT scan (body & tail tumors)
--------------------------------------------------------------- connective tissue thickening 2/2 product of
myofibroblast proliferation, collagen & ground
substance production: systemic sclerosis
a/w HTN, GERD, right heart failure
Dx: ANA, anti-topoisomerase antibodies
Rx scleroderma renal crisis: ACE-I
--------------------------------------------------------------- anti-smooth Ab: autoimmune hepatitis
--------------------------------------------------------------- anti-psychotics mainly block DA D2 receptors
o can cause hyperprolactinemia
o breast tenderness, amenorrhea, galactorrhea
risperidone also binds 5-HT receptors
o improves negative symptoms of schizophrenia
& Rx depression
o most likely atypical to cause EPS at high dose
Rx: benztropine
aripiprazole: partial DA D2 agonist
o does not cause galactorrhea
--------------------------------------------------------------- rigidity, bradykinesia, tremor, akathisia: EPS
--------------------------------------------------------------- carbamazepine A/E: aplastic anemia, SIADH
o monitor with routine CBC
lamotrigine A/E: rash, SJS/TEN
--------------------------------------------------------------- well-circumscribed pale white patches around
acral area & body orifices: vitiligo
autoimmune destruction of melanocytes
peaks @ age 20 - 30
a/w Graves, Type I DM, hypopituitarism,
pernicious anemia, 10 adrenal insufficiency,
alopecia areata
--------------------------------------------------------------- Babinski is the only primitive reflex that may
persist up to age 2 yrs

--------------------------------------------------------------- PVCs are common post-MI; a/w worse prognosis

no Rx unless symptomatic (-blockers)
--------------------------------------------------------------- initial Rx of acute & chronic anal fissures: diet,
stool softener, local anesthetic
chronic or refractory cases: lateral sphincterotomy
---------------------------------------------------------------MCC of esophagitis in HIV
Candida white plaques, oral thrush
Rx: empiric fluconazole,
endoscopy if no improvement
small, round/ovoid ulcers
Rx: acyclovir
large, linear ulcers in distal esophagus
Rx: IV ganciclovir
MC when CD4 < 100
odynophagia without dysphagia: MCC is viral
Dx: esophagoscopy
acyclovir is not effective Rc for CMV due to its
lack of thymidine kinase to convert to active form
--------------------------------------------------------------- dysphagia, heartburn, refractory to GERD Rx:
eosinophilic esophagitis
comorbid asthma, seasonal allergies
manometry shows hypercontractility
--------------------------------------------------------------- acute odynophagia, retrosternal chest pain,
epigastric burning: pill esophagitis
direct mucosal injury due to prolonged contact
result in discrete ulcers on endoscopy
MCC: KCl, tetracycline, aldendronate, NSAIDS,
quinidine, iron
--------------------------------------------------------------- alcoholic with altered mental status, gait instability,
nystagmus, conjugated gaze palsy: Wernickes
no labs or radiological studies necessary
can be induced iatrogenically by giving glucose
without thiamine
--------------------------------------------------------------- apathy, irreversible amnesia, confabulation,:

large head, prominent forehead & jaw, protruding

ears, joint laxity, macroorchidism: Fragile X
hyperactivity, short attention, autism
FMR1 gene with CGG repeats
breast & ovarian ca
active untreated TB
(resume feeds after 2 wks
risk (not endometrial)
of anti-TB therapy)
maternal HIV infection
rapid uterine involution,
herpetic breast lesions
post-partum bleeding,
varicella infection (< 5
rapid return to pre-partum
days prior or 2 days after
improved child spacing,
drug or alcohol abuse
maternal-infant bonding
immunity, GI function,
preventionotitis media,
respiratory/GI illness, UTI
risk of childhood ca,
Type I DM, NEC

exclusively breastfed infants require Vit D suppl

until age 6 months
mastitis & Hep B or C are not C/I to breastfeeding
---------------------------------------------------------------Indications for cytoscopy
gross hematuria with no glomerular disease
microscopic hematuria without evidence of
glomerular disease, but risk for malignancy
recurrent UTIs
obstructive symptoms (strictures, stones)
irritative symptoms without infection
abnormal bladder imaging or urine cytology
--------------------------------------------------------------- risk of bladder cancer: smoking, chronic cystitis,
cyclophosphamide, pelvic radiation, occupational
screening is not recommended, even those at risk
--------------------------------------------------------------- severe ear pain especially at night, exacerbated
by chewing, purulent drainage with fullness, &
conductive hearing loss; ESR

malignant otitis externa: MCC P. aeruginosa

risk factors: elderly with uncontrolled DM
otoscopy: granulation tissue & edematous
external auditory canal
complications: osteomyelitis of skull base or TMJ
Rx: empiric anti-psuedomonal (IV ciprofloxacin)
alt Rx: piperacillin, ceftazidime
DDx: cholesteatoma: keratinized epithelial growth
& discharge in the middle ear; Rx: surgical
--------------------------------------------------------------- cholesteatoma: abnormal squamous epithelium in
middle ear; continuous ear drainage despite ABX
o 2/2 chronic middle ear disease; MC in children
granulation tissue & skin debris accumulation
damage to ossicles result in conductive hearing loss
otoscopy: granulation tissue & skin debris within
retraction pockets of tympanic membrane
Rx: surgery
--------------------------------------------------------------- anovulation as a cause of infertility can be
evaluated with serum progesterone performed
in mid-luteal phase
--------------------------------------------------------------- MVP = MCC of chronic MR in developed countries
2/2 myxomatous degeneration of leaflets & chordae
o chronic severe MR can cause LA dilation,
& lead to a-fib
infective endocarditis can cause MR due to
inadequate leaflet coaptation or leaflet perforation
--------------------------------------------------------------- immunocompromised with lung nodules, seizures,
Gram+, partially acid-fast, aerobic filamentous
branching rod: Nocardia
weight loss, fever, night sweats
causes seizures 2/2 brain abscess (disseminated)
CXR: pulmonary nodules, with cavitation
--------------------------------------------------------------- Actinomyces Rx: PCN
anaerobic, G+ filamentous bacilli (not acid-fast)
yellow pus with sulfur granules

orthostatic hypotension is a common cause of

syncope in elderly due to impaired baroreceptor
sensitivity &/or volume depletion
--------------------------------------------------------------- long-standing progressive heartburn, weight loss,
fatigue, smoking Hx: esophageal cancer
2 histologic types
SCC: a/w smoking & alcohol
adenocarcinoma: a/w Barretts, obesity
Dx: barium swallow followed by EGD & Bx,
& PET scan (disease staging)
--------------------------------------------------------------- maternal hyperglycemia fetal hyperglycemia &
fetal hyperinsulinemia metabolic demand
fetal hypoxia erythropoiesis polycythemia
--------------------------------------------------------------- young patient with cataracts, tinnitus hearing loss:
neurofibromatosis II
acoustic neuroma Dx: MRI with gadolinium
--------------------------------------------------------------- IV diuretics: Rx symptomatic relief of
decompensated CHF
--------------------------------------------------------------- dyspnea, JVD, clear lungs, cardiac silhouette:
early cardiac tamponade 2/2 pericardial effusion
MCC recent viral URI
non-palpable PMI; Becks triad (hypotension, JVD,
muffled heart sounds), pulsus paradoxus
CXR: enlarged/globular silhouette, water bottle
EKG: electrical alternans, low voltage QRS
Dx if hemodynamically stable: echo
hemodynamically unstable Rx: pericardiocentesis
--------------------------------------------------------------- healthy, young patient with CHF, & recent URI:
viral myocarditis due to Coxackie B
dyspnea, JVD, cardiomegaly, S3, bibasilar rales
CXR: pulmonary vascular congestion
--------------------------------------------------------------- bisferiens pulse: a/w aortic insufficiency with or w/o
aortic stenosis, severe aortic insufficiency, HOCM
--------------------------------------------------------------- rivaroxaban: direct factor Xa inhibitor
oral anticoagulant with rapid onset (2 4 hrs)
similar efficacy to LMWH & warfarin for acute

no antidote for major hemorrhage

Rx: recurrent or refractory DVT
--------------------------------------------------------------- thrombolytics are reserved for
hemodynamically unstable PE
IVC filter: Rx lower extremity DVT when
anticoagulation is C/I (hemorrhagic stroke,
active bleeding) or anticoagulation failure
--------------------------------------------------------------- ventricular tachycardia: wide QRS
hemodynamically stable IV amiodarone
hemodynamically unstable synch cardioversion
Hemodynamic instability
altered mental status
signs of shock
ischemic chest discomfort
acute heart failure
--------------------------------------------------------------- SVT with aberrancy (PSVT): narrow complex
hemodynamically stable: vagal maneuvers
(carotid massage, rate control) or IV adenosine can
slow SA & AV node
o #2 Rx: CCB (verapamil) slow AV conduction
hemodynamically unstable synch cardioversion
--------------------------------------------------------------- cyclophosphamide: Rx SLE with renal
hydroxychloroquine: Rx SLE with isolated skin
& joint involvement
A/E: retinopathy (eye exam every 6 months)
--------------------------------------------------------------- HTN, bradycardia, & respiratory depression
(Cushings reflex): intracranial pressure
--------------------------------------------------------------- Prader-Willi: paternal 15q11 deletion
o maternal uniparental disomy
o poor suck & feeding in infancy
o binge-eating & obesity
Angelman: maternal 15q11 deletion
o paternal unilateral disomy
o hand flapping, ataxia, seizures

changing a drug regimen, prodrome viral illness

or diuretic use can cause digoxin toxicity
o neuro (lethargy, confusion, disorientation)
o vision (color vision, scotomas, blindness)
o cardiac (life-threatening arrhythmias)
o GI (anorexia, N/V, abdominal pain)
risk factors: hypokalemia (diuretics)
amiodarone, verapamil, quinidine, propafenone
can serum digoxin levels
o Rx: digoxin dose by 25 50%
evaluation: digoxin level, EKG, PT/INR
--------------------------------------------------------------- atrial tachycardia with AV block is specific for
digitalis toxicity
digitalis ectopy atrial tachycardia
digitalis vagal tone disrupts AV conduction
--------------------------------------------------------------- child with sudden-onset abdominal pain, bloody
diarrhea, anemia, thrombocytopenia, uremia: HUS
MCC: E. coli O157:H7
Rx: supportive, plasmapheresis; dialysis, steroids
--------------------------------------------------------------- lactose intolerance Dx: hydrogen breath test
--------------------------------------------------------------- fever, chills, deep abdominal pain after blunt
abdominal trauma: retroperitoneal abscess 2/2
pancreatic laceration
early findings: normal abdominal CT
devitalized tissue or pseudocyst becomes infected
Dx: serial CT
Rx: percutaneous drainage catheter, culture of
drained fluid, & surgical debridement
--------------------------------------------------------------- duodenum is mostly retroperitoneal, vulnerable
to crush injury overlying vertebral bodies
duodenal hematoma & obstruction can occur
--------------------------------------------------------------- transtentorial herniation due to head trauma,
leads to uncus compression against the tentorium
I/L CN III I/L down-&-out gaze, mydriasis,
& ptosis
I/L PCA C/L homonymous hemianopsia
o I/L hemiparesis & altered mentation

acute onset lower abdominal pain, followed by

bloody diarrhea within 12 24 hr, fever, N/V:
ischemic colitis
a/w complication of procedures on the aortoiliac
vessels (AAA)
MC sites: splenic flexure & recto-sigmoid junction
2/2 impaired flow through inferior mesenteric artery
dull abdominal pain overlying ischemic bowel &
CT scan: thickened bowel wall
Dx: colonoscopy discrete ischemic segment of
cyanotic mucosa with ulcerations
DDx: acute diverticulitis, radiation proctitis,
IBD, C. difficile colitis
--------------------------------------------------------------- diarrhea, rectal bleeding, tenesmus, incontinence:
radiation proctitis
strictures & fistulae may form
--------------------------------------------------------------- BUN & Cr are decreased in pregos due to
increased renal plasma flow & GFR
--------------------------------------------------------------- macroglossia, hemihyperplasia, umbilical hernia
overgrowth disorder & predisposed to neoplasms

Beckwith-Wiedemann syndrome
dysregulation of imprinted gene
fetal macrosomia, rapid growth,
omphalocele or umbilical hernia,
macroglossia, hemihyperplasia
complication Wilms nephroblastoma,
abdominal/renal USS & AFP
monitor newborns for hypoglycemia
--------------------------------------------------------------- EPS (dystonia, choreoathetosis), mental retardation,
self-mutilation: Lesch-Nyhan
--------------------------------------------------------------- lymphadenopathy, hepatosplenomegaly jaundice,
rash, rhinitis: early congenital syphilis
saber shin, Hutchinsons teeth, saddle-nose,
keratitis, deafness: late manifestations (2 yrs)

child with sore throat, dysphagia, odynophagia,

pharyngeal/tonsillar erythema: pharyngitis
o cough, rhinorrhea, conjunctivitis, oral ulcers
= viral pharyngitis Rx: symptomatic
o exudates, edema, palatal petechiae, absence
of viral symptoms rapid antigen test &
throat culture (gold std)
negative viral pharyngitis
positive Strep pharyngitis (GAS)
Rx: oral PCN or amoxicillin
reduces risk of rheumatic fever
Group A Strep is MC in age 5 15 yrs
o tender anterior cervical lymph nodes, tonsillar
erythema & exudates, palatal petechiae
all negative rapid Strep antigen test must be
confirmed with throat culture (high sensitivity)
ASO antibodies peak 1 month after infection, not
useful in Dx acute pharyngitis
--------------------------------------------------------------- MCC of cirrhosis: alcohol abuse, viral hepatitis,
non-alcoholic fatty liver disease
evaluate family Hx, alcohol Hx, Hep B/C serology,
iron studies/HFE protein for hemochromatosis
Clinical features of cirrhosis
non-specific: anorexia, weight loss, weakness,
fatigue, muscle cramps, jaundice, pruritus
GI bleeding, caput medusa, palmar erythema
encephalopathy (sleep disturbance, confusion)
women: amenorrhea/anovulation
men: hypogonadism decreased libido, ED,
gynecomastia, testicular atrophy
synthesis of thyroxine-binding globulins
total T3/T4 (normal TSH)
--------------------------------------------------------------- adrenal insufficiency: fatigue, weakness,
anorexia, weight loss
women: androgen production occurs in adrenals
axillary & pubic hair, loss of libido
men: androgens produced in testes; no findings
--------------------------------------------------------------- aortic coarctation Rx: balloon angioplasty +/- stent
a/w Takayasu arteritis: large vessel granulomatous
vasculitis with massive intimal fibrosis & vascular
narrowing; young Asian females

gait instability, truncal ataxia, nystagmus,

intention tremor, dysmetria: cerebellar dysRx
common in chronic alcoholism
hypotonia leads to pendular knee reflex
--------------------------------------------------------------- Type I collagen mutation: Osteogenesis imperfecta
recurrent fractures, hearing loss, joint laxity,
short stature, scoliosis, blue sclera
--------------------------------------------------------------- mood disturbances (depression, apathy), dementia,
chorea, writhing, facial grimace, ataxia, dystonia:
---------------------------------------------------------------Ascites fluid SAAG
(serum-to-ascites albumin gradient)
1.1 g/dL portal HTN
2/2 cirrhosis, Budd-Chiari,
cardiac ascites
< 1.1 g/dL absence of portal HTN
2/2 malignancy, pancreatitis
nephrotic syndrome, TB
portal HTN: capillary hydrostatic pressure
non-portal HTN: capillary permeability
---------------------------------------------------------------Management of ascites
Na+ & water restriction
spironolactone (up to max dose)
furosemide (not > 1 L/day diuresis; risk of
hepatorenal syndrome or encephalopathy)
paracentesis (monitor renal function)
--------------------------------------------------------------- nephrotic syndrome with palpable kidneys,
hepatomegaly, recurrent pulmonary infections,
ventricular hypertrophy: secondary amyloidosis
2/2 chronic inflammation (RA, IBD, TB,
lymphoma bronchiectasis)
extracellular deposition of fibrils in tissues/organs
Dx: abdominal fat pad Bx
Rx: underlying inflammatory disease
Rx: colchicine (Rx & prophylaxis)
--------------------------------------------------------------- flutamide: non-steroidal anti-androgen that
binds DHT receptors; Rx: prostate cancer
no benefit for those underwent orchiectomy

acute renal failure (Cr > 1.5) with severe cirrhosis

2/2 systemic & renal hypoperfusion
does not respond to fluid resuscitation**
complication of cirrhosis

Hepatorenal syndrome
risk factors advanced cirrhosis with portal HTN
precipitating renal perfusion: GI bleed, vomiting,
sepsis, excessive diuretics, SBP
glomerular pressure & GFR: NSAIDs
(constricts afferents)
renal hypoperfusion: FeNa < 1%
prerenal azotemia
absence of tubular injury
(no RBC, protein, or granular casts)
does not respond to fluid resuscitation
address precipitating factors,
splanchnic vasoconstrictors
(midodrine, octreotide, NE),
definitive Rx: liver transplant
--------------------------------------------------------------- progressive worsening back pain, focal tenderness,
increased radionuclide uptake in lumbar region
radiation therapy: Rx bone pain a/w Hx of
prostate cancer & bone mets after orchiectomy
--------------------------------------------------------------- patients with hypothyroidism have in increased
requirement for levothyroxine after starting
estrogen (estrogen replacement, OCPs)
oral estrogen decrease clearance of TBG
elevated TBG levels, thus free T4 & TSH
Rx: higher dosing of levothyroxine
--------------------------------------------------------------- pregnancy is a/w up-regulation thyroid hormone
due to TBG by estrogen & stimulation of TSH
receptors by -hCG
Thyroid hormones during pregnancy
Total T4

-hCG stimulates TH production

1.5x & estrogen stimulates TBG
Free T4

slight increase


rifampin, phenytoin, & carbamazepine

increase hepatic clearance of thyroid hormones
by enzyme metabolism (deiodination)
---------------------------------------------------------------Idiopathic intracranial HTN
(aka pseudomotor cerebri)
impaired CSF absorption by arachnoid villi
obese women of child-bearing age, OCPs,
tetracycline, isotretinoin, excess Vit. A
symptom o headache (holocranial, pulsatile)
worse at night, awakens from sleep
o transient vision loss, diplopia
o pulsatile tinnitus (whooshing)
papilledema, peripheral vision defect,
CN VI palsy (lateral rectus)
MRI: normal (may see empty sella)
LP: normal CSF analysis
opening pressure > 250 mmHg
(communicating hydrocephalus)
stop offending medication, weight loss,
acetazolamide (if weight reduction fails)
definitive Rx: surgery
complication: blindness
DDx: migraine, cluster headache, viral encephalitis,

papilledema is not C/I to LP unless evidence of

obstructive hydrocephalus or mass lesion
acetazolamide inhibits choroid plexus carbonic
anhydrase, thus CSF production
--------------------------------------------------------------- protracted vomiting a/w pyloric stenosis results in
hypochloremic hypokalemic metabolic alkalosis
Rx: IV rehydration & normalize electrolytes
prior to pyloromyotomy
alkalosis risk of post-op apnea
--------------------------------------------------------------- acute appendicitis: peri-umbilical pain is referred
& visceral; RLQ pain involves parietal peritoneum
is somatic pain
--------------------------------------------------------------- by age 12 months, weight should triple, &
height should double

Dx ureteral stones: USS or non-contrast spiral CT

of abdomen & pelvis
USS for pregos
IV pyelogram: old test for stones
--------------------------------------------------------------- Parkinsons is a clinical Dx: at least 2/3
o resting tremor, rigidity, bradykinesia
no imaging or labs needed to confirm Dx
--------------------------------------------------------------- chronic acid suppression with PPI or H2 blocker
is a risk factor for
C. difficile
o Dx: stool PCR assay for toxin A & B
o osteoporosis 2/2 impaired Ca++ absorption
o pneumonia 2/2 upper GIT colonization
--------------------------------------------------------------- suspected community-acquired pneumonia or
atypical pneumonia (Mycoplasma)
Dx: clinical & CXR
Rx: empiric ABX
--------------------------------------------------------------- TSH-secreting pituitary adenoma: macroadenoma
causes central hyperthyroidism
symptoms MC due to mass effect
presents with goiter, but no Graves findings
--------------------------------------------------------------- Hashimotos: lymphocytic infiltration of thyroid
anti-TPO Abs, elevated TSH, low T4
enlarged, rubbery goiter
can cause transient hyperthyroidism 2/2 initial
inflammatory destruction of thyroid follicles
--------------------------------------------------------------- thyroid lymphomas: MC a/w Hashimotos
rapid thyroid gland enlargement with compressive
symptoms (dysphagia, voice changes)
reduced RAIU
--------------------------------------------------------------- TMP-SMX: prophylactic Rx for toxoplasmosis,
PCP, community-acquired skin MRSA, nocardia,
& uncomplicated UTI
prophylaxis for all post-transplant patients
o vaccines: influenza, pneumococcus, Hep B

Trimethoprim (TMP) causes hyperkalemia 2/2

blockade of epithelial Na+ channels in collecting
tubule @ high doses
serial K+ monitoring required
also competitively inhibits tubular Cr secretion,
results in artificial increase of serum Cr
without affecting GFR
--------------------------------------------------------------- glomerular hyperfiltration is the earliest renal
abnormality in diabetic nephropathy
o detectable several days after DM Dx
o creates intraglomerular HTN & progressive
glomerular damage
Rx: ACE-I reduces intraglomerular HTN
first quantified change: glomerular BM thickening,
followed by mesangial expansion, nodular sclerosis
--------------------------------------------------------------- rapid onset respiratory failure, severe hypotension,
& DIC during labor or immediately post-partum:
amniotic fluid embolism
cardiogenic shock, seizures, or coma
risk factors: adv maternal age, high gravida
Dx: clinical
Rx: respiratory & hemodynamic support
DDx: eclampsia, peripartum cardiomyopathy, PE
--------------------------------------------------------------- severe aortic stenosis can cause anginal chest pain
due to myocardial O2 demand
accompanying prolonged myocardial contraction
& impaired diastole coronary blood flow
--------------------------------------------------------------- HCM: murmur @ LLSB; dual upstroke carotids
aortic stenosis: murmur located in 2nd IC space
with radiation to carotids
--------------------------------------------------------------- myocardium meets increased O2 demand by
inducing dilation of coronary vessels
o unable to increase O2 extraction
--------------------------------------------------------------- anti-tissue transglutaminase Ab: Dx Celiacs
--------------------------------------------------------------- heparin inactivates antitrhombin III, which
inactivates thrombin, factor IXa & Xa
--------------------------------------------------------------- mean values are extremely sensitive to outliers

---------------------------------------------------------------Preconception counseling
initial screening of hemaglobinopathies for
non-African American: CBC of the female only
o further testing if anemic & reduced MCV
African Americans: CBC & Hb electrophoresis
--------------------------------------------------------------- iron level, TIBC, & ferritin are normal in
thalassemia; abnormal with iron deficiency
--------------------------------------------------------------- ceftriaxone use is a/w cholestasis
C/I in newborns at high risk of cholestasis
---------------------------------------------------------------Skin conditions & associated diseases
acanthosis nigricans
insulin resistance
(PCOS, obesity, DM),
GI malignancy
multiple skin tags
insulin resistance,
Crohns (perianal)
porphyria cutanea tarda &
palpable purpura 2/2
Hep C
dermatitis herpetiformis
sudden onset psoriasis,
recurrent herpes zoster,
molluscum contagiosum
severe seborrheic dermatitis HIV,
explosive, itchy seborrheic
GI malignancy
pyoderma gangrenosum
erythema nodosum
sarcoidosis, UC, TB,
histoplasmosis, Bechet
DDx of hyperpigmentation: Addisons, pellagra,
--------------------------------------------------------------- pyoderma gangrenosum: neutrophilic ulcerative
skin disease; purulent base, violaceous borders
a/w underlying systemic disorder (IBD, RA, AML)
Dx: skin biopsy
Rx: local or systemic corticosteroids

ecthyma gangrenosum: hemorrhagic pustule

with surrounding erythema necrotic ulcers
o MCC: P. aeruginosa
--------------------------------------------------------------- erythema nodosum: painful, discrete, pretibial
subcutaneous nodules
MCC: recent Strep pharyngitis
a/w sarcoidosis, UC, TB, coccidiomycosis,
histoplasmosis, Behcet
evaluation: CXR, PPD, ASO titers
--------------------------------------------------------------- hidradenitis suppurativa: chronic inflammatory
occlusion of skin follicles
o nodules or abscess with purulent drainage
scar tissue @ axilla, groin, perineum, scalp
result in linear rope-like bands & sinus tracts
o risk factors: family Hx, smoking, obesity,
mechanical stress on skin
o Dx: clinical; no skin biopsy or cultures
--------------------------------------------------------------- well-defined erythematous plaques with satellite
vesicles or pustules in interigenous & occluded
skin areas (axilla, groin, skin folds): intertrigo
MCC: Candida albicans
--------------------------------------------------------------- hyperpigmented plaques in flexural & interigenous
areas with hyperkeratosis: acanthosis nigricans
risk factors: family Hx, diabetes, obesity, PCOS,
--------------------------------------------------------------- erythematous papules & pustules in central face:
acne (papulopustular) rosacea
not acne vulgaris, no comedones
--------------------------------------------------------------- biliary colic: increased intra-GB pressure against
an obstructed cystic duct
referred pain; exacerbated by fatty meals
spontaneous resolution within 4 -6 hrs
no fever, TTP, or leukocytosis; no inflammation
DDx: cholecystitis (pain > 6 hrs, Murphys sign)
--------------------------------------------------------------- intestinal ileus can be due to a vagal reaction
caused by uereteral colic (renal stone)
RLQ pain, constipation, no flatus
U/A: needle-shaped crystals (uric acid stones)

Dx: abdominal CT (detects radiolucent stones)

ileus resolves when ureterolithiasis is treated
--------------------------------------------------------------- sudden onset epigastric pain, N/V, hematemesis,
peritoneal signs (guarding, rigidity, rebound tender),
pneumoperitoneum: perforated peptic ulcer
gastric content released into peritoneal cavity,
results in peritonitis, rebound tenderness, guarding
surgical emergency!!!
DDx: acute cholecystitis, gallstone pancreatitis,
aortic dissection, biliary colic
--------------------------------------------------------------- acute onset focal neurologic findings (confusion,
ataxia, hyperreflexia, seizures), fever, headache,
behavior changes: herpes encephalitis
MCC of fatal sporadic encephalitis: HSV-1
damages the temporal lobe
CSF: marked lymphocytic pleocytosis, proteins,
erythrocytes (2/2 hemorrhagic destruction of
temporal lobes), normal glucose
Dx: CSF shows HSV DNA on PCR
Rx: empiric IV acyclovir after LP
--------------------------------------------------------------- bacterial meningitis CSF: polymorphonuclear
leukocytes, glucose
--------------------------------------------------------------- hyperCa++, hypophosphatemia, urinary Ca++,
PTH: primary hyperPTH
Dx: 24 hr urine Ca++
Rx: parathyroidectomy criteria for
asymptomatic hypercalcemia
o serum Ca++ 1 mg/dL above upper limit
o young age < 50 yrs
o bone mineral density < 2.5
o reduced renal function (GFR < 60)
DDx: familial hypocalciuric hypercalcemia,
hypercalcemia of malignancy
--------------------------------------------------------------- hypercalcemia without polyuria, polydipsia, or
constipation: familial hypocalciuric hyperCa++
abnormal Ca++-sensing receptor on parathyroid
cells & renal tubules; excess Ca++ reabsorption
AD inherited, benign, asymptomatic hypercalcemia
high/normal PTH, low urine Ca++

Rx: do not treat hyperCa++, no parathyroidectomy

--------------------------------------------------------------- pRBC transfusion can O2-carrying capacity
for severe anemia
when to transfuse pRBCs
o stable patients, no comorbidities: Hb < 7 g/dL
o unstable, symptomatic anemia: Hb < 9 g/dL
--------------------------------------------------------------- eczematous rash on the nipple, Bx: large cells
surrounded by halo-like areas invading epidermis:
breast Pagets
localized to the nipple, ulcerating eczematous
appearance with underlying adenocarcinoma
--------------------------------------------------------------- FFP: contains all clotting factors & plasma proteins
from 1 unit of blood
Rx: active bleeding with severe coagulopathy
(liver disease, DIC, supratherapeutic warfarin)
--------------------------------------------------------------- cryoprecipitate contains insoluble products from
cold FFP (fibrinogen, vWB factor, factor VIII,
factor XIII)
Rx: replacement therapy
--------------------------------------------------------------- PLT transfusion: Rx PLT < 10,000
o or PLT < 50,000 with active bleeding
--------------------------------------------------------------- kleptomania: impulse control disorder to steal
--------------------------------------------------------------- abdo pain, palpable mass, jaundice, dark urine,
age < 10 yrs: congenital biliary cyst
o no fever, N/V, or anorexia
single, extrahepatic cystic dilation of bile duct
Dx: USS (or ERCP for biliary obstruction)
Rx: surgical resection reduces malignancy risk
complications: cholangiocarcinoma
DDx: biliary atresia (early infancy, acholic stools),
cholangitis (fever), pancreatic pseudocyst
--------------------------------------------------------------- chronic diarrhea, short stature, gingivitis, recurrent
lymphadenitis, osteomyelitis at multiple sites,
catalase+ infections: chronic granulomatous dz
o S. aureus, Aspergillus, Serratia, Klebsiella

not susceptible to catalase-negative (S.

pyogenes, S. pneumo, H. influenza)
underweight, dermatitis, lymphadenopathy,
hypergammaglobulinemia, hepatic abscesses,
hepatosplenomegaly, anemia of chronic disease
Dx: nitroblue tetrazolium test
Rx: daily TMP-SMX, gamma-INF 3x/wk
--------------------------------------------------------------- lethargy, bradycardia, AV block, hypotension,
diffuse wheezing: -blocker overdose
wheezing is hallmark
hypoglycemia, bronchospasm, delirium, seizures
initial Rx: isotonic fluid bolus, IV atropine
Rx: IV glucagon ( intracellular cAMP) for
refractory hypotension
--------------------------------------------------------------- prematurity & LBW infants are risk factor for
intraventricular hemorrhage
Dx: transfontanelle USS of all newborns with
predisposing risk factors
--------------------------------------------------------------- Parinaud syndrome: due to pineal gland tumor
(pineal produces melatonin)
MCC: germ cell tumors
central precocious puberty: -hCG
pressure on pretectal midbrain region near
superior colliculus & CN II
limited upward gaze (sun-setting sign), ptosis,
B/L eyelid retraction (Colliers sign)
pseudo-Argyll-Robertson (minimally reactive)
obstructive hydrocephalus: headache, vomiting,
Dx: MRI, AFP & -hCG
--------------------------------------------------------------- ecchymosis on areas exposed to repeated minor
trauma (extensors) in elderly: senile purpura
age-related loss of elastic fibers in perivascular
connective tissue
incidence & severity a/w anticoagulants,
NSAIDs, & corticosteroids
normal labs; no further evaluation
--------------------------------------------------------------- precocious puberty, pigmentation, polyostotic
fibrous dysplasia (3 Ps): McCune Albright
o caf au lait spots, multiple bone defects

o moon facies, bruises

GI hamartomatous polyps, mucocutaneous
pigmentation: Peutz-Jeghers
sporadic phakomatosis, mental retardation,
seizures, visual impairment: Sturge-Weber
--------------------------------------------------------------- MCC of secondary digital clubbing: CF,
lung malignancies, right-to-left shunts
2/2 trapping of megakaryocytes in distal
fingertips, releasing PDGF & VEGF
hypertrophic osteoarthropathy: clubbing &
painful joint enlargement, synovial effusions,
periostosis of long bones; a/w lung cancer
--------------------------------------------------------------- MC complication of PUD: hemorrhage
---------------------------------------------------------------Obstructive Restrictive
lung disease lung disease
< 80%
< 80%
< 70% ()
> 70%
normal or
< 80%

positive bronchodilator response (> 12% FEV1),

normal DLCO, dyspnea, wheezing, cough: asthma
COPD & asthma both show airflow obstruction
only asthma shows complete reversible
airway obstruction with bronchodilators
o asthma: normal or DLCO (if severe)

emphysema COPD: DLCO due to alveolar

--------------------------------------------------------------- DLCO = function of alveolar-capillary membrane
DDx based on DLCO
obstructive restrictive
DLCO emphysema interstitial
anemia, PE,
lung disease, pulmonary
heart failure
r disease
DLCO severe
Causes of DLCO (look at FEV pattern)
restrictive pattern: interstitial fibrosis, bleomycin,
idiopathic pulmonary fibrosis
obstructive pattern: emphysema COPD
normal spirometry: PE, anemia, pulmonary HTN
Causes of DLCO
due to pulmonary blood volume
exercise, supine position, pulmonary hemorrhage,
severe asthma, smoking, polycythemia
--------------------------------------------------------------- DLCO in emphysema due to "adjoining
capillary beds" (decreased surface area)
DLCO in asthma due to "increased pulmonary
blood volumes"
--------------------------------------------------------------- chronic bronchitis: COPD subtype a/w smoking
productive cough 3 months in 2 successive yrs
hypersecretion of mucus & structural changes to
tracheobronchial tree; normal DLCO
CXR: prominent bronchovascular markings
---------------------------------------------------------------Evaluation of hyperthyroidism
Dx: measure TSH & free T4
o TSH, free T4 20 hyperthyroidism
o Dx: MRI pituitary adenoma

TSH, free T4 10 hyperthyroidism

o goiter, ophthalmopathy Graves
o Dx: radioactive iodine uptake (RIU)
RIU = de novo hormone synth
RIU = preformed or exogenous
high RIU: diffuse Graves
high RIU: nodular adenoma, multi-nodular goiter
low RIU thyroglobulin low exogenous TH
low RIU thyroglobulin high thyroiditis
--------------------------------------------------------------- thyroglobulin: produced by follicular cells of
the thyroid; used only within the thyroid gland
--------------------------------------------------------------- fever, neck pain, tender thyroid, elevated ESR:
subacute thyroiditis (de Quervain)
self-limited < 8 wks due to depletion of
preformed thyroid hormone
--------------------------------------------------------------- upper GI bleed Rx: supplemental O2, IV fluids,
NPO, monitor CBC & vitals for ongoing bleeding
---------------------------------------------------------------Manifestations of SLE
feature constitutional: fever, fatigue, weight loss
non-deforming migratory arthritis
butterfly rash & photosensitivity
serositis: pleurisy, pericarditis, peritonitis
thromboembolic events (antiphospholipid)
cognitive dysfunction & seizures
hemolytic anemia, thrombocytopenia,
proteinuria, elevated Cr
hypocomplementemia (C3, C4)
ANA, anti-dsDNA, anti-Smith
false-positive RPR test for syphilis

SLE joint Rx: NSAIDs, low-dose glucocorticoids,

--------------------------------------------------------------- cough & wheezing with ASA-exacerbated
respiratory disease is preceded by refractory
chronic rhinosinusitis a/w nasal polyposis
--------------------------------------------------------------- child with morning headaches, seizures, irritable,
decorticate posturing, space-occupying lesion
infratentorial, benign astrocytomas: MC in kids

--------------------------------------------------------------- fatigue, malaise, fever, night sweats, anorexia,

weight loss, pallor, abdominal pain: CML
leukocytosis with left shift, basophilia, anemia,
thrombocytosis, splenomegaly
myelocytes > metamyelocytes
reciprocal t(9, 22) form Philadelphia Xome
containing the BCR/ABL fusion gene causes
dysregulated tyrosine kinase activity
LAP score (leukocyte alkaline phosphatase)
Rx: tyrosine kinase inhibitors (imatinib)
inhibit BCR/ABL tyrosine kinase activation
--------------------------------------------------------------- leukocyte alkaline phosphatase (LAP) score:
leukemoid reaction, polycythemia vera
LAP score: CML (Dx: Philadelphia Xome)
--------------------------------------------------------------- acute promyelocytic leukemia (APL) is a/w
retinoic acid receptor
+Auer rods, +myeloblasts
no fever, no splenomegaly
Rx: all-trans retinoic acid (ATRA)
--------------------------------------------------------------- MC thyroid malignancy: papillary carcinoma
best prognosis
MC mets to local lymph nodes
risk factors: childhood head/neck irradiation,
family Hx of thyroid ca
--------------------------------------------------------------- follicular thyroid carcinoma: hematogenous
anaplastic thyroid ca: rapidly enlarging mass;
worst prognosis (months)
--------------------------------------------------------------- resistant HTN: despite 3 anti-hypertensives
Secondary causes of HTN
serum Cr, proteinuria, RBC casts
continuous abdominal bruit,
severe HTN ( 180/120),
diffuse atherosclerosis (PAD, PVD)
recurrent flash pulmonary edema
serum Cr (after starting ACE-I)
HTN, mild hyponatremia,
easily provoked hypokalemia


aldosterone/renin > 20:1

headache, palpitations, diaphoresis
paroxysmal elevated BP
adrenal incidentaloma
central obesity, facial plethora,
proximal weakness, striae,
amenorrhea/erectile dysfunction
fatigue, dry skin, cold intolerance,
constipation, weight gain
hypercalcemia, renal stones
polyuria, polydipsia
confusion, depression, psychosis
differential HTN, headache,
epistaxis, blurred vision,, LVH
brachial-femoral delay, rib notching
continuous to-&-fro machine-like
murmur (posterior chest) due to
large collateral circulation

hypercalcemia: bones, stones, moans, groans

hyperPTH can cause HTN, arrhythmias, ventricular
hypertrophy, vascular & valvular calcifications
significant HTN & 10 hyperPTH; MEN syndrome
---------------------------------------------------------------Acute decompensated heart failure
feature acute dyspnea, orthopnea, PND, HTN,
accessory muscle use, tachycardia,
tachypnea, bibasilar crackles, JVD, S3,
peripheral edema
stable: supplemental O2,
IV furosemide, IV vasodilator (nitro)
hypotension or shock: supplemental O2,
IV furosemide, IV vasopressor (NE)

acute decompensated HF can present with acute

pulmonary edema
---------------------------------------------------------------Tetanus prophylaxis
clean, minor
dirty, severe
3 tetanus
tetanus toxoid if tetanus toxoid if
toxoid doses
last dose was
last dose was
10 yrs ago
5 yrs ago
no TIg
no TIg
tetanus toxoid
tetanus toxoid
uncertain, or
vaccine only,
vaccine + TIg

< 3 tetanus doses no TIg

--------------------------------------------------------------- diastolic dysfunction = heart failure with
preserved LV ejection fraction (contractility)
elevated diastolic pressure reduced C.O.
---------------------------------------------------------------Drugs/supplements that affect
warfarin metabolism
acetaminophen* NSAIDs
ABX/antifungals thyroid hormone
cranberry juice
Gingko biloba
( bleed risk)
Vit E
p450 inducers carbamazepine
spinach (greens)
St. Johns wort
effects/efficacy OCPs
--------------------------------------------------------------- lupus anticoagulant: causes artificially
prolonged aPTT by binding phospholipids
risk of thrombosis
--------------------------------------------------------------- episodic flushing, secretory diarrhea, wheezing,
tricuspid regurgitation

Carcinoid syndrome
episodic flushing, telangiectasias,
cyanosis, secretory diarrhea, cramping,
bronchospasm, tricuspid regurgitation,
niacin deficiency (pellagra)
24 hr urine 5-HIAA
CT/MRI abdomen/pelvis localizes tumor
OctreoScan (detect mets), echo
octreotide only if symptomatic & prior to
surgery for liver mets

carcinoid tumors can secrete histamine, 5-HT,

VIP that are metabolized in the liver
o liver mets results in hormone release into
systemic circulation
hallmark: plaque-like deposits of fibrous tissue
on endocardium tricuspid regurgitation & right
heart failure

5-HT is synthesized in carcinoid cells from

tryptophan, also used for niacin
o 5-HT production pellagra
DDx: right-sided IE (fever, malaise, arthralgias)
--------------------------------------------------------------- folic acid depletion: 4 5 months
elderly on a tea & toast diet
Vit B12 stores: 3 4 yrs
--------------------------------------------------------------- perifollicular hemorrhage, poor wound healing,
swollen gums: Vit C deficiency
RBC fragility, hyporeflexia, muscle weakness,
blindness: Vit E deficiency
--------------------------------------------------------------- unilateral pulsatile headache, vomiting,
photophobia, 4 72 hrs duration: migraine
Rx acute attacks: IV anti-emetics (chlorpromazine,
prochlorperazine, metoclopramide), esp. w/ N/V
o monotherapy or adjunct to NSAIDs & triptans
migraine prophylaxis: amitriptyline, propranolol
--------------------------------------------------------------- most effective in reducing UTI risk a/w
neurogenic bladder: intermittent catheterization
indwelling catheters can acquire a biofilm
---------------------------------------------------------------Nephritic syndrome
Nephrotic syndrome
HTN, oliguria,
edema, hypoalbuminemia,
periorbital edema
hyperlipidemia, VTE
hematuria, RBC casts
no hematuria, fatty casts
proteinuria < 3.5 g/day
proteinuria > 3.5 g/day
pediatric etiologies
post-strep GN, HUS
minimal change disease
adult etiologies
IgA nephropathy,
focal segmental GN,
crescentic GN
membranous nephropathy,
(rapidly progressive GN) membranoproliferative,
lupus nephritis,
diabetic glomerularnepho

Hep B is a risk factor for membranous nephropathy

o immunofluorescence: granular
membranoproliferative glomerulonephritis is
a/w Hep C infection
o can cause nephritic or nephrotic syndrome

Nephrotic histopathology
crescent formation: focal segmental GN
thick BM & subepithelial spikes: membranous
mesangial hypercellularity: membranoproliferative
--------------------------------------------------------------- parents are not allowed to refuse life-saving Rx
for a child, including religious reasons
obtain court order to proceed with intervention
--------------------------------------------------------------- adolescents can receive confidential care w/o consent
for contraception, pregnancy, & STDs
--------------------------------------------------------------- presbyopia: age-related lens elasticity
prohibits accommodation, thus loss of near vision
peaks at age 40, Hx of eye problems
--------------------------------------------------------------- weakness, postprandial epigastric pain, +FOBT:
gastric cancer
Dx: endoscopy/Bx positive for adenocarcinoma
Staging gastric adenocarcinoma
initial staging: abdomen & pelvis CT
limited stage surgical resection
advanced stage chemotherapy +/- laparotomy
--------------------------------------------------------------- nocturnal wheezing & cough: GERD
---------------------------------------------------------------Esophageal perforation
etiology Boerhaaves, endoscopy, esophagitis
(infectious/pill/caustic), ulcer
features chest/abdo pain, fever,
subcutaneous emphysema, crepitus
CXR: wide mediastinum, pneumoTx,
CT: esophageal wall thickening,
mediastinal air-fluid level
water soluble contrast esophagogram
ABX, parenteral nutrition, supportive care
surgical repair
--------------------------------------------------------------- -blockers can exacerbate severe reactive airway
disease, but safe with mild/moderate COPD/asthma
o Rx: use cardioselective -blockers

MCC of sudden cardiac arrest is sustained

ventricular tachycardia or fibrillation due to
acute MI or ischemia
survival rated depends on effective CPR, prompt
rhythm analysis & defibrillation for V-fib
o #1 Rx: compression-only CPR
Rx: epinephrine for asystole, PEA, or refractory
ventricular arrhythmias after defibrillation
--------------------------------------------------------------- hereditary non-polyposis CRC (HNPCC): aka
Lynch Syndrome
MC a/w endometrial carcinoma
---------------------------------------------------------------MCC of osteomyelitis
children & adults: S. aureus (coagulase+)
sickle cell disease: Salmonella & S. aureus
neonates: E. coli & group B strep
age < 1 yr: group B strep
diabetics: Pseudomonas
foot puncture: Pseudomonas
o Rx: fluoroquinolones & surgical debridement
vertebral body: S. aureus
--------------------------------------------------------------- recent onset confusion, fever, muscle rigidity,
diaphoresis, CK: NMS
o drug-induced idiosyncratic reaction
MCC: haloperidol, some atypicals
o within 2 wks of initiation
---------------------------------------------------------------Features of compartment syndrome
o pain on passive stretching
o pain out of proportion to injury
o rapidly increasing & tense swelling
o paresthesia
reperfusion of a limb following arterio-occlusive
ischemia > 4 6 hr can lead to intracellular &
interstitial edema
increased pressure muscle & nerve ischemia
Rx: elevated compartment pressures that do not
show rapid improvement fasciotomy
DDx: necrotizing fasciitis, gas gangrene,
embolic occlusion, DVT (vague pain)
complication: Volkmann contracture

Hep C can be asymptomatic or nonspecific

ALT can be normal or 2x normal
consideration for Rx requires liver biopsy as the
best clinical predictor of disease progression &
assess response to treatment
liver biopsy determines staging & guide Rx
Rx: peginterferon & ribavirin
HHC surveillance for cirrhosis: USS every 6 months
--------------------------------------------------------------- early phase of acute pneumonia with consolidation
can have persistent blood flow to areas of impaired
ventilation (V/Q mismatch) leads to physiologic
intrapulmonary (right-to-left) shunting & arterial
hypoxemia (deoxygenated blood to left heart)
laterally positioning the affected lung in the
dependent (lowest) position will worsen the shunt
--------------------------------------------------------------- conditions that cause decreased perfusion of
well-ventilated alveoli (PE) amount of
physiologic dead space, resulting in wasted
ventilation, but not hypoxemia
poor ventilation of well-perfused alveoli
(consolidated lung) leads to hypoxemia
--------------------------------------------------------------- monthly bloating, headaches, breast tenderness,
irritability decreased libido, anxiety: PMS
occurs 1 2 wks before menses
resolves with onset of menses
DDx: hypothyroid, perimenopause, migraine,
--------------------------------------------------------------- bipolar: not required to have depressive episode
o antipsychotics have rapid onset of action,
best for Rx acute mania
o mood stabilizers require gradual titration
Bipolar disorder Rx
mild/mod monotherapy with atypicals
(risperidone, olanzapine, aripiprazole)
alternative lithium or valproate as monotherapy
severe mania atypical + lithium or valproate
Maintenance Rx
lamotrigine olanzapine
haloperidol can Rx acute mania, not maintenance

valproate A/E: weight gain & acute pancreatitis

lamotrigine: Rx of bipolar depressive episodes;
--------------------------------------------------------------- post-menopausal asymptomatics with adnexal mass
require transvaginal USS, then CA-125
elevated CA-125 in post-menopause
suggests ovarian cancer
if simple cyst < 10 cm & normal CA-125: follow
conservatively with periodic USS
needle aspiration is C/I
--------------------------------------------------------------- Rx emergency reversal of warfarin-induced
anticoagulation: FFP
--------------------------------------------------------------- desmopressin can be used pre-operatively for
mild hemophilia A to prevent excess bleeding
o indirectly increases factor VIII by causing
vWF release from endothelial cells
--------------------------------------------------------------- paraplegia, bladder/fecal incontinence, sensation
absent from nipple downward: upper thoracic
cord lesion
absent sensation from umbilicus downward:
lower thoracic cord lesion
--------------------------------------------------------------- ipratropium: anti-muscarinic
Rx acute COPD exacerbation, combined with
short-acting -agonists (albuterol)
--------------------------------------------------------------- Rx proven to prolong COPD survival: cessation of
smoking, supplemental O2, lung reduction surgery
--------------------------------------------------------------- Hep A is the MC vaccine-preventable disease of
travelers, especially developing countries
yellow fever vaccine
o sub-Saharan Africa, S. America
--------------------------------------------------------------- alcohol cessation & low purine diet can prevent
acute gouty arthritis
ethanol is metabolized to lactate; competes with
urate for renal excretion
also avoid diuretics & pyrazinamide
Rx: NSAIDs, colchicine

headache, N/V, abdominal discomfort, confusion,

pink-red skin: carbon monoxide poisoning
Dx: carboxyHb level
o pulse oximetry may be normal; unreliable
Rx: 100% O2 CO half-life from 5 hr to 1 2 hr
or hyperbaric O2
---------------------------------------------------------------Causes of inadequate response to anti-hypertensives
o NSAIDs, decongestants, glucocorticoids
o excess alcohol
o screen for secondary causes
--------------------------------------------------------------- sudden onset syncope without warning signs,
structural heart disease, ectopic beats: arrhythmia
thiazides can predispose to ventricular arrhythmia
DDx: vasovagal, autonomic dysFx, postural
--------------------------------------------------------------- methadone is for pregos addicted to heroin to
prevent uncontrolled withdrawal in the fetus
prenatal exposure to heroin & methadone
increases risk of IUGR, macrocephaly, SIDS
Neonatal abstinence syndrome
irritability, high-pitched cry, poor sleep, tremors,
seizures, sweating, sneezing, vomiting, diarrhea
o heroin withdrawal: within 48 hr
o methadone withdrawal: 48 72 hr
Rx: symptomatic, morphine (systematically wean)
--------------------------------------------------------------- penile fracture: due to crush injury
tearing of tunica albuginea, forms a hematoma
Rx: retrograde urethrogram to r/o urethral injury,
then surgical exploration
---------------------------------------------------------------o phenytoin: Rx partial seizures
o carbamazepine: Rx trigeminal neuralgia
fetal hydantoin syndrome: nail/digit hypoplasia,
cleft lip/palate, MR, cardiac defects, microcephaly
o phenytoin rate of fetal Vit K degradation
o pregos on phenytoin during last trimester
should receive prophylactic Vit K to prevent
neonatal bleeding
--------------------------------------------------------------- fetal exposure to valproate: risk of NTDs,
cardiac anomalies, dysmorphic facies

large anterior mediastinal mass, -hCG, AFP:

non-seminomtous germ cell tumor
young males, locally invasive
most are primary tumors
Dx: testicular USS (r/o primary tumor)
DDx: seminoma ( -hCG only), benign teratoma,
bronchogenic cyst, Hodgkins
--------------------------------------------------------------- choriocarcinoma: -hCG
seminoma: -hCG only
non-seminomtous tumor: -hCG, AFP
benign teratoma: no markers
---------------------------------------------------------------#1 testicular sex cord stromal tumor: leydig cell tumor
gynecomastia, precocious puberty
estrogen due to aromatase expression with
secondary inhibition of LH & FSH
undetectable -hCG & AFP
--------------------------------------------------------------- subacute combined degeneration: neurologic
complication of Vit B12 deficiency
progressive symmetric polyneuropathy (legs)
degeneration of dorsal spinal column, gait ataxia
corticospinal disease (UMN signs)
peripheral neuropathy, memory loss, dementia
Dx: elevated methylmalonic acid
--------------------------------------------------------------- Toxoplasmosis Rx: empiric sulfadiazine &
prophylaxis: TMP-SMX
--------------------------------------------------------------- large sample size: decreases p-value & narrows CI
---------------------------------------------------------------Wilms tumor (nephroblastoma)
arise from metanephros
(precursor of renal parenchyma)
MC renal malignancy of childhood
peak @ age 2 5 yrs; sporadic,
associated syndromes
o WAGR (Wilms, Aniridia, GU
anomalies, mental Retardation)
o Beckwith-Wiedemann
o Denys-Drash


asymptomatic, firm abdominal mass,

does not cross midline
USS, then contrast-enhanced CT
excision or nephrectomy,
chemotherapy +/- radiation
5 yr survival with Rx: 90%
MC site of mets: lungs

DDx: neuroblastoma
o arises from neuro crest cells (precursor of
sympathetic chain & adrenal medulla)
o can arise anywhere in sympathetic NS, but
typically the adrenals
firm, nodular mass that crosses midline
o metastatic sites: long bones, bone marrow,
skull, liver, lymph nodes, skin
o urine HVA, VMA catecholamines
o XR: calcifications & hemorrhages
--------------------------------------------------------------- relative risk can be calculated from cohort studies
by comparing incidence
odds ratio measures association in case-control
studies; compares the odds of exposure
o if outcome/disease is uncommon, odds ratio
is a close approximation of relative risk
(rare disease assumption)
if low incidence OR approximates RR
---------------------------------------------------------------Thoracic aortic aneurysm
ascending aortic aneurysm: cystic medial necrosis
(aging) or connective tissue disorders (Marfan)
descending aortic aneurysm: atherosclerosis
o HTN, hypercholesterolemia, smoking
CXR: wide mediastinum, increased aortic knob,
tracheal deviation
Dx: contrast-enhanced CT
--------------------------------------------------------------- De Quervain tenosynovitis: inflammation of
abductor pollicis longus & extensor pollicis brevis
MC in new mothers holding infants
Finkelstein test (grasps thumb & ulnar deviate
the wrist)
--------------------------------------------------------------- acute, severe retro-orbital pain, same time of day,
wakes patient from sleep, male: cluster headache

attacks occur in clusters: daily for 6 8 wks,

then remission for up to 1 yr
redness, I/L tearing, rhinorrhea, I/L Horners
acute Rx: 100% O2, subcutaneous sumatripan
prophylaxis Rx: verapamil, lithium, ergotamine
---------------------------------------------------------------Iron deficiency anemia in age < 2 yr
risk factors prematurity**
lead exposure
infants who consume
o low-iron formula
cow, soy, or goat milk
introduced before age 1 yr
o exclusive breastfeeding after
age 6 months
toddlers who consume
o 24 oz/day milk (> 3 glasses)
o < 3 servings/day iron-rich food
CBC in all age 9 12 months
empiric iron supplementation,
recheck Hb in 4 wks,
start cow milk @ age 1 yr

term infants have adequate iron stores for 6 months

excess cow milk is low in iron & causes occult
intestinal blood loss
goat milk is folate deficient
--------------------------------------------------------------- all pregos without C/I: influenza vaccination
o @ any trimester
--------------------------------------------------------------- cough, erythema nodosum, anterior uveitis, arthritis:
most are asymptomatic, incidental CXR findings
DDx: acute HIV, TB, histoplasmosis, Hodgkins
--------------------------------------------------------------- primary CNS lymphoma Rx: irradiation
suspected if no response to ABX
--------------------------------------------------------------- all exclusively breastfed infants should start on
VitD daily within 1st month of life
solid foods @ < 6 months risk of GI infections

Vit B12 supplements for exclusively breastfed

infants born to strict vegetarian mothers
--------------------------------------------------------------- acute confusion, fluctuating LOC, inability to
sustain attention: delirium
--------------------------------------------------------------- epinephrine (Rx asthma, croup)
-agonist effect: reduces bronchial secretions &
mucosal edema
-agonist effect: smooth muscle relaxation
--------------------------------------------------------------- fibromuscular dysplasia: non-inflammatory,
non-atherosclerotic condition; women age < 50
abnormal development of arterial wall
primarily affect renal arteries HTN
involvement of carotid or vertebral arteries cause
TIA, amaurosis fugax, stroke, headache, dizziness
secondary hyperaldosteronism 2/2 decreased
perfusion to kidneys (aldosterone: renin ratio < 20)
Dx: abdominal CT angiography or duplex USS
Rx: angioplasty with stent placement
o Rx: ACE-I if poor surgical candidate
ACE-I is C/I in B/L renal artery stenosis
--------------------------------------------------------------- painful non-itchy pustules & honey-crust lesions
on mouth, nose, & neck: non-bullous impetigo
MCC: S. aureus, group A Strep (S. pyogenes)
risk factors: eczema, abrasion, insect bites
no fever, no systemic symptoms
Rx: topical mupirocin
complications: post-strep GN
DDx: HSV (orolabial region), VZV, erysipelas
--------------------------------------------------------------- 3+ proteinuria, hematuria, dense intramembranous
deposits staining for C3: membranoproliferative
caused by IgG against C3 convertase of
alternative complement pathway, leads to
persistent complement activation
--------------------------------------------------------------- cor pulmonale: RV failure from pulmonary HTN
due to COPD, PVD, or OSA

Findings of cor pulmonale


COPD, interstitial lung disease,

pulmonary vascular disease, OSA
symptom dyspnea on exertion, fatigue, lethargy,
exertional syncope, exertional angina
peripheral edema, loud S2,
JVD + prominent a wave, RV heave,
tricuspid regurgitation
EKG: partial/complete RBBB, RAD,
RVH, RA enlargement
echo: pulmonary HTN, dilated RV,
tricuspid regurgitation
right heart catheterization (gold std Dx):
RV dysfunction, pulmonary HTN,
absence of left heart disease
--------------------------------------------------------------- constrictive pericarditis is an important cause
of right heart failure
--------------------------------------------------------------- adrenal vein sampling: Dx adrenal hyperplasia
vs. adenoma (primary hyperaldosteronism)
aldosterone > 15; aldosterone:renin ratio > 20
--------------------------------------------------------------- symptoms of CAD can be unmasked or worsened
with thyrotoxicosis
Cardiovascular effects of thyrotoxicosis
sinus tachycardia, PACs, PVCs
hemodynamics systolic HTN, pulse pressure,
contractility & C.O., SVR,
myocardial O2 demand
heart failure
high-output failure
coronary vasospasm,
anginal symptoms in pre-existing
coronary atherosclerosis
systolic HTN in thyrotoxicosis is due to
hyperdynamic circulation from contractility
hypothyroidism causes HTN due to SVR
--------------------------------------------------------------- thiazide A/E: hyperglycemia, LDL & TGs,
hyponatremia, hypokalemia, hypercalcemia,
uric acid retention (risk of acute gout)

arrest of labor in stage 1: 6 cm with ROM &

no cervical changes for 4 hr despite adequate,
OR no change 6 hr & inadequate contractions
o Rx: c-section
protracted labor: slower than expected progress
Stages of labor
0 6 cm dilated
6 10 cm dilated (complete)
10 cm dilated delivery
delivery placenta expulsion
--------------------------------------------------------------- bloody/purulent nasal discharge, oral ulcers,
sinusitis, dyspnea, hemoptysis, renal insufficiency,
microscopic hematuria, RBC casts: Wegeners
granulomatosis with polyangiitis
URI & lower respiratory infections & RPGN
CXR: nodular densities & alveolar/pleural opacities
Dx: c-ANCA & tissue Bx
Rx: high-dose corticosteroids & cyclophosphamide
--------------------------------------------------------------- unilateral, intermittent bloody nipple discharge:
intraductal papilloma
benign, no palpable masses (too small)
MC in perimenopausal
--------------------------------------------------------------- painful, rubbery, firm breast mass with cyclic
symptoms with menstruation: fibrocystic change
o premenopausal women
o Dx/Rx: aspiration shows clear fluid, mass
disappears, observe for 4 6 wks
o biopsy if the mass recurs
painless, firm, mobile, solitary breast lump in
women age 15 25: fibroadenoma
nipple discharge, breast mass, or incidental finding
on mammography: DCIS
o postmenopausal
eczematous nipple changes & discharge: Pagets
--------------------------------------------------------------- scleroderma renal crisis: acute onset renal failure
(w/o previous kidney disease) & malignant HTN
(headache, blurry vision, nausea)
microangiopathic hemolytic anemia with
schistocytes & thrombocytopenia

---------------------------------------------------------------Antiphospholipid antibody syndrome

clinical arterial/venous thrombosis (VTE, PE)
o 3 consecutive unexplained fetal loss
before 10th wk
o 1 unexplained fetal loss after 10th
o 1 premature birth of normal neonate
before 34th wk due to preeclampsia,
eclampsia or placental insufficiency
lupus anticoagulant
anti-cardiolipin antibody
anti-2-glycoprotein 1 antibody
1 clinical & 1 lab criterion
lupus anticoagulant: prolongs PTT in vitro
--------------------------------------------------------------- young female, decreased visual acuity in one eye,
pain on eye movement, change in color perception:
optic neuritis
afferent pupil defect & central scotoma
DDx: orbital cellulitis, anterior uveitis
--------------------------------------------------------------- anterior uveitis: unilateral eye is painful & red
blurred vision, perilimbal injection
keratic precipitates & corneal stromal edema
--------------------------------------------------------------- splenomegaly, pruritus with hot baths due to
histamine release: polycythemia vera
myeloproliferative disorders are common causes
of uric acid overproduction; purine catabolism
o gouty arthritis is a common manifestation
---------------------------------------------------------------Vasovagal syncope
inciting age < 60: emotional stress, orthostatic stress
(prolonged standing, venipuncture)
age > 60: micturition, cough, defecation
feature prodrome pallor, dizziness, nausea, sweating
short duration of syncope (minutes)
symptoms improve in supine position
mainly clinical
upright tilt table test if uncertain
self-limited; avoid triggers

Rx for a single episode of major depression:

continue for 6 months following patient response
multiple episodes Rx: maintenance therapy
occupational (shipyard, construction, mining, pipes)
latency period: > 20 yrs
progressive dyspnea (months), clubbing,
bibasilar end-expiratory crackles
(no cough, sputum, or wheezing)
risk for lung cancer & malignant mesothelioma
CXR: benign pleural plaques, interstitial fibrosis
DLCO, PFT: restrictive pattern
complication: cor pulmonale (RV heave)
---------------------------------------------------------------Enzyme deficiencies
21-hydroxylase (CAH)
cortisol & aldosterone
ambiguous genitalia (girls)
salt waste ( Na+, K+)
11- hydroxylase
cortisol & aldosterone
ambiguous genitalia (girls)
fluid & Na+ retention,
11-deoxycorticosterone HTN
(weak mineralocorticoid)
cortisol & testosterone
all phenotypic female
fluid & Na+ retention,
hypogonadism @ puberty
(weak glucocorticoid)

classic CAH Dx: 17-OH-progesterone

partial deficiency of 21-hydroxylase present in
childhood: non-classic CAH
o precocious puberty, hirsutism/virilism,
medication-resistant acne, accelerated growth
o Dx: cosyntropin stimulation test (gold std)
licorice is known to inhibit 11- hydroxylase;
chronic consumption can result in
--------------------------------------------------------------- post-operative pneumonia deteriorating into
septic shock with lactic acidosis 2/2 tissue hypoxia
Rx: IV normal saline, ABX

external validity: how generalizable are results

to other populations?
internal validity: are results in this specific
cohort valid? (design, method, analysis)
---------------------------------------------------------------Vaccines for adults with HIV
chronic liver disease (HBV, HCV)
men/men sex, IVDA
all unimmunized to HBV
all age 9 26
all annually (IM inactivated)
all age 11 18
meningococcu large groups in close quarters,
asplenia or complement deficiency
pneumococcus PCV13 once, then
PPSV23, 8 wks later & every 5 yrs
Td, Tdap
Tdap once, then Td every 10 yrs
Tdap for each pregnancy

live vaccines (MMR, varicella, intranasal influenza,

zoster) are C/I for CD4 < 200
MMR should be given if CD4 > 200 & no evidence
of immunity
o HIV+ are at increased risk for measles
--------------------------------------------------------------- vaccinate 14 days before or after splenectomy
Vaccines for asplenic adults
pneumococcus sequential PCV13, then PPSV23;
PPSV23 again in 5 yrs & age 65
H. influenza
1x Hib vaccine
meningococcu quadrivalent vaccine every 5 yrs
IM inactivated vaccine annually
HAV, HBC, Tdap 1x, Td every 10 yr
S. pneumo is MCC of sepsis post-splenectomy
--------------------------------------------------------------- late-term pregnancies (41 42 wks) risk for
uteroplacental insufficiency
antenatal fetal surveillance begin @ 41 wks: BPP
diffuse placental calcifications on USS are
common in late-term; indicates a mature placenta
--------------------------------------------------------------- D-dimer: product of cross-linked fibrin degradation

monosymptomatic (isolated) enuresis: urinary

incontinence > 2x/wk in age 5 yrs
workup: U/A; imaging for +daytime symptoms
or recurrent UTIs
#1 Rx: behavior modification, enuresis alarm
#2 Rx: (short-term) desmopressin; alt Rx: TCAs
--------------------------------------------------------------- acute onset severe liver injury with encephalopathy
& INR > 1.5, without cirrhosis or underlying liver
disease: fulminant hepatitis
acute liver failure: MCC are acute viral hepatitis,
acetaminophen toxicity, ischemic hepatopathy
(shock liver), Wilsons
o concurrent alcohol use increases propensity
of hepatotoxicity from acetaminophen
RUQ pain, pruritus, jaundice, encephalopathy
acute AST & ALT (1000s), PTT, bilirubin
decreasing aminotransferases & worsening PT/INR,
indicates progressive liver failure
PT is the most important prognostic indicator
---------------------------------------------------------------Intrapartum fetal HR monitoring
fetal head compression
can be normal
uteroplacental insufficiency
cord compression, cord prolapse,

intermittent variable decelerations (< 50%) are

well tolerated by the fetus; does not require a
change in management
recurrent variable decelerations (> 50%) are
concerning for fetal academia; prompt intervention
o #1 Rx: O2 & change maternal position
o discontinue uterotonic drugs
o #2 Rx: artificial ROM & amnioinfusion
o #3 Rx: c-section
--------------------------------------------------------------- terbutaline: 2-agonist tocolytic
Rx tachysystole (> 5 contractions in 10 min)
MCC: cocaine overdose, tonic-clonic seizures
rhabdomyolysis releases K+, CPK, & myoglobin

CPK is a/w acute tubular necrosis due to

U/A: +blood, but no RBCs on microscopy
Rx: hydration, mannitol, urine alkalinization
o avoid -blockers: unopposed activation
worsens HTN & causes coronary vasospasm
--------------------------------------------------------------- aseptic meningitis MCC: Coxsackie or Echovirus
---------------------------------------------------------------Management of acute STEMI
o supplemental O2 (if O2 Sat < 90%)
o chewed ASA
o clopidogrel
o sublingual nitrate (not for RV infarct,
hypotensive, severe aortic stenosis)
o metoprolol (not for hypotensive, bradycardia,
decompensated CHF, heart block)
o high-dose statin
o LMWH or unfractionated heparin
persistent pain, HTN, or heart failure: IV nitro
(not for hypotension, RV infarct, severe AS)
persistent severe pain: IV morphine
(anxiolytic & preload reduction)
unstable sinus bradycardia: IV atropine
acute pulmonary edema: IV furosemide
(not for hypotensive or hypovolemic)
reperfusion: PCI within 90 min; thrombolysis if
PCI not available within 120 min
---------------------------------------------------------------Guidelines for primary PCI of acute STEMI
within 12 hr of symptom onset, AND
within 90 min of first medical contact to device
time at PCI-capable facility, OR
o within 120 min at non-PCI-capable facility
--------------------------------------------------------------- fibrinolytics is a/w recurrent MI, ICH, mortality
compared to PCI
--------------------------------------------------------------- headaches worse at night, N/V, LOC, cognitive
dysFx, vision changes, worse with maneuvers that
ICP (leaning forward, Valsalva, coughing):
intracranial HTN
Cushing reflex: HTN, bradycardia, resp depressn;
suggests brainstem compression

DDx: sinusitis (purulent nasal discharge), acute

angle closure glaucoma, temporal arteritis
--------------------------------------------------------------- oliguria, azotemia & BUN/Cr > 20:1 in post-op:
acute prerenal failure from hypovolemia
#1: rule out urinary catheter obstruction
Dx: IV fluid challenge
--------------------------------------------------------------- low-dose dopamine infusion can dilate renal
arterioles GFR & urine output (temporary)
---------------------------------------------------------------Chronic Hep C strongly a/w
porphyria cutanea tarda (photosensitivity,
vesicles/erosions on dorsum hand)
essential mixed cryoglobulinemia (circulating
immune complexes deposit in small/med vessels)
o IgM complexes with anti-hepatitis C IgG
o vasculitis of skin, kidney, nerves, joints
membranoproliferative GN
---------------------------------------------------------------Chronic Hep C features
fatigue, arthralgia, Raynauds
low complement
intermittent elevations of AST/ALT, RF
Dx: viral hepatitis serology
confirm Dx: kidney/skin Bx
Rx: plasmapheresis (cryoglobulins),
glucocorticoids & cyclophosphamide
complications: cirrhosis & HCC
---------------------------------------------------------------MCC of nephrotic syndrome
focal segmental
African-Am & Hispanics,
obesity, HIV, heroin use
adenocarcinoma (breast,
lung), NSAIDs, Hep B, SLE
Hep B & C
e glomerulonephritis
minimal change
adults: NSAIDs, lymphoma
IgA nephropathy
upper URI

secondary: diabetes & primary amyloidosis (MM)

---------------------------------------------------------------MCC of nephritic syndrome
IgA nephropathy

rapidly progressive GN
thin BM disease
lupus nephritis (low complement)
post-streptococcal GN (low complement)
membranoproliferative GN (low complement)
mixed cryoglobulinemia (low complement)
--------------------------------------------------------------- atypical presentations of ACS: N/V, dyspnea,
epigastric pain; MC in women, elderly, diabetics
initial evaluation: EKG
DDx: acute cholecystitis, pancreatitis, PUD
--------------------------------------------------------------- hilar mass, mediastinal adenopathy, cough,
dyspnea, weight loss: small cell lung cancer
Paraneoplastic syndromes a/w lung cancer
PTHrP (hypercalcemia)
ACTH (Cushings)**
hematologic hypercoagulability (Trousseaus)
ataxia, autonomic/sensory neuropathy
hypertrophic osteoarthropathy
(a/w adenocarcinoma)
dermatomyositis & polymyositis
**a/w small cell lung cancer
Trousseau's: spontaneous recurrent or migratory
venous thromboses, arterial emboli caused by
non-bacterial thrombotic endocarditis
--------------------------------------------------------------- shoulder pain & weakness with arm lifting:
rotator cuff pathology (tendonitis or tear)
limited mid-arc abduction & external rotation
Dx: lidocaine injection
o improvement = tendonitis/impingement
o no improvement = tear
Dx rotator cuff tear: drop arm test, shoulder MRI
o MCC: fall on outstretched hands
--------------------------------------------------------------- nephrosclerosis 2/2 HTN
atherosclerotic lesions of afferent & efferent
arterioles & glomerular capillary tufts
nephrosclerosis glomerulosclerosis

nephrosclerosis = hypertrophy & intimal

medial fibrosis of renal arterioles
o glomerulosclerosis = progressive loss of
glomerular capillary surface area with
glomerular & peritubular fibrosis
--------------------------------------------------------------- diabetic nephropathy: #1 cause of ESRD
1st year: GFR, glomerular hyerperfusion, renal
extracellular matrix, BM thickening, mesangial
expansion, & fibrosis
5 10 yrs: microalbuminuria, overt nephropathy
--------------------------------------------------------------- hypoparathyroidism (PTH deficiency): hypoCa++,
hyperphosphatemia, normal renal function
hypoCa++: perioral tingling/numbness, tetany,
cramps, carpopedal spasm, seizures
causes: post-surgical, autoimmune, DiGeorge,
defective Ca++-sensing receptors, irradiation
--------------------------------------------------------------- phenytoin, carbamazepine, rifampin can cause
Vit D deficiency by inducing p450
resulting in secondary hyperparathyroidism:
hypoCa++, hypophosphatemia
--------------------------------------------------------------- CKD impairs 1--hydroxylase, which converts
25-OH Vit D to 1,25-OH Vit D Vit D deficiency
resulting in secondary hyperparathyroidism:
hypoCa++, hyperphosphatemia
--------------------------------------------------------------- inadequate Ca++ intake 20 hyperparathyroidism
bone resorption Ca++
25-OH Vit D to 1,25-OH Vit D, which
stimulates gut Ca++ absorption
renal phosphate loss hypophosphatemia
--------------------------------------------------------------- weight loss, anorexia, constipation, easy fatigue,
dry mucous membranes, confusion, polyuria
hypercalcemia induces urinary Na+ wasting,
resulting in volume depletion, further impairing
renal clearance of Ca++

Management of hypercalcemia
short-term: aggressive hydration;
(Ca++ > 14)
normal saline & calcitonin

or symptomatic

bisphosphonate (zoledronate)
no immediate Rx unless
(12 14)
symptomatic (same as above)
mild (< 12) or
no immediate Rx
avoid thiazides, lithium, volume
depletion & prolonged bed rest
saline hydration restores intravascular volume &
promotes urinary Ca++ excretion
loop diuretics only if volume overloaded
o avoid diuretics if volume-depleted
--------------------------------------------------------------- hyperthyroidism-related tachysystolic a-fib
Rx: propranolol
--------------------------------------------------------------- atypical community-acquired pneumonia with
CNS & GI features: Legionnaires
fever with relative bradycardia
intracellular G-negative rod
CXR: unilateral patchy infiltrates
Dx: urine antigen testing & culture
Rx: fluoroquinolone or macrolide
Suspicion of Legionella pneumonia
exposure recent travel within previous 2 wks
(cruise ships, hotel)
nosocomial (hospital, nursing home)
fever > 39 (102.20 F) with bradycardia,
confusion (CNS), watery diarrhea (GI),
unilateral lung diffuse crackles
hyponatremia, mild hepatitis,
hematuria, proteinuria
CXR: unilateral interstitial infiltrates
Gram stain: neutrophils, no organisms
urine antigen testing & culture
Legionella stains poorly; intracellular
DDx: influenza, mycoplasma, PCP, TB
--------------------------------------------------------------- amoxicillin/clavulanate: Rx sinusitis, otitis media
ceftriaxone: Rx pneumococcus, H. influenza
clindamycin: Rx aspiration pneumonia
vancomycin: Rx nosocomial pneumonia (MRSA)
--------------------------------------------------------------- PPV & NPV depend of prevalence of a disease

shifting the cutoff point to the left: & FP will

decrease PPV (PPV = TP/ (TP + FP))
--------------------------------------------------------------- selective survival bias occurs in case-control
studies; cases are selected from the entire disease
population instead of newly diagnosed (cancer)
--------------------------------------------------------------- strongest predictor of AAA expansion & rupture:
active smoking
other risks: large diameter & rate of expansion
o HTN has a weak association
indications for AAA repair
o > 5.5 cm
o expansion rate > 1 cm/yr
o symptomatic (regardless of size)
--------------------------------------------------------------- MC complication of AAA repair: bowel ischemia
due to inadequate colonic collateral perfusion to
left colon & sigmoid 2/2 loss of IMA perfusion
presents with abdominal pain & bloody diarrhea
Rx: check sigmoid perfusion after graft placement
--------------------------------------------------------------- morphine contributes to post-op ileus by
decreasing GI motility
o post-op ileus: hypoactive/absent bowel sounds
mechanical obstruction: hyperactive BS
--------------------------------------------------------------- child with meningeal signs & erythematous
petechial/purpuric rash: N. meningitides
(meningococcal meningitis)
rash appears within 24 hr of infection
--------------------------------------------------------------- HSV causes temporal lobe encephalitis in
neonates & infants; presents with seizures
--------------------------------------------------------------- causes of anatomic defects in the uterus or
fallopian tubes: Hx of PID, in utero DES,
endometriosis, congenital malformations
Dx: hysterosalpingogram
--------------------------------------------------------------- elevated serum prolactin suppresses ovulation by
inhibiting GnRH release amenorrhea
--------------------------------------------------------------- mid-luteal serum progesterone tests for ovulation
ovulation corpus luteum produces progesterone

--------------------------------------------------------------- excess androgens in PCOS suppress ovulation by

suppressing GnRH & FSH by feedback inhibition
--------------------------------------------------------------- inhibin B: use to determine ovulatory reserve;
with declining reserves
--------------------------------------------------------------- MCC of acute pancreatitis: alcohol, gallstones
others: hypertriglyceridemia, hypercalcemia,
recent ERCP, trauma, viral infection, medications
eruptive xanthomas Dx: fasting lipid profile
o triglycerides > 1000 causes pancreatitis
--------------------------------------------------------------- club foot Rx: stretching, manipulation, serial casts
surgery if conservative management fails
--------------------------------------------------------------- acute urticaria (< 6 wks)
well-circumscribed, raised erythematous plaques
with central pallor; intense pruritus
worsen over minutes hrs; resolve within 24 hr
mast cell activation in superficial dermis, which
histamine release pruritus & swelling
angioedema can occur in deep dermal & SC tissues
MCC: IgE mediated, direct mast cell activation,
NSAIDs, infection, idiopathic
--------------------------------------------------------------- atopic dermatitis (eczema): pruritic erythematous,
scaly patches on extensor surfaces
epidermal dysfunction of stratum corneum synthesis
MC in infancy; cheeks, scalp, extensor limbs
MC site (adults): flexural areas, face, wrist, forearm
o lichenified plaques on flexural creases
risk factors: low humidity, stress, overheating,
excessive bathing, irritants
complication: eczema herpeticum, cellulitis/abscess
--------------------------------------------------------------- eczema herpeticum: HSV superinfection in areas
of severe atopic dermatitis (eczema)
o numerous umbilicated vesicles over
erythematous skin
o a/w fever & adenopathy
o Rx: acyclovir
erysipelas: red, indurated, tense, shiny plaque
with raised, sharply demarcated margin

o a/w fever & chill

o MCC: Group A strep
--------------------------------------------------------------- contact dermatitis: direct skin exposure to irritant
erythematous papules & vesicles; indistinct margins
Type IV hypersensitivity
vesicular fluid can be 20 infected by Strep or Staph
--------------------------------------------------------------- chronic follicular occlusive disease on
intertriginous skin (axilla, groin) with painful
nodules & sinus tracts: suppurative hidradenitis
--------------------------------------------------------------- erythema multiforme: target lesions with
erythematous, iris-shaped macules
painful, pruritic, symmetrical on extensors,
including palm/soles
a/w HSV, coccidiomycosis, Mycoplasma
--------------------------------------------------------------- pityriasis rosea: self-limited, cutaneous reaction
following a viral etiology
papulosquamous rash of oval-shaped lesions whose
long axes are oriented along skin folds ('Christmas
tree' pattern); trunk & proximal extremities
initial lesion: pink to salmon-colored 'herald' patch
plaque with raised margin & collarette scale, with
eruption into scaly & ovoid papules & plaques on
the back or flexor surfaces
--------------------------------------------------------------- infant with failure to thrive, normal anion gap
acidosis, & alkalotic urine: renal tubular acidosis
o Type I RTA: poor K+ & H+ excretion
a/w nephrolithiasis
o Type II RTA: poor HCO3 resorption
a/w Fanconis
o Type IV RTA: aldosterone resistance
a/w CAH (hyperkalemic, hyperchloremic
metabolic acidosis)
labs: low serum HCO3 & hyperchloremia, leads
to normal anion gap metabolic acidosis
Rx: oral sodium bicarbonate
--------------------------------------------------------------- fluphenazine: typical antipsychotic, injection
A/E: hypothermia by inhibiting autonomic
Rx: avoid prolonged cold exposure

--------------------------------------------------------------- congenital syphilis: transplacental transmission

XR: metaphyseal dystrophy & periostitis
initially asymptomatic
early sign: cutaneous palm/sole lesions,
rhinorrhea, hepatosplenomegaly, jaundice, anemia
late findings (age > 2 yr): frontal bossing,
Hutchinson teeth, high arched palate, saddle nose,
interstitial keratitis, perioral fissures
--------------------------------------------------------------- scaphoid fx: MCC is fall on outstretched arm
proximal fragment vulnerable to avascular necrosis
XR can take up to 10 days to show abnormalities
Rx: thumb spica 6 10 wks, repeat XR in 1 wk
--------------------------------------------------------------- glucosuria, phosphaturia, aminoaciduria:
Fanconi syndrome
--------------------------------------------------------------- 2 day Hx of periorbital swelling, skin infection
3 wks ago (Rx: dicloxacillin), dark urine, HTN
U/A: RBC casts & mild proteinuria
labs: low C3
Dx: post-strep GN
--------------------------------------------------------------- hematuria 5 days after URI, normal C3: IgA
--------------------------------------------------------------- fever, rash, arthralgia; hematuria, sterile pyuria,
peripheral eosinophilia, medication use (NSAIDs,
sulfonamides, PCN, cephalosporins, diuretics):
acute interstitial nephritis
U/A: WBC casts, eosinophiluria, mild proteinuria
--------------------------------------------------------------- likely PE based on modified Wells criteria
o confirm Dx: CT angiography: filling defect
unlikely PE criteria evaluate with D-dimer
o D-dimer < 500 excludes PE
o D-dimer > 500 CT angiography
--------------------------------------------------------------- COPD: progressive in expiratory flow rate;
FEV1/FVC < 0.7
air trapping & airflow obstruction TLC,
vital capacity
destruction of alveolar-capillary membrane

COPD: chronic bronchitis +/- emphysema

long-term supplemental O2 prolongs survival
indications: PaO2 < 55, SaO2 < 88%, Hct > 55%,
or evidence of cor pulmonale or pulmonary HTN
survival benefits if used for 15 hrs/day
--------------------------------------------------------------- cellulitis MCC: -hemolytic strep & S. aureus
systemic signs: high fever, chills, malaise,
fatigue, confusion
Rx (+systemic signs): IV nafcillin or cefazolin
Rx (no systemic signs): oral dicloxacillin
chronic fungal foot infections (tinea pedis) can
be a nidus for recurrent bacterial cellulitis
o Rx: itraconazole, terbinafine
--------------------------------------------------------------- acyclovir nephrotoxicity: acyclovir accumulation
in collecting ducts exceed solubility crystalluria
MC with high-dose IV acyclovir
Rx: adequate hydration & dosage adjustment
--------------------------------------------------------------- hypothyroidism can cause
o hyperlipidemia & hypercholesterolemia
o hyponatremia ( free water clearance)
o asymptomatic creatinine kinase, ALT/AST
--------------------------------------------------------------- hypothyroidism & adrenal insufficiency must be
ruled out before Dx of SIADH
--------------------------------------------------------------- thyrotoxicosis can cause hypercalcemia due to
bone resorption
--------------------------------------------------------------- bulimia: binging at least 2x/wk, 3 months
o no amenorrhea
binge-eating disorder: no compensatory behavior
to prevent weight gain (purging)
---------------------------------------------------------------Interstitial cystitis (painful bladder syndrome)
women, a/w psychiatric disorders
(anxiety) & fibromyalgia
pain with filling, relief with voiding
chronic pelvic pain
frequency, urgency, dyspareunia
bladder pain, no other cause 6 wks
normal U/A


not curative; focus on quality of life,

behavior modification, avoid triggers,
analgesics for exacerbations
DDx: cystocele, PID, stress incontinence, UTI
---------------------------------------------------------------Acetaminophen intoxication
first 24 hrs, can be asymptomatic
single dose 7.5 g & 4 hr since ingestion
o Rx: activated charcoal & check serum levels
nomogram showing hepatotoxic levels
o Rx: N-acetylcysteine
o non-toxic levels repeat levels in 2 hr
--------------------------------------------------------------- cough with blood-tinged sputum: TB
highest risk: emigration from endemic area
--------------------------------------------------------------- ARPKD: infant with large flank mass, respiratory
distress from pulmonary hypoplasia, Potter facies
ADPKD: asymptomatic in childhood
---------------------------------------------------------------Management of severe hematochezia (lower GI bleed)
initial evaluation: NGT aspiration
o +blood, +/- bile upper endoscopy
o no blood, +bile colonoscopy
if bleed continues Technitium-99 labeled RBC
scintigraphy is less invasive, more sensitive than
o if RBC scan identifies bleed, follow up with
angiography or repeat colonoscopy
capsule endoscopy: Dx chronic GI bleed with
negative upper & lower endoscopy
--------------------------------------------------------------- vesicoureteral reflux Dx: voiding cystourethrogram
screen for hydronephrosis: renal USS
long-term eval for scarring: renal scintigraphy
evaluate renal function: serial Cr
--------------------------------------------------------------- Hep C is a risk factor for cirrhosis, HCC,
cryoglobulinemia, membranoproliferative GN
--------------------------------------------------------------- Burr cells (echinocytes): speculated, serrated RBCs
o MC in liver disease & ESRD
Spur cells (acanthocytes): irregular RBC projections

o MC in liver disease
Howell-Jolly: basophilic remnants of nuclei
o Hx of splenectomy or functional asplenia
Target cells: bulls eye RBC
o thalassemia, chronic liver disease, alcoholics
--------------------------------------------------------------- medication-induced torticollis: metoclopramide,
typical antipsychotics, prochlorperazine
--------------------------------------------------------------- MCC of acquired torticollis: URI, minor trauma,
cervical lymphadenitis, retropharyngeal abscess
Dx: XR to r/o cervical fx or dislocation
--------------------------------------------------------------- erectile dysfunction in diabetics can be due to
autonomic neuropathy, medications, circulation,
or hypogonadotropic hypogonadism
o gynecomastia, testicular atrophy
Dx: early-morning total testosterone; all diabetics
Dx: serum prolactin
excess prolactin suppresses GnRH
Rx: sildenafil (diabetics, normal testosterone)
--------------------------------------------------------------- acquired hypogonadotropic hypogonadism 2/2
hypothalamic dysfunction
insufficient GnRH pulses, LH & FSH only
amenorrhea, irregular menses
MCC: significant stressor, eating disorder,
excessive exercise
#1 Rx: reduce stress & exercise intensity
#2 Rx: pulsatile GnRH
--------------------------------------------------------------- respiratory distress, tachycardia, tachypnea, fever,
upper petechial rash, sub-conjunctival hemorrhage,
multiple long bone fx,: fat embolism
12 72 post-injury
CNS: confusion, agitation stupor, coma
Dx: fat droplets in urine or intra-arterial fat globules
on fundoscopy
Rx: respiratory support
--------------------------------------------------------------- chronic non-healing wound (burns) with scarred
or inflamed skin: squamous cell ca
SCC arising within burn wounds: Marjolin ulcer
Dx: Bx to r/o malignancy

DDx: malignant melanoma, dysplastic nevi,

BCC, actinic keratosis
--------------------------------------------------------------- Hx of recurrent unexplained DVTs
Dx: factor V Leiden mutation is resistant to
protein C inactivation
--------------------------------------------------------------- increased dead space ventilation in COPD
worsens respiratory acidosis
chronic hypercapnic respiratory failure in COPD
maintains a normal pH due to renal compensation
( HCO3 retention)
--------------------------------------------------------------- MCC euvolemic hypernatremia: diabetes insipidus
dilute urine, elevated serum osmolality
--------------------------------------------------------------- isolated systolic HTN: elasticity
increases CV risk in elderly
Rx: monotherapy with low-dose thiazide, ACE-I,
or long-acting CCB
--------------------------------------------------------------- circulating BNP correlates with severity of LV
filling pressure & mortality; a/w S3
--------------------------------------------------------------- +Anti-HBs, +Anti-HBc, -HBsAg: resolved HBV
+Anti-HBs only: HBV vaccinated
+IgM anti-HBc: window phase
HBsAg: first marker; precedes symptoms
HBcAg: not detectable
+HBsAg, +IgG anti-HBc > 6 months: chronic HBV
--------------------------------------------------------------- B/L proptosis & impaired extraocular motion
(decreased convergence, diplopia), exophthalmos:
Graves ophthalmopathy
also gritty/sandy sensation, photophobia, tearing
infiltrative ophthalmopathy from accumulation of
glycosaminoglycans in retro-orbital muscles, leads
to proptosis (specific to Graves)
risk factors: females, advanced age, smoking
anti-thyrotropin receptor auto-antibodies directly
cause retro-orbital tissue expansion
--------------------------------------------------------------- bacterial meningitis Rx: IV ceftriaxone & vanco
CSF: WBC (neutrophil predominance), low
glucose, elevated protein

--------------------------------------------------------------- MCC of atrial flutter: reentrant circuit around

tricuspid annulus, slows the impulse through the
cavotricuspid isthmus
MC location of ectopic foci causing a-fib:
pulmonary veins (myocardial sleeve)
AVNRT: reentrant circuit by 2 separate pathways
within the AV node
AVRT: reentry circuit via accessory bypass tract
--------------------------------------------------------------- lung cancer & malignant melanoma can present
with multiple brain metastases
MC site of brain metastases: lung cancer
Dx: chest CT
--------------------------------------------------------------- mitral regurgitation: murmur with squatting
MVP: murmur intensity with squatting
--------------------------------------------------------------- preoccupation with a slight or imagined defect,
significant impairment: body dysmorphic disorder
related to OCD, with repeated thoughts &
compulsive behavior to hide or treat the defect
Rx: therapeutic alliance, psychotherapy, SSRI
--------------------------------------------------------------- COPD patient with catastrophic worsening of
respiratory symptoms: spontaneous pneumoTx
risk factor: smoking leads to chronic destruction
of alveolar sacs, forming large alveolar blebs
which eventually rupture & leak into pleural space
---------------------------------------------------------------Evaluation of bilious emesis
#1 Rx: stop feeds, IV fluids, NG tube
#2 Rx: abdominal XR
if pneumoperitonium, hematemesis, unstable vitals
if dilated loops of bowel contrast enema
o microcolon meconium ileus a/w CF
o rectosigmoid transition zone Hirschsprung
if NG tube misplaced upper GI contrast series
(barium) shows Ligament of Treitz on right side &
corkscrew pattern malrotation/volvulus
o Rx: Ladd procedure (fixed bowel)
if double bubble sign duodenal atresia

congenital aganglionic megacolon (Hirschsprung)

may be a/w Downs
delayed passage of meconium > 48 hr
XR: dilated loops of small & large bowel
Dx: rectal biopsy show absence of ganglion cells
--------------------------------------------------------------- diffuse bronchial obstruction & purulent sputum:
acute exacerbation of COPD
o diffuse rhonchi & wheezing, PaCO2
Dx: spirometry FEV1/FRC < 0.70
--------------------------------------------------------------- dullness to percussion, decreased breath sounds,
B/L coarse crackles: CHF
o due to transudative pleural effusion
--------------------------------------------------------------- immobility is MCC of decubitus ulcers
MC over bony prominences; ischemic necrosis
--------------------------------------------------------------- lesions on skin & viscera, abdo pain, fever,
malaise, weight loss: bacillary angiomatosis
o large, pedunculated exophytic papules
CT: nodular, contrast-enhanced intrahepatic lesions
Dx: tissue biopsy; prone to hemorrhage
--------------------------------------------------------------- pleuritic chest pain, dyspnea, tachypnea,
tachycardia, hypoxemia after immobilization
Approach to suspected PE
stabilize with O2 & IV fluids
contraindications to anticoagulation? IVC filter
assess with Modified Wells (pretest probability)
PE likely IV heparin, then order diagnostics
o PE unlikely CT angiogram (or V/Q scan)
+PE anticoagulate
-PE stop anticoagulation
early empiric anticoagulation should be initiated
prior to pursuing confirmatory diagnostics in
patients with likely PE
anticoagulation prevents further clotting, but does
not lyse existing clots
--------------------------------------------------------------- MCC of isolated aortic stenosis in elderly:
age-dependent idiopathic sclerocalcific changes

MCC of isolated aortic regurgitation in young adults

in developed countries: bicuspid aortic valve
MCC of aortic regurgitation in developing country:
rheumatic heart disease
--------------------------------------------------------------- GVHD is common after bone marrow transplant
due to activation of donor T lymphocytes
maculopapular rash on palms & soles, face
occult-positive diarrhea, abnormal LFTs, jaundice
pulmonary: bronchiolitis obliterans
--------------------------------------------------------------- activation of host T lymphocytes mediates graft
rejection, resulting in depression of myelopoiesis
severe neutropenia for several days risk of
--------------------------------------------------------------- Reye syndrome: children age < 15 yrs
vomiting & agitation, progressing to lethargy,
stupor, restlessness
hyperammonemia, hypoglycemia, prolonged PT,
bilirubin, ALP, AST/ALT, & LDH
liver Bx: microvesicular steatosis
Rx: supportive
--------------------------------------------------------------- troponin T is most sensitive & specific for MI,
but slow to return to normal (10 days)
CK-MB normalizes within 1 2 days; reinfarction
---------------------------------------------------------------C. difficile colitis
risk factors
recent ABX, advanced age, PPIs
pathogenesis Enterotoxin A: watery diarrhea
Cytotoxin B: colonic epithelial cell
necrosis & fibrin deposition
presentation fever, watery diarrhea, leukocytosis
fulminant colitis with toxic megacolon,
white/yellow pseudomembranes
stool toxin via PCR
metronidazole or oral vancomycin
---------------------------------------------------------------Causes of normal anion gap metabolic acidosis
diarrhea, laxative abuse
fistulas (pancreatic, ileocutaneous)
carbonic anhydrase inhibitors
renal tubular acidosis (RTA)

ureteral diversion
--------------------------------------------------------------- non-anion gap metabolic acidosis & hyperkalemia
with mild renal dysfunction: renal tubular acidosis
aldosterone resistance retention of H+ & K+
MC in poorly controlled diabetes
--------------------------------------------------------------- diarrhea/laxatives cause hypokalemia due to K+ loss
in stool & aldosterone from volume depletion
--------------------------------------------------------------- Aldosterone Saves Sodium & Pushes
--------------------------------------------------------------- renal artery stenosis 20 hyperaldosteronism due
to low kidney perfusion
o hypokalemia, metabolic alkalosis, HTN
--------------------------------------------------------------- GERD can be the primary trigger of asthma
all patients with asthma-like symptoms should be
inquired about reflux symptoms
Dx & Rx: oral PPI
--------------------------------------------------------------- most effective non-pharmacologic measure to
decrease BP: weight loss
also DASH diet, low Na+, moderate alcohol
--------------------------------------------------------------- supracondylar humerus fx: outstretched hand fall
MC complication: entrapment of brachial artery
or median nerve
--------------------------------------------------------------- proximal humerus fx: axillary nerve injury
--------------------------------------------------------------- fibrates decrease triglycerides & increase HDL
no improvement in CV outcome or mortality
--------------------------------------------------------------- surreptitious vomiting causes hypokalemic,
hypochloremic metabolic alkalosis
o hypokalemia due to aldosterone caused
by volume depletion
--------------------------------------------------------------- newborns of mothers with active HBV should be
passively immunized: HBV Ig & HBV vaccination
o HBV Ig provides temporary protection

somatostatin & octreotide act by reducing

splanchnic blood flow, inhibiting gastric acid
secretion, & gastric cytoprotective effects
Rx upper GI bleed when endoscopy is
unsuccessful, C/I, or unavailable; or adjunct
--------------------------------------------------------------- asthma-like symptoms for several days, diffuse
wheezes, fine inspiratory crackles, peripheral
eosinophilia: eosinophilic pneumonia
--------------------------------------------------------------- iatrogenic esophageal rupture (recent endoscopy)
#1 Dx: CXR may show left-sided pleural effusion,
pneumomediastinum, & pneumoTx
confirm Dx: water-soluble contrast esophagram
Rx: surgical closure of esophagus & drainage of
mediastinum within 6 hrs
complications: mediastinitis
--------------------------------------------------------------- bullous pemphigoid: autoimmune blistering,
triggered by medications (furosemide, NSAIDs,
captopril); MC in elderly
pruritus, tense bullae & urticarial plaques with an
erythematous or urticarial base
IgG & C3 linear deposits @ dermal-epidermal Jx
--------------------------------------------------------------- pemphigus: autoantibodies against desmogleins
superficial, flaccid blisters; +Nikolsky sign
MC on skin & oral mucous membranes
IgG deposits between epidermal cells
antibodies against desmoglein
Rx: prednisone, MTX; azathioprine
--------------------------------------------------------------- selegiline: MAO-B inhibitor
if taken with SSRI or TCA serotonin syndrome
agitation, confusion, tachycardia, muscle rigidity
--------------------------------------------------------------- FRC prevents post-op atelectasis
atelectasis is a common complication 24 hr post-op;
reduces vital capacity & FRC
moving from supine to sitting increases FRC
o also chest physiotherapy, incentive spirometry,
coughing, repositioning, & ambulation
opioid analgesics suppress respiratory drive

congenital long QT syndrome increases risk for

syncope, TdP, & sudden death
Rx: refrain from vigorous exercise, avoid meds
that prolong QT, monitor electrolytes
Rx: propranolol
symptomatics Rx: propranolol & pacemaker
C/I: sotalol (class III) prolongs QT
--------------------------------------------------------------- electrolyte imbalances causing prolonged QT:
hypoCa++, hypoK+, hypoMg++
--------------------------------------------------------------- greatest risk factor for cerebral palsy: prematurity
o comorbidities: intellectual disability,
epilepsy, strabismus, scoliosis
--------------------------------------------------------------- GAD: 3 symptoms, at least 6 months
o impaired sleep, poor concentration, irritability,
easy fatigue, muscle tension, restlessness
#2 Rx: benzos, buspirone
o benzos: adjunct for acute anxiety
o buspirone: monotherapy or with SSRIs
--------------------------------------------------------------- systemic vasculitis, upper & lower airway
granulomatous inflammation, glomerulonephritis:
Wegeners (granulomatosis with polyangiitis)
epistaxis, chronic purulent rhinorrhea, otitis,
sinusitis, saddle nose deformity
painful subcutaneous nodules, palpable purpura,
ulcerative lesions
labs: +c-ANCA, CRP
U/A: RBC casts, proteinuria, sterile pyuria
Rx: cyclophosphamide & corticosteroids
---------------------------------------------------------------Osteoporosis risk factors
excess alcohol causes a dose-dependent risk
modifiable: low estrogen, malnutrition, low Ca++,
low Vit D, glucocorticoid or anticonvulsant use,
immobility, smoking, excess alcohol, low BMI
non-modifiable: advanced age, small body size,
female, late menarche or early menopause,
Caucasians & Asians, family Hx

child with chronic back pain, neurologic dysFx

(urinary incontinence), & palpable step-offs in
lumbosacral area: spondylolisthesis
forward slippage of vertebrae (L5 over S1)
DDx: lumbosacral strain, herniated disk,
ankylosing spondylitis, epidural abscess, tumor
--------------------------------------------------------------- daily alcohol intake ( 3 men, 2 women) can
raise BP, causing refractory HTN
--------------------------------------------------------------- exogenous testosterone use: gynecomastia,
erythrocytosis, hepatotoxicity, LDL, HDL
DDx: autologous blood transfusion & EPO do
not cause gynecomastia
--------------------------------------------------------------- diarrhea in HIV+ patients requires stool culture,
exam for ova & parasites, & test for C. difficile
for Dx prior to ABX
--------------------------------------------------------------- follicular conjunctivitis, corneal neovascularization
with concurrent nasopharynx infection & discharge
trachoma: major cause of blindness worldwide
Chlamydia trachomatis serotypes A C
Dx: Giemsa stain of conjunctival scrapings
Rx: topical tetracycline or oral azithromycin
complication: corneal scarring
--------------------------------------------------------------- eye pain, photophobia, decreased vision,
dendritic ulcer: herpes simplex keratitis
abrupt fever, proptosis, swollen eyelids,
restricted EOM movements: orbital cellulitis
--------------------------------------------------------------- female athletes have GnRH & LH, resulting in
estrogen deficiency
o secondary amenorrhea, infertility,
osteopenia, vaginal & breast atrophy
---------------------------------------------------------------Treatment of acne vulgaris
closed/open comedones on face;
minimal inflammation
Rx: topical retinoid; or add
salicylic, azelaic, or glycolic acid
inflammatory inflamed papules (< 5 mm),
pustules, erythema

(cystic) acne

mild Rx: topical retinoid + benzoyl

moderate Rx: add topical ABX
(erythromycin, clindamycin)
severe Rx: add oral ABX
large (> 5 cm) nodules, may form
sinus tracts & scarring
severe Rx: add oral ABX
unresponsive: oral Isotretinoin
(diminishes sebum excretion)

benzoyl peroxide: Rx inflammatory features

isotretinoin A/E: teratogenic, hyper-TG-emia
--------------------------------------------------------------- diabetic retinopathy: microaneurysms,
exudates, hemorrhages, macular edema
non-proliferative: cotton-wool spots
proliferative: neovascularization
Rx: laser photocoagulation
--------------------------------------------------------------- sudden, unilateral visual impairment noted upon
waking, disc swelling, venous dilation &
tortuosity, retinal hemorrhages, cotton-wool spots:
central retinal vein occlusion
--------------------------------------------------------------- smoking increases risk of macular degeneration
primary risk factor: age
grid test: straight lines appear wavy
atrophic form: multiple sores in macular region
exudative form: new blood vessels may leak,
bleed, & scar the retina
--------------------------------------------------------------- myasthenia gravis: normal reflexes, sensory, &
symptoms seen on exertion, resolves with rest
nasal speech, difficulty chewing or swallowing
--------------------------------------------------------------- vegans are at risk for low Vit D & bone loss
---------------------------------------------------------------Vaginal cancer
Squamous cell
Clear cell
age > 60
age < 20
HPV 16 or 18,
in utero exposure
cervical dysplasia Hx, to DES


upper 1/3 wall of
upper 1/3 wall of
posterior vagina
anterior vaginal
malodorous vaginal discharge,
postmenopausal or post-coital bleeding,
irregular vaginal mass, plaque, or ulcer
lesion biopsy

risk factors for SCC are similar to cervical cancer:

smoking & HPV 16 or 18
--------------------------------------------------------------- neutrophilic crypttis is seen in UC & Crohns
bimodal age: 20s & 60s
--------------------------------------------------------------- fever, colicky abdo pain, chronic diarrhea with
bloody stool, weight loss: UC
crypt abscesses
--------------------------------------------------------------- dyspnea, orthopnea, LE edema, B/L crackles,
displaced apical impulse: decompensated CHF
due to LV systolic dysfunction
hyponatremia parallels disease severity &
independent predictor of adverse clinical outcomes
2/2 renin, NE, & ADH free water retention &
dilutional hyponatremia
Rx: fluid restriction, furosemide, & ACE-I
o furosemide enhances K+ excretion
--------------------------------------------------------------- anaphylaxis usually have prior exposure to the
offending substance from preformed IgE to
cause Type I hypersensitivity
Rx: IM epinephrine
o alpha-1 increases vasoconstriction
o beta-2 relax bronchial smooth muscles &
decrease vascular permeability
--------------------------------------------------------------- reversible cholinesterase inhibitors (donepezil,
rivastigmine, galantamine) slows cognitive decline
a/w Alzheimers
---------------------------------------------------------------Thyroid nodule evaluation
initial evaluation: TSH & USS
cancer risk factors: family Hx, childhood radiation
exposure, cervical lymphadenopathy

suspicious USS findings: hypoechoic,

microcalcifications, internal vascularity
abnormal USS & +risk factors require FNA
normal USS, no risk factors, nrml/ TSH FNA
low TSH iodine-123 scintigraphy
o uptake = hyperfunctional hot nodule = low
cancer risk Rx for hyperthyroidism
o uptake = hypofunctional cold nodule =
high cancer risk FNA
--------------------------------------------------------------- AV block in patients with infective endocarditis
is suspicious for perivalvular abscess extending
into adjacent cardiac conduction tissues
aortic valve endocarditis & IVDA is a/w risk of
periannular extension of endocarditis
--------------------------------------------------------------- mitral valve perforation is a complication of
mitral endocarditis
presents as acute CHF & mitral regurgitation
--------------------------------------------------------------- insoluble renal crystal deposition resulting in
acute renal failure: hyperuricemia, indinavir,
acyclovir, sulfonamides
---------------------------------------------------------------SPIKES for delivering bad news
Set up situation: privacy, include participants
Perception: open-ended questions to assess
patient perception of the situation
Invitation: ask how much info is wanted
Knowledge: give bad news in simple,
straightforward language
Empathy: use empathetic statements
Strategy: summarize & make a plan
--------------------------------------------------------------- secondary malignancy is common in patients with
Hx of Hodgkins treated with chemotherapy &
radiation within 20 yrs
MC secondary solid tumor: lung
o cough, hemoptysis, chest pain, dyspnea
also risk of subsequent acute leukemia & non-HL
--------------------------------------------------------------- aspergilloma: a/w pre-existing lung cavity 2/2
TB, sarcoidosis, bronchial cysts, & neoplasms
mobile, intra-cavitary mass with air crescent

diverticula: high intraluminal pressure causes

mucosa & muscularis mucosa to herniate
do not include all bowel layers: false diverticula
MC risk factor: chronic constipation
MC site: sigmoid; bleeds occur from right colon
--------------------------------------------------------------- discrete skin nodule containing normal epidermis,
produces keratin: epidermal inclusion cyst
dome-shaped, firm, freely mobile with a central
Rx: resolves spontaneously, but can recur
Rx: excision for cosmetic reasons
--------------------------------------------------------------- benign, painless subcutaneous mass with
overlying epidermis; soft/rubbery & irregular:
--------------------------------------------------------------- episodes of apnea precipitated by emotional trigger
in age 6 months 2 yrs: breath-holding spell
cyanotic-type: crying followed by breath-holding
in forced expiration, apnea, limpness, LOC
o brief episodes with rapid return to baseline
pallid-type: triggered by minor trauma followed
by LOC, breath-holding, pallor, diaphoresis
o brief episode, then confusion & sleepiness
a/w iron deficiency anemia
Dx: CBC, serum ferritin
Rx: reassurance; no long-term sequelae
---------------------------------------------------------------HBV Treatments
interferon-alpha: short-term Rx; young patients
with compensated liver disease
lamivudine: increasing drug resistance
entecavir: use in decompensated cirrhosis; lower
rate of drug resistance
tenofovir: most potent, limited drug resistance
--------------------------------------------------------------- pegylated interferon & ribavirin: Rx HCV
add teleprevir for chronic Hep C
--------------------------------------------------------------- male with dysuria, pyuria, urinary frequency &
urgency, mucopurulent urethral discharge:
chlamydial urethritis
negative Gram stain & culture: C. trachomatis
Dx: nucleic acid testing of first-catch urine

Rx: azithromycin or doxycycline

DDx: gonococcal urethritis (G-negative cocci),
acute bacterial cystitis
--------------------------------------------------------------- erythematous & edematous cutaneous plaque with
peau d orange overlying breast mass with
spontaneous discharge & axillary lymphadenopathy:
inflammatory breast carcinoma
Dx: biopsy for histology
--------------------------------------------------------------- child with macrocytic anemia, low reticulocyte count,
& congenital abnormalities: Diamond-Blackfan
syndrome (congenital hypoplastic anemia)
o intrinsic defect of erythroid progenitor cells
result in increased apoptosis
macrocytic: no hypersegmentation of nucleus
congenital abnormalities: short stature, webbed
neck, cleft lip, shield chest, triphalangeal thumb
Rx: corticosteroids
--------------------------------------------------------------- caf-au-lait spots, microcephaly, microphthalmia,
short stature, horseshoe kidney, absent thumbs,
progressive pancytopenia & macrocytosis in a
child: Fanconis anemia
--------------------------------------------------------------- cancer-related anorexia/cachexia syndrome:
hypercatabolic state a/w accelerated loss of skeletal
& adipose tissue
Rx: progesterone analogs (megestrol acetate,
medroxyprogestone acetate)
o appetite, weight gain, & well-being
o alt Rx: mirtazapine (TCA)
--------------------------------------------------------------- seizures, mental retardation, port wine stain or
nevus inflammeus along trigeminal nerve:
hemianopia, hemiparesis, hemisensory loss,
ipsilateral glaucoma
skull XR: tramline intracranial calcifications
DDx: tuberous sclerosis (adenoma sebaceum)
---------------------------------------------------------------Indications for urgent dialysis (AEIOU)
metabolic acidosis (pH < 7.1)
symptomatic hyper-K+,
severe hyper-K+ (> 6.5)


methanol, ethylene glycol,

salicylate, lithium,, carbamazepine
volume overload refractory to diuretics
symptomatic encephalopathy,
bleeding, pericarditis
--------------------------------------------------------------- functional hypothalamic amenorrhea:
suppression of hypothalamic-pituitary-ovarian axis
without a anatomic or metabolic cause
GnRH, LH/FSH, estrogen
causes: excess physical training, anorexia nervosa,
marijuana use, starvation, stress, depression,
chronic illness
risk of bone mineral density due to estrogen
progestin challenge: no withdrawal bleeding
---------------------------------------------------------------Risk factors for cholelithiasis
40, Fat, Fertile, Females
rapid weight loss, bariatric surgery
HRT, OCPs, pregos
--------------------------------------------------------------- monomorphous pink papules on face, arms, trunk,
in absence of comedones 2/2 prednisone use for
SLE: steroid-induced folliculitis
DDx: adolescent acne, androgen abuse, PCOS, SLE
--------------------------------------------------------------- wound site with abundant cloudy-gray discharge
& dusky, friable subcutaneous tissue, decreased
sensation at wound edges: necrotizing SSI
fever, hypotension, tachycardia
dishwasher drainage, crepitus
MC in diabetics, MCC is polymicrobial
Rx: early surgical exploration, IV ABX
--------------------------------------------------------------- invasive ductal carcinoma: determine Px & Rx
by overexpression of HER2 oncogene via FISH
or immunohistochemical staining
HER2/neu overexpression = worse prognosis
+HER2 Rx: trastuzumab & anthracycline
o trastuzumab + chemotherapy can lead to
obtain baseline echocardiogram
--------------------------------------------------------------- fixed upper-airway obstruction (laryngeal edema
2/2 food allergy) inspiratory & expiratory airflow

flattens the top & bottom of a flow-volume curve

Rx: epinephrine, systemic corticosteroids,
--------------------------------------------------------------- asthma causes airflow during effort-independent
phase of exhalation, causing the flow-volume loop
to have a scooped out exhalation pattern, smaller,
& shifted to the left (obstructive pattern)
flow-volume look remains normal in panic attacks
pneumoTx & pulmonary edema causes reduced
lung compliance; increased expiratory flow rates,
smaller, shifted to the right (restrictive pattern)

--------------------------------------------------------------- microangiopathic hemolytic anemia (DIC, HUS,

TTP) & artificial mechanical valves schistocytes:
serum haptoglobin, LDH, indirect bilirubin, &
urinary urobilinogen
+ or increased
--------------------------------------------------------------- white granular patch/plaque over the buccal mucosa
that cannot be scraped off, Hx of alcohol & tobacco:
oral leukoplakia

hyperplasia of squamous epithelium

reactive precancerous lesion for SCC
resolves with cessation of tobacco
development of induration or ulceration Bx
--------------------------------------------------------------- white plaques on oral mucosa, oropharynx, or
tongue with underlying erythema; can scrape off:
oral candidiasis
localized, shallow, painful oral ulcers on gray base:
aphthous stomatitis
multiple vesicular lesions with erythematous border
within oral cavity & perioral area: gingivostomatitis
persistent, nodular, erosive/ulcerative lesion with
surrounding erythema or induration: SCC
--------------------------------------------------------------- fever, painful enlargement of testes, & irritative
voiding symptoms (urinary frequency & urgency):
acute epididymitis
as STD: a/w urethritis, pain, urethral discharge
o MCC: chlamydia & gonococcus
as non-STD: elderly, a/w UTI
o MCC: E. coli
--------------------------------------------------------------- bright red, firm, friable, exophytic nodules in HIV:
bacillary angiomatosis (Bartonella)
Rx: oral erythromycin
--------------------------------------------------------------- weakness, fatigue, muscle cramps: hypokalemia
EKG: broad, flat T-waves, U-waves, ST depression,
& PVCs
MCC: HCTZ, diarrhea, anorexia, hyperaldosteronism
--------------------------------------------------------------- most accurate estimate of gestational age:
crown-rump length via 1st trimester USS
pregnancy dating by LMP assumes a normal
28-day cycle with fertilization on day 14
--------------------------------------------------------------- karyotyping of fetal tissue is not indicated after
one spontaneous abortion, but after recurrent
pregnancy loss, or loss in 2nd trimester
--------------------------------------------------------------- abdominal pain after traumatic injury with
vertebral fracture & retroperitoneal hemorrhage:
paralytic ileus

also 2/2 abdominal surgery

XR: air-fluid levels & distended gas-filled loops
in small & large intestines
Rx: bowel rest, supportive care
DDx: mesenteric ischemia, SBO
---------------------------------------------------------------Evaluation of chest pain
assess pre-test probability of CAD
low risk: men < 40, women < 50, atypical chest
pain & no cardiac risk factors no Dx testing
intermediate risk: able to exercise?
o yes & normal EKG exercise EKG test
o yes & abnormal EKG exercise imaging test
o no pharmacologic stress imaging test
any positive result coronary angiography
high risk: coronary angiography evaluation &
pharmacologic Rx for CAD
--------------------------------------------------------------- fever, fatigue, pharyngitis, exudative tonsillitis,
& polymorphous rash after taking amoxicillin:
infectious mono
posterior cervical lymphadenopathy
Rx: supportive management for several weeks
---------------------------------------------------------------Common oropharyngeal lesions in children
recurrent ulcers on anterior oral
(canker sore)
no fever or systemic symptoms
vesicles & ulcers on posterior
oropharynx & hard palate,
fever, pharyngitis
Coxackie A
Rx: supportive; self-limited in 1 wk
gingivostomatitis vesicles & ulcers on anterior oral
mucosa & perioral area, fever,
pharyngitis, erythematous gingiva
Rx: oral acyclovir
Group A Strep
tonsillar exudates, fever,
anterior cervical lymphadenopathy
infectious mono
tonsillar exudates,
posterior cervical adenopathy
+/- hepatosplenomegaly
--------------------------------------------------------------- dipyridamole (& adenosine) is a coronary
vasodilator used in myocardial perfusion scanning
to reveal areas of restricted perfusion

redistribution of coronary blood flow from

diseased segments to non-diseased segments
= coronary steal
--------------------------------------------------------------- secondary bacterial pneumonia: prodrome
viral URI, high fever, blood-streaked sputum
MCC: S. aureus
CXR: B/L mid-field infiltrates, thin-walled abscess
cavities suggesting necrotizing bronchopneumonia
with secondary pneumatoceles
--------------------------------------------------------------- high PaCO2 & low PaO2 is a/w hypoventilation
MCC: COPD, OSA, obesity, scoliosis
hypoventilation & reduced inspired O2 is a/w
normal A-a gradient
--------------------------------------------------------------- PE, atelectasis, pleural effusion, PCP, pulmonary
edema cause V/Q mismatch & A-a gradient
A-a gradient: any process that results in
impaired gas exchange hypoxia
---------------------------------------------------------------Meningococcal vaccination
all adolescents age 11 12;
optional at age 19 21 for high risk
& 1st year college students
age 16 21 (if primary vaccine given
before age 16)
age > 21
considered if @ high risk
---------------------------------------------------------------Live-attenuated vaccines
oral polio
yellow fever
avoid in patients on TNF antagonists
--------------------------------------------------------------- MCC of macrocytic anemia in sickle cell disease
is folate deficiency
sickle cell disease is a chronic hemolytic anemia
with an appropriate reticulocyte response
RBC turnover & consumption of folate in bone
marrow folate deficiency
--------------------------------------------------------------- fever, pharyngitis, tonsillar exudates, absent cough,
& tender, anterior cervical lymphadenopathy:

Strep pharyngitis
--------------------------------------------------------------- subdural hematoma is MC in elderly &
alcoholics due to tearing of bridging veins 2/2
brain atrophy
ruptured aneurysm results in subarachnoid
headache, confusion, somnolence, focal neural
deficits within hours of trauma: epidural hematoma
--------------------------------------------------------------- tumor of arachnoid granulation = meningioma
--------------------------------------------------------------- episodic numbness, weakness, spastic paraparesis,
paresthesia, gait abnormalities, vision loss: MS
--------------------------------------------------------------- middle ear effusion without signs of acute infection,
+ conductive hearing loss: serous otitis media
due to auditory tube dysfunction 2/2 HIV
lymphadenopathy or obstructing lymphomas
dull tympanic membrane & hypomobile
--------------------------------------------------------------- boy with gout, hypotonia & persistent vomiting:
deficiency of HPRT for purine metabolism
uric acid accumulates in peripheral tissue
MC @ age 6 months
mental retardation, choreoathetosis, spasticity,
dystonia, self-mutilation, gouty arthritis & tophi
Rx: allopurinol
--------------------------------------------------------------- knee pain, adolescent male athlete: Osgood-Schlatter
traction apophysitis @ tibial tubercle\
absence of knee swelling
pain reproduced by knee extension with resistance
--------------------------------------------------------------- anterior knee pain that worsens with descending
steps or hills; MC overuse injury in runners:
patellofemoral stress syndrome
--------------------------------------------------------------- MC predisposing factor for aortic dissection: HTN
--------------------------------------------------------------- intermittent vision loss with changes in head
position: papilledema

most significant factor in suicide risk assessment:

previous attempts & clear plan

Assessment of suicidality
Sex, Age, Depression,
Previous attempt, EtOH use, Rational thought
loss (psychosis), Social support (lack of),
Organized plan, No spouse or significant other,
--------------------------------------------------------------- colicky abdominal pain & distension, N/V,
obstipation, diffuse tenderness: SBO
mild leukocytosis & modest amylase
XR: multiple air-fluid levels
Rx #1: bowel rest, NG tube decompression, pain
control, fluids
fever, tachycardia, leukocytosis, metabolic acidosis
risk of strangulation
o Rx: surgical exploration
---------------------------------------------------------------Indications for prophylactic anti-D immune globulin
for unsensitized Rh-negative prego
no antepartum prophylaxis if father is Rh-negative
@ 28 32 wk gestation
within 72 hr of delivery of Rh+ infant;
spontaneous, threatened, or induced abortion
ectopic pregnancy
hydatidiform molar pregnancy
CVS or amniocentesis
abdominal trauma
2nd or 3rd trimester bleeding
external cephalic version
--------------------------------------------------------------- anti-D immune globulin binds D antigens on
fetal RBCs in the mothers circulation to prevent
formation of anti-D alloimmunization
if mother is sensitized (elevated antibody titers),
Rx: fetal monitoring for hemolytic disease
--------------------------------------------------------------- intravascular hemolysis: RBC breakdown in
blood vessels; schistocytes
o prosthetic valves, DIC, TTP, HUS, PNH
extravascular hemolysis: a/w spleen & RES
o autoimmune hemolytic anemia in CLL

---------------------------------------------------------------Acute HIV infection

presents 2 4 wks after exposure
mononucleosis-like syndrome (fever, night sweats,
diarrhea, weight loss, lymphadenopathy, arthralgia)
generalized macular rash
painful mucocutaneous ulcerations
GI: diarrhea, abdominal distension, flatulence
Dx: low threshold for HIV testing; viral load;
negative HIV Ab, normal CD4
Rx: combination anti-retrovirals
DDx: IBD, connective tissue disease, lymphoma,
Whipples, hyperthyroidism, Celiacs
---------------------------------------------------------------Rx chronic stable angina
antianginals -blocker (#1; improves survival)
CCB (peripheral & coronary vasodilation)
nitrates (long-acting)
ASA, statin
smoking cessation, exercise, weight loss,
BP & diabetes control
avoid -blockers if hypotensive or bradycardic
--------------------------------------------------------------- reddish nodule that later ulcerates @ site of injury,
spreads along lymphatics forming subcutaneous
nodules & ulcers: sporotrichosis
--------------------------------------------------------------- leprosy: chronic granulomatous disease that
affects peripheral nerves & skin; MC in Asians
MCC: Mycobacterium leprae
early: insensate, hypopigmented plaque
peripheral nerve damage & muscle atrophy with
crippling deformities
face, ears, wrists, buttocks, knees, eyebrows
Dx: skin biopsy (acid-fast bacilli)
--------------------------------------------------------------- child with unsteady wide-based gait & weakness
of lower limbs, decreased vibratory & position
sense, absent B/L ankle jerks, high plantar arches:
Friedreich Ataxia
AR inheritance, excess trinucleotide repeats
a/w necrosis & degeneration of cardiac muscle
fibers myocarditis, fibrosis, cardiomyopathy
MCC of death: arrhythmia & CHF

Rx: prenatal counseling for subsequent pregnancy

---------------------------------------------------------------Pertussis in infants & children
Catarrhal phase
mild cough, rhinitis
(1 2 wks)
Paroxysmal phase
coughing paroxysms with
(2 6 wks)
inspiratory whoop,
posttussive emesis,
apnea & cyanosis (infants)
symptom resolution
(wks months)

total duration if untreated: 3 months

lymphocyte predominant leukocytosis
Dx: Pertussis PCR or culture of nasopharyngeal
Rx on clinical suspicion: empiric macrolides
(azithromycin, erythromycin, clarithromycin)
o respiratory isolation at home for 1st 5 days
prevention: acellular pertussis vaccine
o 5 doses of DTaP between age 2 months 6 yrs
o Tdap booster once at age 11 18 & pregos
o does not provide lifelong immunity
complications: pneumonia, weight loss,
pneumoTx, subconjunctival hemorrhages,
respiratory failure, death (infants)

Pertussis Rx & post-exposure prophylaxis

age < 1
azithromycin x5 days
age 1
azithromycin x5 days, or
clarithromycin x7 days, or
erythromycin x14 days
ABX prophylaxis for all close contacts
regardless of vaccination status
---------------------------------------------------------------Indications for renal & bladder USS
age < 2 yrs with a first febrile UTI to evaluate
for anatomic abnormalities
any age child with recurrent febrile UTI
UTI in a child of any age with family Hx of
renal or urologic disease, HTN, or poor growth
child does not respond to appropriate ABX

persistent or worsening symptoms to assess for

renal abscess
--------------------------------------------------------------- voiding cystourethrogram: newborns < 1 month,
children age < 2 yrs with recurrent UTI, or first UTI
from organism other than E.coli
---------------------------------------------------------------Screening for average risk patients
Breast cancer
50 -75
mammogram (2 yrs)
Cervical cancer 21 65
Pap every 3 yrs
Colon cancer
50 75
annual FOBT or
colonoscopy (10 yrs)
15 65
HIV antibody 1x
men 35+
lipid panel every 5 yrs
BP every 2 yrs
female 65+ DEXA scan
--------------------------------------------------------------- chronic, intermittent, painful eyelid swelling that
regresses with hot compresses: chalazion
nodular, rubbery lesion; no redness or discharge
chronic granulomatous obstruction of a
Meibomian gland
recurrent lesions histology to r/o malignancy
(Meibomian gland carcinoma)
DDx: BCC, hordeolum (stye)
--------------------------------------------------------------- acute infection of an eyelid gland: hordeolum
Rx: anti-staphylococcal ABX
--------------------------------------------------------------- retinoblastoma: MC intraocular tumor of children
inactivation of Rb suppressor gene
strabismus, decreased vision, ocular inflammation,
glaucoma, orbital cellulitis
Dx: USS or CT of a mass with calcifications
MCC of death: liver & brain mets
--------------------------------------------------------------- MCC of bronchiolitis in age < 2 yrs: RSV
fever, rhinorrhea, cough, mild respiratory distress
--------------------------------------------------------------- solitary, non-healing ulcer in the keratinized
epithelium of the vermillion zone of lower lip &
Hx of sun exposure, immunocompetent: SCC
invasive cords of squamous cells & keratin pearls

invasive clusters of spindle cells surrounded by

palisaded basal cells: BCC
elevated or rolled border with central ulceration
Rx low-risk & superficial: 5-FU or imiquimod
Rx low-risk lesions on trunk or extremities:
electrodessication & curettage (ED&C)
Rx high-risk nodular BCC on face: Mohs surgery
--------------------------------------------------------------- shallow, fibrin-coated ulcerations with underlying
mononuclear infiltrates: aphthous ulcer
Rx: topical corticosteroids
--------------------------------------------------------------- hoarding disorder Rx: CBT & SSRI
--------------------------------------------------------------- DDx of T-wave inversion: MI, old pericarditis,
myocarditis, myocardial contusion, digoxin toxicity
--------------------------------------------------------------- adult with palpable purpura, proteinuria, hematuria:
mixed cryoglobulinemia
also hepatosplenomegaly, peripheral neuropathy,
arthralgia, hypocomplementemia
MC a/w Hep C
Dx: circulating cryoglobulins
DDx: Henoch-Schonlein (normal complement)
--------------------------------------------------------------- ranolazine: late Na+ channel blocker
Rx stable angina with recurrent symptoms,
already on -blocker, CCB, or nitrates
o not for initial therapy
--------------------------------------------------------------- Klumpke palsy: excessive traction of C8 & T1
during delivery; intact Moro & biceps reflexes
Claw hand, Horners (ptosis, miosis)
Rx: gentle massage & PT to prevent contractures
--------------------------------------------------------------- D-xylose test of proximal small bowel absorption
normal: D-xylose excretion in urine
abnormal: high fecal D-xylose excretion,
minimal D-xylose in urine (MCC: Celiacs)
false+: bacterial overgrowth, urinary retention,
delayed gastric emptying, renal dysfunction, ascites
--------------------------------------------------------------- anemia of lymphoproliferative disorders is due
to bone marrow infiltration with cancerous cells

o lymphadenopathy, hepatosplenomegaly
--------------------------------------------------------------- new-onset a-fib should have TSH & T4 screening
for hyperthyroidism
--------------------------------------------------------------- Rx uncomplicated diverticulosis: dietary fiber
o resultant large, bulky stools colon width
Rx uncomplicated diverticulitis: bowel rest & ABX
o fever, leukocytosis, peritoneal inflammation
---------------------------------------------------------------Maternal estrogen effects on newborns
o breast hypertrophy (boys & girls)
o swollen labia
o physiologic leukorrhea (non-purulent)
o uterine withdrawal bleeding
Rx: routine care & observation
--------------------------------------------------------------- uncomplicated pyelonephritis Rx: urine culture
& empiric oral ABX against Go Rx: oral fluoroquinolone or TMP-SMX
hypotensive patients require hospitalization &
blood cultures, fluids, & empiric IV ABX
abdominal & pelvic CT if symptoms persist
despite 48 -72 hr of Rx, Hx of nephrolithiasis,
gross hematuria, urinary obstruction or
complicated pyelonephritis
complicated pyelonephritis: progression to
renal abscess or papillary necrosis, sepsis with
multi-organ failure, shock, renal failure
o MC with immunosuppression, diabetes,
renal stones, anatomic abnormalities
o Rx: IV ceftriaxone, cefepime,
--------------------------------------------------------------- acute pyelonephritis in pregos: hospitalization
Rx: IV ceftriaxone +/- gentamicin, aztreonam
--------------------------------------------------------------- diabetics with acute pyelonephritis are managed
with IV ABX for 48 72 hrs, then switched to oral
fluoroquinolone or TMP-SMX; 10 14 days
non-diabetics with mild/moderate pyelonephritis,
Rx: oral ABX only
gentamicin: Rx UTI with severe infection or risk
for drug-resistant organisms

post-operative fever, leukocytosis, parotitis:

acute bacterial parotitis
MCC: S. aureus
MC in elderly & post-op dehydration
purulent saliva from parotid duct
prevention: adequate hydration & oral hygiene
--------------------------------------------------------------- young woman with a breast lump: return after
menstrual period, if no signs of malignancy
--------------------------------------------------------------- left-sided weakness, +Babinski, Hx of HTN &
DM Type II: acute ischemic stroke
Dx: head CT without contrast to r/o hemorrhage
Rx: fibrinolytics (IV alteplase (tPA))
ASA should be held for 24 hrs
Rx with ASA is indicated if fibrinolytics are C/I
heparin would increase risk of IC hemorrhage
--------------------------------------------------------------- well-appearing infant that regurgitates milk, eczema,
painless bloody stools: milk protein allergy
infants age 2 8 wks
family Hx of allergies, eczema, or asthma
non-IgE-mediated rectal & colonic inflammation
Rx: eliminate dairy & soy protein from maternal
diet if breastfed; hydrolyzed formula
o resolves within 2 wks of diet modification
o can resume/tolerate dairy & soy by age 1 yr
--------------------------------------------------------------- failure to thrive, irritability, Sandifer syndrome:
infantile GERD
Sandifer syndrome: periodic opisthotonic posturing
Rx: thickened feeds, PPI, esophageal pH probe
monitoring, upper endoscopy
--------------------------------------------------------------- somatic & parasympathetic fibers of CN III have
separate blood supplies
in diabetics, CN III neuropathy is ischemic;
affect somatic fibers only
o down & out gaze & ptosis only
nerve compression affects BOTH somatic &
parasympathetic fibers
o down & out gaze, ptosis, fixed & dilated
pupil, loss of accommodation

symmetrical distal sensorimotor polyneuropathy

is MC type of diabetic neuropathy
stocking glove sensory loss
neuropathic pain is present at rest, worse at night
Rx: TCAs (amitriptyline), gabapentin, NSAIDs
o TCAs may worsen urinary symptoms &
orthostatic hypotension; Rx: gabapentin
o NSAIDs: C/I in renal dysfunction
--------------------------------------------------------------- pronator drift assess UMN damage
o seen in some stroke patients
Rombergs assess proprioception
--------------------------------------------------------------- any patient with an acute, severe illness can have
abnormal thyroid function tests: euthyroid sick
syndrome (aka low T3 syndrome)
total & free T3, normal T4 & TSH
thyroid function tests are not recommended in
acutely ill patients; unreliable
DDx: subclinical hypothyroidism ( TSH,
normal T4)
---------------------------------------------------------------Non-allergic rhinitis
Allergic rhinitis
nasal congestion,
watery rhinorrhea,
rhinorrhea, postnasal
sneezing, eye itching
drainage (dry cough)
early age of onset
late age onset (> 20)
allergen or seasonal
no allergic triggers
pale/blue nasal
perennial symptoms
erythematous nasal
a/w asthma, eczema
mild Rx: intranasal
Rx: intranasal
antihistamine spray or
glucocorticoids or
intranasal glucocorticoids antihistamines
mod/severe Rx: combo
--------------------------------------------------------------- all cirrhotic patients require diagnostic endoscopy
to asses risk for variceal hemorrhage
small, non-bleeding varices Rx: propranolol
as primary prophylaxis, results in unopposed
alpha-mediated vasoconstriction
endoscopic band ligation is an alternative Rx
endoscopic sclerotherapy is for active bleeding

octreotide: Rx active variceal bleeding by

causing splanchnic vasoconstriction & reduced
portal blood flow by inhibiting glucagon release
--------------------------------------------------------------- molar pregnancy: abnormal trophoblastic
proliferation following abnormal fertilization
o Rx: D&C
o F/U: serial -hCG post-evacuation
o complication: gestational trophoblastic neoplasia
complete mole: 2 sperm + 1 empty ovum
o no fetal tissue (completely empty)
o symptomatic: theca lutein ovarian cysts,
-hCG, hyperemesis graviarum
partial mole: 2 sperm + 1 haploid ovum (triploid)
o abnormal placenta + fetal tissue
---------------------------------------------------------------Manifestations of hyperthyroidism
symptom o anxiety, insomnia
o palpitations
o heat intolerance
o perspiration
o weight loss
o goiter
o HTN, tachycardia
o tremors of fingers/hands
o hyprreflexia
o proximal muscle weakness
o lid lag
o a-fib
chronic thyrotoxic myopathy: inability to comb
hair, difficulty holding arms up, muscle atrophy
---------------------------------------------------------------Suspected hyperthyroidism
initial Dx test: plasma TSH
if plasma TSH is low measure free T4
o elevated free T4 clinical hyperthyroidism
24-hr RIU scan to differentiate Graves from
toxic adenoma
next test: EKG to r/o arrhythmia
initial Rx: propranolol for symptomatic relief
definitive Rx: radioactive iodine
complications if untreated: rapid bone loss 2/2
direct osteoclastic bone resorption, & a-fib

cobalamin deficiency can result in peripheral

neuropathy or posterior column defects due to
defective myelin synthesis
folate supplementation can improve the anemia,
but may precipitate or worsened neuro deficits
folate & Vit B12 are cofactors in homocysteine to
methionine conversion
--------------------------------------------------------------- autoimmune hemolysis: IgG autoantibodies
bind to RBC membrane & promotes removal in
the spleen reticuloendothelial system
--------------------------------------------------------------- OCD in a child after recent group A Strep
infection: pediatric autoimmune
neuropsychiatric disorders a/w streptococcal
infections (PANDAS)
OCD #1 Rx: CBT & high-dose SSRI
--------------------------------------------------------------- acalculous cholecystitis: MC in critically ill
o extensive burns, severe trauma, prolonged TPN
or fasting, mechanical ventilation
presents similar to calculous cholecystitis
due to cholestasis & GB ischemia, leading to
secondary infection by enteric organisms
no prior Hx of GB disease
Dx: CT shows GB wall thickening & distension
with pericholecystic fluid
Rx: ABX & percutaneous cholecystostomy, then
cholecystectomy once stable
complications: sepsis & death if undetected
--------------------------------------------------------------- severe N/V during 1st trimesters, a/w ketonuria &
metabolic alkalosis: hyperemesis gravidarum
volume depletion causes contraction metabolic
alkalosis & R-A-A system activation


Hyperemesis gravidarum
HG in a prior pregnancy,
multifetal gestation,
gestational trophoblastic disease (molar)
severe, persistent N/V in 1st trimester,
enlarged uterus than expected,
abnormally elevated -hCG,
> 5% loss of pre-pregnancy weight,
ketonuria, metabolic alkalosis


pelvic USS, thyroid function,

electrolytes, U/A, BUN, Cr,
dietary modification, hydration, ginger
Vit B6 +/- doxylamine
--------------------------------------------------------------- hypocapnia is a normal phenomenon of late
pregos due to direct stimulation by progesterone
on central respiratory center
respiratory drive & relative hyperventilation
--------------------------------------------------------------- fever, cough, abdo pain, diarrhea, night sweats,
weight loss, splenomegaly & ALP, CD4 < 50:
disseminated Mycobacterium avium complex
Dx: blood cultures
Rx: azithromycin or clarithromycin
CD4 < 50 prophylaxis: azithromycin
---------------------------------------------------------------Solitary pulmonary nodule
rounded opacity, < 3 cm, surrounded by
pulmonary parenchyma, no lymphadenopathy
step #1: determine if low, intermediate or high
probability for malignancy
o low risk no follow-up
o intermediate risk FDG-PET scan
o high risk surgical resection
step #2: FDG-PET scan for nodules 0.8 cm &
intermediate risk
o suspicious for malignancy surgical resection
o negative results serial CT scans
---------------------------------------------------------------Chronic HBV infection
immune tolerance phase: high levels of HBV
replication, normal ALT; can last 10 30 yrs
immune clearance phase causes immune-mediated
destruction of infected hepatocytes & fluctuating
ALT levels
inactive carrier state: measure 3 normal ALT
& 2 3 normal HBV DNA levels; 3 6 months
--------------------------------------------------------------- a-fib with rapid ventricular response: rate control
should be attempted with -blocker or CCB
hemodynamically unstable: synch cardioversion

rhythm control with digoxin: Rx patients unable

to achieve rate control, recurrent symptoms, or
LV systolic dysfunction
all patients require CHA2DS2-VASc score to
assess thromboembolic risk
--------------------------------------------------------------- narrow-complex SVT with abrupt onset/offest:
o includes AVRNT, AVRT, atrial tachycardia,
& junctional tachycardia
Rx: IV adenosine or vagal maneuvers if
hemodynamically stable
o temporarily slow AV node conduction to
unmask hidden P waves with a-flutter or
atrial tachycardia
o terminates PSVT by interrupting AV nodal
reentry circuit
--------------------------------------------------------------- B/L digital clubbing with sudden onset arthropathy
& tenderness affecting wrist & hand joints, Hx of
smoking: hypertrophic osteoarthropathy
screening: CXR to r/o malignancy
--------------------------------------------------------------- HIV+: HSV & VZV can cause severe, acute
retinal necrosis a/w pain, keratitis, uveitis
o most cases due to reactivation
initially: keratitis & conjunctivitis with pain,
followed by rapid progressive visual loss
fundoscopy: central retinal necrosis & pale
peripheral lesions
--------------------------------------------------------------- CMV retinitis: painless
fundoscopy: fluffy or granular lesions around
retinal vessels & associated hemorrhages
o no keratitis or conjunctivitis
--------------------------------------------------------------- untreated complete heart block can lead to
ventricular arrhythmias or asystole
symptomatic 3rd degree heart block Rx:
temporary pacemaker & ID reversible causes
permanent pacemaker if no reversible causes
Sphingomyelinase def.
-hexosaminidase A def.
AR inheritance; MC in Ashkenazi Jews

onset: age 2 6 months

loss of motor
loss of motor
feeding difficulties
feeding difficulties
cherry red macula
cherry red macula
--------------------------------------------------------------- constitutional growth delay: normal birth
weight & height, but between age 6 mo 3 yrs,
height velocity slows, then regains normal
growth velocity at 5th 10th percentile
delayed puberty & growth spurt, but
eventually occurs, reaching normal adult height
bone age is delayed
Rx: F/U in 6 months after puberty has occurred;
no supplement with testosterone or GH
--------------------------------------------------------------- oropharyngeal dysphagia: difficulty initiating
swallowing; a/w coughing, choking, nasal
esophageal dysphagia initially with solids, then
liquids is MC mechanical obstruction
o Hx of prior radiation, caustic injury,
complex stricture, or surgery for laryngeal
or esophageal cancer
Dx: barium swallow, then upper endoscopy
esophageal dysphagia for both solids & liquids is
MC motility disorder
Dx: barium swallow, confirm with manometry
--------------------------------------------------------------- folate deficiency is MCC of megaloblastic anemia
in chronic alcoholics by impairing enterohepatic
cycle & absorption
---------------------------------------------------------------Approach to childhood lead poisoning
risk factors: home built before 1978, pica,
sibling with lead poisoning, low socioeconomics,
immigrant or international adoptee
no risk factors no further testing
+risk factors draw venous lead levels
o mild Rx: no meds, repeat level in < 1 month
o moderate Rx: DMSA, oral succimer

severe Rx: Dimercaprol + Ca++ EDTA

also for acute encephalopathy
--------------------------------------------------------------- easy fatigue, difficulty concentrating, insomnia,
muscle weakness, clumsiness, memory loss,
peripheral neuropathy: chronic lead exposure
o inquire about occupation Hx
microcytic anemia, basophilic stippling
--------------------------------------------------------------- nasopharyngeal carcinoma presents with recurrent
otitis media, epistaxis, & nasal obstruction
a/w EBV, smoking, nitrosamine consumption
--------------------------------------------------------------- V-fib & sustained V-tach are complications of MI
Rx: early defibrillation before epinephrine or
in unwitnessed cardiac arrest or witnessed arrest
occurring > 5 min before defibrillator arrival, a
cycle of CPR should precede defibrillation
--------------------------------------------------------------- MCC of thyrotoxicosis with reduced RIU uptake
is subacute lymphocytic (painless) thyroiditis
o leakage of thyroid hormone due to
inflammatory damage of thyroid follicles
---------------------------------------------------------------MCC of thyrotoxicosis with low RIU uptake
subacute painless thyroiditis (painless)
subacute granulomatous thyroiditis (de Quervain,
iodine-reduced thyroid toxicosis
levothyroxine overdose
struma ovarii
---------------------------------------------------------------Aromatase deficiency
in utero: no placental estrogen masculinization
of mother that resolves after delivery
gestational androgens results in virilized XX child,
normal internal genitalia, ambiguous externally;
delayed puberty, 10 amenorrhea, clitoromegaly,
osteoporosis, polycystic ovaries
undetectable estrogens, high LH/FSH
DDx: CAH (virilized female, normal internals),
Kallman (delayed puberty, absent LH/FH)

involuntary contraction of perineal musculature,

at least 6 months: vaginismus
pain with intercourse or attempted penetration
underlying cause is psychologic
Rx: relaxation, Kegels, dilators to desensitize
--------------------------------------------------------------- Varenicline: partial agonist at nicotinic ACh Rc,
more effective than bupropion
all meds are enhanced by nicotine replacement Rx
--------------------------------------------------------------- sudden cardiac death 2/2 CVD is MCC of death
in dialysis & renal transplant patients
--------------------------------------------------------------- nocturnal respiratory symptoms can occur as
GERD can exacerbate asthma
GERD exacerbates airflow obstruction by
vagal tone, bronchial reactivity, &
microaspiration of gastric contents
initial Rx of GERD: lifestyle modification
(elevation of bed head, diet, weight loss)
Rx: PPI improves peak expiratory flow,
nocturnal respiratory symptoms, & GERD
--------------------------------------------------------------- MCC of vulvovaginitis in pre-pubertal kids:
vaginal foreign bodies; MC is toilet paper
o foul-smelling discharge, intermittent bleeding
or spotting, urinary complaints
Rx small foreign body: Ca++ alginate swab or
irrigation with warm fluids after topical anesthetic
sedation or general anesthesia may be required
never perform bimanual exam in a child
---------------------------------------------------------------Serum sickness-like reaction
etiology ABX (PCN, -lactams, TMP-SMX),
Type III hypersensitivity reaction
features fever, urticarial rash, polyarthralgia
(1 2 wks after first exposure);
headache, edema, lymphadenopathy,
splenomegaly (less common)
hypocomplementemia, ESR & CRP
avoid offending agent; resolves with 48 hrs,
steroids for severe cases

DDx: untreated Strep pharyngitis, arthritis, fever,

erythema marginatum (acute rheumatic fever)

--------------------------------------------------------------- dizziness, headache, pruritus after shower, &

splenomegaly: polycythemia vera
high histamine release also cause peptic ulcers
o hypercellular bone marrow
o production of all three cell lines, esp. RBCs
o risk of thrombosis & bleeding due to elevated
PLT count & impaired PLT function
o low serum iron due to iron utilization
primary polycythemia: low erythropoietin
o polycythemia vera
o primary familial & congenital polycythemia
secondary: high/normal erythropoietin
o hypoxemia, congenital, hepatic or renal tumors,
post-renal transplant, testosterone supp/abuse
--------------------------------------------------------------- SCC of the mucosa of head & neck is common
with a Hx of alcohol & tobacco use
firm, non-tender, palpable solitary cervical node
Dx: panendoscopy (laryngoscopy, bronchoscopy,
esophagoscopy) to detect primary tumor
o F/U lymph node biopsy for histologic Dx
---------------------------------------------------------------MCC of Vit B12 deficiency: pernicious anemia
1. anti-intrinsic factor antibodies functional IF for
Vit B12 absorption
2. chronic atrophic gastritis IF production by
parietal cells & risk of gastric cancer
periodically monitor for gastric cancer
--------------------------------------------------------------- Vit B12 deficiency is common after total or partial
gastrectomy or chronic gastritis
o 2/2 loss of intrinsic factor
Vit B12 is a cofactor in purines & DNA synthesis
ineffective erythropoiesis megaloblastic anemia
total RBC count & reticulocyte count are low
shiny tongue (glossitis) & pale palmar creases
--------------------------------------------------------------- ineffective erythropoiesis is a hallmark of both
Vit B12 & folate deficiency
delayed nuclear maturation # of megaloblasts
ineffective erythropoiesis due to transition to
mature RBC & death of immature precursors
total RBC count & reticulocyte count are low

antiviral Rx for influenza: oseltamivir

o must be started within 48 hrs for efficacy
confirm Dx: nasal swab for influenza antigens
--------------------------------------------------------------- fever, leukocytosis, LUQ pain: splenic abscess
left pleuritic chest pain, left pleural effusion,
MCC: Staph, Strep, Salmonella
MC risk factors: infective endocarditis with
hematogenous spread
Rx: ABX + splenectomy
percutaneous drainage for poor surgical candidate
DDx: malaria, Hodgkins, infectious mono, TB
--------------------------------------------------------------- anorexia, constipation, thirst, easy fatigue,
hypercalcemia, smoking Hx: SCC of lung
o sCa++mous cell carcinoma
PTHrP Ca++ resorption from bone & renal Ca+
+ resorption from distal tubule
CXR: hilar mass
DDx: small cell carcinoma (a/w ACTH or SIADH),
adenocarcinoma (a/w hypertrophic osteoarthropathy)
--------------------------------------------------------------- OTC cold meds containing acetaminophen &
phenylephrine can provoke warfarin-associated
IC hemorrhage
acetaminophen potentiates warfarin effects
phenylephrine elevates BP
Rx: prothrombin-complex concentrate (rapid &
short-term warfarin reversal) & IV Vit K
(promotes clotting factor synthesis; 12 24 hr)
alt Rx: FFP if PCC not available; FFP takes longer
to prepare/administer & more volume infusion
feature watery diarrhea, weight loss, lethargy,
facial flushing, N/V, muscle weakness
hypokalemia ( intestinal K+ secretion),
acholrhydria ( gastric acid secretion),
hypercalcemia ( bone resorption),
hyperglycemia ( glycogenolysis),
secretory diarrhea: Na+, osmolal gap
watery diarrhea, VIP > 75 pg/mL
abdominal CT (usually pancreatic tail)
IV fluids, octreotide to decrease diarrhea

VIP binds intestinal epithelial cells to increase

fluid & electrolyte secretion into intestinal lumen
maybe a/w MEN Type I
--------------------------------------------------------------- steatorrhea, hepatomegaly, PUD: systemic
o pruritus, facial flushing, urticaria
--------------------------------------------------------------- striatal neuro-degeneration: Huntingtons
spongiform encephalopathy: CJD
loss of nigrostriatal DA neurons: Parkinsons
selective loss of cholinergic neurons: Alzheimers
neurodegeneration of frontal/temporal lobes: Picks
--------------------------------------------------------------- rationalization: excusing an unacceptable
behavior/emotion in a false, but logically rational
way to avoid the true reason for a behavior, to
prevent anxiety & protect self-esteem
can result in a delay in care or difficult Rx course
--------------------------------------------------------------- repression: blocking upsetting ideas/impulses
from entering consciousness; blocking inner states
denial: blocking external sensory data
--------------------------------------------------------------- acute dyspnea, pleuritic chest pain, tachycardia,
follwed by hypotension, syncope: acute massive PE
accompanied by RV dilation & hypokinesis 2/2
occlusion of the pulmonary artery, which RA, RV,
& pulmonary artery pressure
can cause RBBB & right axis deviation
septal deviation toward LV results in LV preload
& cardiac output
PCWP & SVR are not affected
--------------------------------------------------------------- hypovolemic shock: RA, RV, pulmonary artery,
& PCWP; SVR to maintain organ perfusion
cardiogenic shock: PCWP & SVR, C.O.
o cardiac index, RA pressure
septic shock: peripheral vasodilation & SVR,
RA, pulmonary artery, & PCWP, C.O.
o mixed venous O2 saturation
--------------------------------------------------------------- acute mitral regurgitation as a complication of
MI can result in cardiogenic shock

o flash pulmonary edema & crackles

--------------------------------------------------------------- MCC of 20 HTN in children, to-&-fro bruit @ CVA:
fibromuscular dysplasia
angiogram: sting of beads
--------------------------------------------------------------- viral meningitis: self-limited inflammation of
leptomeninges cause by viral infection
MCC: echovirus or coxsackie virus
MC in infants; incidence decreases with age
prodrome constitutional & URI symptoms; next
36 48 hrs high fever, headache, irritability, &
nuchal rigidity
WBC (lymphocyte predominance), normal
glucose, mildly elevated protein
Rx: supportive; resolves in 7 10 days
DDx: bacterial (neutrophils, protein, glucose),
TB meningitis (lymphocytes, protein, glucose)
--------------------------------------------------------------- hemolytic anemia, cytopenias, hypercoagulability:
Dx: RBC CD55 & CD59 testing
--------------------------------------------------------------- oral corticosteroids: Rx acute asthma exacerbation
---------------------------------------------------------------Management of GERD
no cancer risk factors or alarm symptoms PPI
o if refractory, try another PPI or to 2x daily
male, age > 50, symptoms for > 5 yrs, or cancer risk
factors or alarm symptoms upper endoscopy
o if no evidence of esophagitis manometry
GI alarm symptoms
hematemesis, persistent vomiting, anemia,
melena, weight loss, dysphagia/odynophagia
--------------------------------------------------------------- intrauterine fetal demise: in utero fetal death
after 20 wks gestation, before labor onset
o Dx: USS
next: coagulation profile to detect incipient DIC
o retention of dead fetus can cause chronic
consumptive coagulopathy due to gradual
release of thromboplastin from the placenta

low/normal fibrinogen may indicate early signs of

consumptive coagulopathy if a/w PLT count,
PT, PTT, or fibrin split products
o fibrinogen is usually higher in pregos
if any coagulation derangements prompt delivery
if normal coagulation parameters
o watchful expectancy or labor induction
o expectant management complications:
chorioamnionitis & DIC
---------------------------------------------------------------Congenital hypothyroidism
etiology thyroid dysgenesis (MCC)
features most are asymptomatic,
jaundice, lethargy, hoarse cry, dry skin,
poor feeding, constipation, large tongue
TSH, free T4, via newborn screening
--------------------------------------------------------------- maternal Graves: transplacental passage of
TSH receptor antibodies congenital Graves:
poor feeding, jitteriness, tachycardia, weight loss
--------------------------------------------------------------- synchronized cardioversion: Rx a-fib, a-flutter,
stable monomorphic v-tach
temporary transvenous pacemaker: sick sinus
syndrome, 2nd or 3rd degree heart block
--------------------------------------------------------------- duodenal hematoma: MCC direct blunt abdominal
trauma; MC in children
Dx: CT with oral contrast
#1 Rx: NG suction & parenteral nutrition;
spontaneous resolution in 1 2 wks
#2 Rx: surgical removal if conservative Rx fails
---------------------------------------------------------------Vaccines for pregos
all pregos
Tdap & inactivated influenza
Hep A & B (high risk)
Pneumococcus (2nd & 3rd trimester
if high risk),
H. influenza (if asplenic),
Meningococcus (if high risk),
Anti-D Ig (if Rh-negative mother)
HPV, MMR, Varicella, smallpox,
intranasal influenza
**avoid conception for 4 wks

unvaccinated pregos with confirmed rubella

exposure are offered termination of pregnancy
or Rx prego with IV Ig
serology not needed if documentation of vaccine
---------------------------------------------------------------Evaluation of nipple discharge
unilateral likely malignant
Dx: mammogram +/- USS, surgical evaluation
bilateral color of discharge??
o bloody or serous mammogram
o milky, non-bloody
palpable mass or skin changes??
yes mammogram
no likely physiologic discharge
physiologic galactorrhea
o painless, B/L milky-brown-gray-green
o MCC: hyperprolactinemia
Dx: pregnancy test, TSH & prolactin
o Dx: pituitary MRI if prolactin is elevated
--------------------------------------------------------------- frequent exposure to ototoxic agents
(aminoglycosides for P. aeruginosa) for CF Rx
can cause sensorineural deafness
--------------------------------------------------------------- back pain, constipation, anemia, renal dysfunction,
o hypercalcemia causes polyuria,
constipation, confusion, or acute pancreatitis
--------------------------------------------------------------- acute onset polyarticular & symmetric arthritis
that resolves within 2 wks: viral arthritis 2/2
Parvovirus B19
o adults in frequent contact with children
morning stiffness < 30 min, no joint swelling
o MCP, PIP, wrist, knees, ankles
transient aplastic anemia
Dx: anti-B19 IgM antibodies
Rx: resolves spontaneous in 2 3 wks, no Rx
DDx: RA (arthritis > 6 wks), SLE, rheumatic fever
--------------------------------------------------------------- progressive dyspnea, tricuspid regurgitation,
peripheral edema: pulmonary HTN due to LV
systolic dysfunction

mean pulmonary arterial pressure 25 mmHg @

rest (normal 20 mmHg)
#1 initial Rx: furosemide & ACE-I
S. aureus or
S. aureus
Group A Strep
feature localized painful,
rapidly enlarging
non-itchy pustules flaccid bullae with
& honey-crusted
yellow fluid,
collarette of scale @
periphery of lesion
topical mupirocin oral ABX (cephalexin,
dicloxacillin, clinda)



congenital syphilis: failure to thrive, meningitis,

seizures, congenital defects
--------------------------------------------------------------- MCC of complicated influenza pneumonia: S. aureus
MC in hospitalized, nursing homes, IVDA, CF
Gram+ cocci in clusters
Rx: anti-staphylococcal ABX
--------------------------------------------------------------- TNM staging is most important prognostic factor
in breast cancer
--------------------------------------------------------------- depressed patients must be closely monitored for
suicidality within the first few weeks of initiating
pharmacotherapy; more likely to act on impulses
as motivation & initiative improve before a
depressed outlook
--------------------------------------------------------------- tachypnea, retractions, grunting, nasal flaring, &
cyanosis @ birth: respiratory distress syndrome
MCC are immature lungs & surfactant deficiency
risk factors: prematurity, maternal diabetes,
cesarean without labor
maternal diabetes delays surfactant maturation
due to fetal hyperinsulinemia, which antagonizes
cortisol, thus blocks sphingomyelin maturation
CXR: ground glass opacities, air bronchograms
---------------------------------------------------------------Cholesterol embolism (atheroembolism)
cardiac catheterization or angiography;
with comorbid hypercholesterolemia,

predisposing factors: warm, humid climates,

poverty, crowding, pre-existing skin trauma,
atopic dermatitis
prevention: hand-washing
complications: post-strep GN, rheumatic fever
--------------------------------------------------------------- melena, episodic gnawing, nocturnal abdominal
pain relieved by eating: duodenal ulcer
unopposed acid enters duodenum causing pain
high a/w H. pylori infection
Rx H. pylori-associated PUD: triple therapy with
PPI + amoxicillin + clarithromycin
Rx PUD only: PPI or H2 blocker
DDx: gastric ulcer (pain worse with eating)
--------------------------------------------------------------- CHF 2/2 restrictive cardiomyopathy, bibasilar rales,
right-sided pleural effusion: hemochromatosis
LV volume is normal with symmetric thickening
Rx of hemochromatosis (phlebotomy) can
reverse the cardiac dysfunction
DDx: amyloidosis, sarcoidosis, & scleroderma
all cause non-reversible cardiac dysfunction
---------------------------------------------------------------Stages of syphilis
painless chancre
Dx: spirochetes on darkfield microscopy
Rx: IM benzathine PCN G 1x
PCN-allergic: oral doxycycline x14 days

diffuse rash (+ palms/soles), hepatitis,

condyloma lata, lymphadenopathy
Rx: IM PCN G 1x
PCN-allergic: oral doxycycline x 14 days
Rx: IM PCN G 3x doses
PCN-allergic: doxycycline x 28 days
Tabes dorsalis, Argyll-Robertson pupil,
dementia, aortic insufficiency, gummas
Rx: IV PCN G x14 days
PCN-allergic: ceftriaxone x 14 days
intrapartum transmission
PCN-allergic: desensitize to PCN


livedo reticularis, blue toe syndrome,
acute kidney injury, amaurosis fugax,
Hollenhorst plaques, intestinal ischemia
Cr, eosinophilia, hypocomplementemia,
confirm Dx: skin or renal Bx (biconcave,
needle-shaped clefts within occluded vessel)
--------------------------------------------------------------- patient undergoing coronary angiography are at
risk for contrast-induced nephropathy
U/A: muddy-brown granular & epithelial casts
Rx: benign, resolves in 3 5 days
--------------------------------------------------------------- pseudocyesis is a form of conversion disorder
normal endometrial stipe, pregnancy test negative
Rx: psych evaluation
DDx: missed abortion (intrauterine collapsed
gestational sac, +pregnancy test), ectopic
(adnexal mass & empty uterus, +pregnancy test)
--------------------------------------------------------------- neoadjuvant therapy: given before standard Rx
adjuvant therapy: given in addition to standard Rx
induction therapy: initial dose of treatment to
rapidly kill tumor cells & induce remission
consolidation therapy: given after induction Rx
with multi-drug regimen to further reduce tumor
maintenance therapy: given after consolidation Rx
to kill residual tumor cells; keep patient in remission
salvage therapy: Rx for a disease when standard
Rx fails (radiation for PSA recurrence after
radical prostatectomy)
--------------------------------------------------------------- cirrhosis increases risk for HCC, but HCC does
not risk of cirrhosis
Management of cirrhosis
periodic surveillance of LFTs, INR, albumin, etc
compensated: asymptomatic or vague symptoms
USS for HCC +/- AFP; every 6 months
decompensated: jaundice, pruritus, upper GI bleed;
assess complications
o varices: start non-selective -blockers,
repeat EGD annually**
o ascites: dietary Na+ restriction, diuretics,
paracentesis, abstain from alcohol

hepatic encephalopathy: lactulose, Rx

underlying cause
--------------------------------------------------------------- childhood Hx of recurrent renal stones, +family Hx,
+urinary cyanide nitroprusside screening test, &
hexagonal crystals on U/A: cystinuria
defective transport of dibasic amino acids (Lys, Arg)
poor solubility of cysteine leads to renal stones
--------------------------------------------------------------- persistent abdo pain or dyspepsia post-op or years
after cholecystectomy: post-cholecystectomy
due to biliary or extra-biliary causes
elevated ALP, mildly abnormal ALT/AST, &
dilated common bile duct on USS
MCC: common bile duct stones or sphincter dysFx
Dx: endoscopic USS, then ERCP or MRCP
---------------------------------------------------------------Management of Cushings
#1 test: ACTH levels & urinary cortisol
low ACTH adrenal CT
o MCC: exogenous glucocorticoids
o exclude adrenal adenoma & hyperplasia
normal/high ACTH pituitary MRI
o mass > 6 mm dexamethasone supp test
no mass or < 6 mm inferior petrosal
sinus sampling (invasive)
MCC: ACTH-producing pituitary adenoma,
ectopic ACTH, or ectopic CRH
ectopic ACTH: rapid onset HTN, hypokalemia,
proximal muscle weakness, metabolic alkalosis,
hyperglycemia; less likely to have central obesity,
moon facies
---------------------------------------------------------------Prevention of recurrent nephrolithiasis
fluids (produce > 2 L urine/day)
reduce Na+, reduce protein, reduce oxalate,
normal Ca++ intake, increase citrate
thiazides (passive Ca++ reabsorption),
potassium citrate (urine alkalization),
allopurinol (for uric acid stones)
reduced dietary Ca++ leads to oxalate
absorption in the gut excreted into urine &
binds urinary Ca++ Ca++ oxalate stones

fever, odynophagia, dysphagia, drooling, stiff neck,

muffled voice, inability to extend neck & widened
prevertebral space: retropharyngeal abscess
MC in age 6 months 6 yrs
prodrome URI direct spread of infection
polymicrobial (Group A Strep, S. aureus, anaerobes)
Dx: CT with contrast
complications: airway compromise, bacteremia,
carotid artery rupture, jugular venous thrombosis
--------------------------------------------------------------- young adult with cirrhosis, neuropsych symptoms,
& Kayser-Fleischer rings: Wilsons (aka
hepatolenticular degeneration)
AR inheritance
resting tremor, muscle rigidity, slurred speech,
depression, paranoia, catatonia
impaired ceruloplasmin secretion, thus decreased
secretion of copper in biliary system
Cu++ deposition in liver, basal banglia, cornea
also a/w Fanconis, hemolytic anemia, neuropathy
Dx: liver biopsy, low ceruloplasmin, slit lamp,
urinary Cu++ excretion
#1 Rx: D-penicillamine or trientine
o oral zinc prevents copper absorption
#2 Rx: liver transplant
--------------------------------------------------------------- liver disease, hyperpigmentation, arthropathy,
diabetes, impotence, dilated cardiomyopathy:
--------------------------------------------------------------- productive cough, hemoptysis, recurrent fevers,
recent travel: pulmonary TB
chest CT: upper lobe cavitary lesions with
surrounding alveolar infiltrates
--------------------------------------------------------------- MC benign cutaneous vascular tumor in adults:
cherry angioma (aka senile hemangioma)
age 3rd 4th decade, increases with age
sharply circumscribed areas of congested capillaries
& post-capillary venules in papillary dermis
benign, no Rx required
--------------------------------------------------------------- MC benign vascular tumor in children:
superficial infantile (strawberry) hemangioma

red, demarcated plaques that blanch

grows rapidly in first 1 2 yrs of life, then
spontaneously regress in childhood
Rx: propranolol if at risk for complications
--------------------------------------------------------------- spider angiomas are estrogen dependent
MC in pregos, OCP use, cirrhosis (hyperestrogen)
dilated cutaneous arterioles with a central papule
& radiating blanching capillaries
--------------------------------------------------------------- recurrent sinopulmonary & GI bacterial infections
in adults may indicate humoral immunity defect
o a/w food allergies & autoimmune disease
Dx: quantitative serum Ig levels
--------------------------------------------------------------- NSAIDs can cause SIADH
o NSAIDs potentiate the action of ADH
hypotonic hyponatremia with euvolemia
Dx: r/o hypothyroidism & adrenal insufficiency
Dx: urine & plasma osmolality
low plasma osmolality with high urine osmolality
serum uric acid is low due to urinary excretion
& hemodilution
--------------------------------------------------------------- mineralocorticoid deficiency: hypotonic
hyponatremia with hypovolemia; elevated K+
--------------------------------------------------------------- nephrotic syndrome & advanced renal failure:
hypotonic hyponatremia with hypervolemia
--------------------------------------------------------------- incidence of carpal tunnel syndrome in pregos
2/2 estrogen-mediated depolymerization of ground
substance, causing interstitial edema
initial Rx: wrist splinting
#2 Rx: NSAIDS (risk of miscarriage), local
corticosteroid injection, surgical decompression
---------------------------------------------------------------Urinary incontinence
loss of urethral support, intraabdominal
pressure exceeds urethral sphincter
leaking with cough, sneeze, laugh, lifting
detrusor overactivity
sudden, overwhelming, frequent need
Overflow impaired detrusor contractility,
bladder outlet obstruction

constant involuntary dribbling &

incomplete emptying
epidural anesthesia: block afferent & efferent
nerves from the bladder; can cause overdistension
post-partum urinary retention: indwelling catheter
for 24 hr to decompress the bladder
--------------------------------------------------------------- ankylosing spondylitis & IBD (UC) are a/w
HLA-B27; may occur together
both are +p-ANCA, despite absence of vasculitis
--------------------------------------------------------------- infantile colic: crying 3 hr/day, 3 days/wk,
for 3 wks; typically evenings
o resolves spontaneously by age 4 months
Rx: calming techniques, reassurance
--------------------------------------------------------------- misoprostol: synthetic prostaglandin, used with
mifepristone to terminate pregnancies 49 days
--------------------------------------------------------------- cyanosis & respiratory distress immediately after
birth, scaphoid-abdomen: congenital
diaphragmatic hernia
XR: displaced cardiac silhouette, gasless abdomen
--------------------------------------------------------------- acute gout Rx: NSAIDs (indomethacin),
colchicine, corticosteroids
prophylactic Rx: allopurinol
--------------------------------------------------------------- male pubertal gynecomastia resolves within a few
months 2 yrs without intervention; reassurance
--------------------------------------------------------------- antiphospholipid antibody syndrome promotes
arterial/venous thromboses & recurrent
spontaneous abortions
o thrombocytopenia & prolonged PTT
prophylactic Rx: LMWH & low-dose ASA
--------------------------------------------------------------- leukopenia & thrombocytopenia in SLE is due to
peripheral immune-mediated destruction
o pancytopenia is common with SLE
--------------------------------------------------------------- alcoholic hepatitis: AST:ALT > 2; < 300 IU/L
o also GGT & ferritin (acute phase reactant)

dermatomyositis is an idiopathic inflammatory

myopathy with immune-mediated muscle injury
that can be due to a paraneoplastic syndrome
from malignancy (lung cancer)
Dx: muscle biopsy
--------------------------------------------------------------- Achilles tendon reflex can be decreased or
absent with age
lower extremity weakness, rectal tone,
bowel/bladder incontinence, & brisk LE DTRs:
possible spinal cord compression
--------------------------------------------------------------- ovulatory phase: cervical mucus is profuse,
clear & thin, stretches 6 cm, exhibits ferning,
& pH > 6.5 (more basic than usual)
o ideal for spermatozoa entering uterus
pre- & post-ovulatory: scant, opaque, & thick mucus
--------------------------------------------------------------- Hx of pelvic surgery or irradiation can develop a
urinary fistula
Dx: intravenous pyelography
--------------------------------------------------------------- young male with lower abdominal pain, tenesmus,
bloody diarrhea with acutely worsening fever,
leukocytosis, hypotension, & tachycardia:
ulcerative colitis complicated by toxic megacolon
may be the first presentation of UC
Dx: abdominal XR with colonic distension > 6 cm
+ 3 signs
o fever > 380C, HR > 120, leukocytosis, anemia
Rx: bowel rest, NG tube, steroids (if UC), ABX
o sigmoidoscopy is used to confirm UC, but
risk of perforation in toxic megacolon
severe cases: subtotal colectomy & end-ileostomy
--------------------------------------------------------------- sulfasalazine: Rx Crohns, UC, RA
--------------------------------------------------------------- fever, malaise, productive cough, eosinophilia,
hemoptysis: allergic bronchopulmonary
aspergillosis (ABPA)
hypersensitivity reaction to Aspergillus
MC a/w asthma & CF

academia alone does not lead to CNS depression,

but the underlying cause results in lethargy &
altered mental status
CO2 retention due to underlying COPD can lead
to CO2 narcosis (PaCO2 > 60 mmHg)
--------------------------------------------------------------- DIC depletes clotting factors & 20 fibrinolysis
thrombocytopenia, prolonged PT & PTT,
decreased fibrinogen, schistocytes
--------------------------------------------------------------- predominant unconjugated hyperbilirubinemia
o bilirubin production (hemolysis)
o bilirubin uptake (portosystemic shunt)
o abnormal conjugation (Gilberts)
predominant conjugated hyperbilirubinemia
o hepatocellular injury
o bilirubin excretion in bile canaliculi
o intrahepatic cholestasis (10 biliary cirrhosis)
o extrahepatic cholestasis (biliary obstruction)
normal transaminases & ALP suggest inherited
bilirubin metabolism disorders
elevated transaminases & normal ALP suggest
intrinsic liver disease (viral, hemochromatosis)
elevated ALP suggest intrahepatic cholestasis or
biliary obstruction
--------------------------------------------------------------- painless jaundice, fatigue, weight loss, pruritus,
acholic stools with dark urine, ALP, GGT:
malignant biliary obstruction
MCC: adenocarcinoma, cholangiocarcinoma
Dx: USS or CT; ERCP if non-diagnostic
DDx: acute choledocholithiasis (acute RUQ pain),
chronic autoimmune hepatitis, chronic pancreatitis
--------------------------------------------------------------- elderly patient with hip fracture should undergo
definitive surgical correction
surgery can be delayed up to 72 hrs to evaluate
surgical risk & address unstable comorbidities
---------------------------------------------------------------Ovarian & adnexal torsion
risk factors ovarian mass 5 cm, reproductive age,
infertility Rx with ovulation induction
sudden onset unilateral pelvic pain,
tender adnexal mass, N/V,


vaginal bleeding is uncommon

-hCG to exclude ectopic pregnancy,
USS with color Doppler
laparoscopy with detorsion

rotation of ovary around infundibulopelvic

(suspensory ligament) & utero-ovarian ligaments
adnexal torsion: includes fallopian tube
MC right-side: longer ligament
DDx: appendicitis, ruptured ovarian cyst,
endometriosis, tubo-ovarian abscess
--------------------------------------------------------------- gradual onset fever, chills, lower abdominal pain,
vaginal discharge: tubo-ovarian abscess
risk factors: multiple partners, young age, Hx of PID
--------------------------------------------------------------- ovarian hyperstimulation syndrome: ovarian
enlargement from multiple cysts with fluid shifts
out of the intravascular space
o results in ascites & hypovolemia
complication of gonadotrophin Rx for infertility
--------------------------------------------------------------- major depressive disorder (MDD): persistent &
pervasive sadness, self-critical ruminations, &
suicidality a/w feeling worthlessness & hopeless
2 wks
can be diagnosed anytime during acute grief;
bereavement period is not an exception
Rx: SSRI & psychotherapy
--------------------------------------------------------------- electroconvulsive Rx: refractory to antidepressants
o #1 Rx if not eating/drinking; acutely suicidal,
catatonic, or psychotic
--------------------------------------------------------------- first-time DVT with a reversible inciting incident
Rx: unfractionated or LMWH within 48 72 hrs
if hemodynamically stable
o prevents extension of the clot & future clots
rather than lysis of the present clot
o streptokinase & tPA: only Rx STEMI
--------------------------------------------------------------- low bone mass with normal mineralization:
normal serum Ca++, phosphorus, PTH, & ALP

--------------------------------------------------------------- defective mineralization of organic bone matrix:

osteomalacia 2/2 Vit D deficiency
defective mineralization of growth plates in kids:
skin pigmentation,
exclusive breastfeeding,
inadequate sun exposure,
maternal Vit D deficiency
feature craniotabes (ping-pong ball skull),
delayed fontanelle closure, frontal bossing,
costochondral hypertrophy (rachitic rosary)
genu varum
metaphyseal cupping & fraying,
epiphyseal widening, osteopenia
Ca++ & phosphorus, ALP & PTH
Vit D fortified baby food or formula; or
--------------------------------------------------------------- Vit D deficiency causes marked hypophosphatemia,
ALP, normal Ca++, secondary hyperPTH
XR: bone density with thin cortex, codfish
vertebral bodies, & pseudofractures (Looser zones)
--------------------------------------------------------------- large anterior fontanelle, lethargy, poor feeding,
macroglossia: congenital hypothyroidism
frontal bossing, anterior shin bowing, saddle-nose,
notched/gap teeth: congenital syphilis
bucket-handle fx = classic metaphyseal lesion:
child abuse
--------------------------------------------------------------- large tender, soft-tissue mass with localized pain
MC primary malignant bone tumor in children,
MC @ metaphysis of long bones: osteosarcoma
o distal femur, proximal tibia & humerus
XR: sunburst periosteal rxn, Codman triangle
ALP, LDH, ESR (inflammation)
risk factors: Pagets, radiation & chemotherapy
Rx: tumor excision, chemotherapy
--------------------------------------------------------------- deficits in reciprocal social communication,
limited play, poor eye contact, speech delay,
repetitive behaviors: autism

absence of language delay distinguishes

Aspergers from autism
--------------------------------------------------------------- sensorineural deafness, cataracts, purpura,
hepatosplenomegaly: congenital rubella
--------------------------------------------------------------- young female with fever, rash that started on face
that spreads to body that spares palms & soles,
joint pain, B/L conjunctival injection, cervical
lymphadenopathy: rubella
polyarthritis is MC in young females
Rx: supportive
complication: post-infectious encephalitis
DDx: measles (high fever > 104), RMSF (starts on
wrist & ankles, involve palms/soles)
--------------------------------------------------------------- liver transplant is the only effective Rx of
fulminant hepatic failure (Hep B infection)
fulminant hepatic failure: hepatic encephalopathy
that develops within 8 wks of acute liver failure
high mortality rate, high priority for transplant
--------------------------------------------------------------- interferon & lamivudine: Rx acute Hep B infection
--------------------------------------------------------------- cross-sectional study = prevalence study
simultaneous measure of exposure & outcome
calculate odds ratio
--------------------------------------------------------------- case-control study: selects patient with/without
outcome, & determine previous exposure status
--------------------------------------------------------------- iron stores must be evaluated prior to starting
supplemental erythropoietin for CKD/ESRD
o Rx: IV iron if on dialysis
A/E: worsening HTN, headache, flu-like syndrome,
red cell aplasia
--------------------------------------------------------------- rapid testing for Strep pharyngitis for those with
2 Centor criteria: fever, tonsillar exudates,
tender anterior cervical adenopathy, absent cough
--------------------------------------------------------------- pagophagia: pica for ice; iron deficiency anemia

influenza: sudden & dramatic onset with

systemic symptoms out of proportion to mild
nasal & respiratory symptoms
self-limited 3 10 days
Rx: oseltamivir (neuraminidase inhibitor) for all
confirmed or suspected cases within 48 hrs &
those at high risk for complications
Rx > 48 hrs: rest, analgesics, cough suppressants
--------------------------------------------------------------- post-exposure prophylaxis of animal bites from
a healthy-appearing domesticated animal can be
observed for 10 days, without PEP
o animals that become sick should be euthanized
& brain tested for rabies start PEP
low-risk animal bite (squirrel, chipmunk): no PEP
exposure to high-risk wild animal (raccoon, bat,
skunk) PEP if animal is unavailable for testing
o if available for testing, start PEP, then
discontinue if test is negative
PEP: receive both active & passive immunization
rabies vaccine & human rabies Ig
o if previously vaccinated revaccination only
--------------------------------------------------------------- symptomatic sinus bradycardia (fatigue,
syncope, dizziness, hypotension, angina, CHF)
#1 Rx: identify & Rx reversible causes
#2 Rx: IV atropine
alt Rx: IV epinephrine, dopamine,
transcutaneous or transvenous pacing
--------------------------------------------------------------- adenosine: transient block of impulse conduction
@ AV node; Rx PSVT
--------------------------------------------------------------- IV glucagon: Rx - blocker or CCB toxicity
--------------------------------------------------------------- although depressive symptoms can develop in
response to a stressor, meeting full criteria for
major depressive episode rules out adjustment
disorder & grief reaction
symptoms cause significant functional impairment
--------------------------------------------------------------- symmetric duskiness & coolness of fingertips/toes:
norepinephrine-induced vasospasm
o -1 agonist vasoconstriction results in
ischemia & necrosis of distal fingers & toes

--------------------------------------------------------------- Raynauds causes finger ischemia, progressing

from pallor cyanosis erythema
MC due to cold exposure or stress
--------------------------------------------------------------- drug-induced immune hemolytic anemia is a
rare complication of ibuprofen
gastric ulcers, GI bleeding, epigastric pain
--------------------------------------------------------------- corneal abrasion: absence of eye pain suggests
trigeminal nerve (V1) dysfunction, which
controls corneal sensation
--------------------------------------------------------------- peak airway pressure = airway resistance +
plateau pressure
plateau pressure = elastic pressure + PEEP
PEEP is calculated with end-expiratory hold
--------------------------------------------------------------- incidence of a disease is not changed by any Rx
prevalence may be affected by Rx of disease
--------------------------------------------------------------- hypercalcemia of immobilization: osteoclastic
bone resorption; pre-existing high bone turnover
median onset: 4 wks after immobilization
prevention: hydration & bisphosphonates
--------------------------------------------------------------- MCC of respiratory alkalosis: hyperventilation 2/2
pneumonia, high altitude, salicylate intoxication
---------------------------------------------------------------Obesity & precocious sexual development
adiposity can stimulate sexual hormone production
centrally & peripherally
adipocytes cause insulin & leptin
insulin stimulates
adrenal androgens peripheral adrenarche
(body odor, pubic & axillary hair, acne)
risk factor for PCOS, DM Type II
DHEA-S & low testosterone
o ovarian estrogen peripheral thelarche
leptin stimulates activation of
o hypothalamic-pituitary-gonadal axis & pulsatile
GnRH central precocious puberty LH/FSH
stimulation thelarche

first indicators of hypovolemia: pulse rate &

peripheral vascular constriction to maintain BP
--------------------------------------------------------------- acute pain & swelling of mid-line sacrococcygeal
skin & subcutaneous tissue: pilonidal cyst
MC in young males with body hair
infection of hair follicles form an abscess that
ruptures, forming a pilonidal sinus tract
Rx: drainage & excision of sinus tracts
DDx: perianal abscess, perianal fistula
--------------------------------------------------------------- unexplained CHF with diastolic dysfunction,
ventricular wall thickness with normal LV size,
proteinuria, easy bruising: cardiac amyloidosis
waxy skin, macroglossia, hepatomegaly, CTS
AA amyloidosis 2/2 RA, Crohns, osteomyelitis,
TB, lymphoma, vasculitis
Dx: abdominal fat pad biopsy with amyloid deposits
---------------------------------------------------------------Causes of hyponatremia
hypovolemic volume depletion (acute blood loss),
hyponatremia primary adrenal insufficiency,
GI loss (diarrhea, vomiting, bleed),
renal loss (diuretics)
SIADH (drugs, malignancy),
hyponatremia psychogenic polydipsia,
secondary adrenal insufficiency,
CHF, cirrhosis,
CKD, nephrotic syndrome

hypovolemic hyponatremia has appropriate ADH,

also renin, angiotensin, & aldosterone,
resulting in hypokalemic metabolic alkalosis
Rx: isotonic saline repletion suppresses ADH &
allow kidneys to excrete excess water
--------------------------------------------------------------- radial head subluxation (nursemaids elbow):
axial traction on forearm with elbow extended
arm held extended & pronated
no swelling or deformity
Dx: clinical, radiographs are normal
Rx: closed reduction with forearm supination &
elbow flexion, OR forearm hyperpronation

--------------------------------------------------------------- Trendelenburg sign: weakness of gluteus medius

& minimus; or superior gluteal nerve impingement
--------------------------------------------------------------- MCC of acute abnormal uterine bleed in adolescent:
immature hypothalamic-pituitary-ovarian axis,
resulting in anovulatory cycles
anovulation cause persistent endometrial proliferation
followed by heavy menses
#1 Dx: r/o pregnancy & bleeding disorders
Rx for acute abnormal uterine bleeding if
hemodynamically stable
#1 Rx: high-dose IV or oral conjugated equine
estrogen (rapid endometrium regrowth)
Rx: high-dose combined OCPs
high-dose progestin
tranexamic acid (anti-fibrinolytic)
estrogen promotes regrowth of endometrium over
the denuded epithelium from heavy bleeding
--------------------------------------------------------------- hypoventilation causes respiratory acidosis in the
post-ictal state
post-ictal state can be complicated by lactic acidosis
2/2 prolonged, forceful skeletal muscle activity
o manifest as metabolic acidosis
--------------------------------------------------------------- MCC cause of aplastic anemia in kids: Fanconis
short stature, microcephaly, abnormal thumbs,
hypogonadism, caf-au-lait spots, low-set ears
macrocytic anemia, thrombocytopenia
Dx: chromosomal breaks on genetic analysis
Rx: stem cell transplant
--------------------------------------------------------------- prolactin is stimulated by TRH & 5-HT;
inhibited by DA
hypothyroidism TRH/TSH prolactin
prolactin inhibits GnRH LH/FSH result in
o amenorrhea, libido, bone density
--------------------------------------------------------------- malaria chemoprophylaxis in areas with
chloroquine-resistant P. falciparum
o sub-Saharan Africa, south & southeast Asia
Rx: mefloquine (safe for pregos)
alt Rx: doxycycline, atovaquone-proguanil

--------------------------------------------------------------- duodenal atresia 2/2 to Down syndrome

requires surgical repair
pre-op cardiac assessment is essential (VSD, ASD)
--------------------------------------------------------------- repeated vomiting causes hypokalemic,
hypochloremic metabolic alkalosis
loss of H+ as HCl results in HCO3- retention &
no stimulus for HCO3- release by pancreas
ECV loss decreases renal perfusion activates
the R-A-A system aldosterone causes
hypokalemia & contraction alkalosis
Rx: IV normal saline & K+
--------------------------------------------------------------- anion gap = Na+ - (HCO3- + Cl-)
o normal anion gap: 6 12 mEq/L
---------------------------------------------------------------MCC of anion gap metabolic acidosis
lactic acidosis (hypoxia, poor tissue perfusion)
ketoacidosis (DKA, starvation, alcoholism)
methanol ingestion
ethylene glycol ingestion (oxalate accumulation)
salicylate poisoning (with respiratory alkalosis)
uremia (ESRD)
--------------------------------------------------------------- venous blood that contains a similar O2 content
as arterial blood may indicate cyanide poisoning
--------------------------------------------------------------- osmolar gap: calculated for suspected ethanol,
methanol, or ethylene glycol toxicity
--------------------------------------------------------------- HIV screening test: p24 antigen & HIV antibodies
o +result: confirm Dx with HIV-1/HIV-2
antibody differentiation immunoassay
initial HIV screen: 1x scene for age 15 65
regardless of risk factors
o Rx for TB, Rx for another STD
annual screening for high-risk groups: IVDA,
MSM, sex workers, sex partner of +HIV, STD Hx,
homeless shelter living, correctional facility
HIV testing with each pregnancy
--------------------------------------------------------------- Hep C screening criteria: elevated ALT, +HIV
status, HCV risk factors (IVDA Hx, blood
transfusion before 1992, chronic hemodialysis)

sexual contacts of +HCV should be screened

--------------------------------------------------------------- suspected acute appendicitis during pregnancy
MC symptom: RLQ pain
Dx: USS with graded compression
--------------------------------------------------------------- acute pancreatitis: most patients recover with
conservative management in 3 5 days
severe acute pancreatitis: +organ failure
local release of activated pancreatic enzymes into
the vascular system & vascular permeability,
leads to systemic hypotension, capillary leak,
shock, & end-organ damage
risk factors


Severe pancreatitis
age > 75, obesity, alcoholism,
CXR: infiltrates or pleural effusion
fever, hypotension, tachycardia,
tachypnea, basilar crackles,
abdominal tenderness or distension,
worsening BUN, low urine output
Cullen sign: periumbilical bluish
discoloration; hemoperitoneum
Grey-Turner sign: reddish-brown
around flanks; retroperitoneal bleed
CT or MRCP to look for
pancreatic necrosis & extrapancreatic
supportive, IV fluids to replace lost
intravascular volume
pseudocyst, necrotizing pancreatitis,
peripancreatic fluid collection, ARDS,
acute renal failure, GI bleeding

pancreatic pseudocyst: fluid collection

surrounded by a necrotic or fibrous capsule
o complication of acute pancreatitis; 3 4 wks
--------------------------------------------------------------- tick bite, acute febrile illness, altered mental status,
no rash: Ehrlichiosis (lone star tick)
o RMSF without spots
SE & south central US
leukopenia & thrombocytopenia, LFTs & LDH
Rx: empiric doxycycline

ceftriaxone: Rx neuro & cardiac manifestations

of Lyme disease
--------------------------------------------------------------- furosemide can cause hypoK+ & hypoMg++,
leading to V-tach
hypoK+ also potentiates effects of digoxin
--------------------------------------------------------------- PSVT: MCC is re-entrant pathway into AV node
sudden onset palpitations & generalized weakness
MCC of paroxysmal tachycardia without
structural heart disease
Rx: IV adenosine or vagal maneuvers AV node
conduction to unmask hidden P-waves within
QRS to clarify Dx of a-flutter or atrial tachycardia
o carotid massage, cold water face immersion,
Valsalva, eyeball pressure
--------------------------------------------------------------- pulseless electrical activity (PEA) Rx: CPR &

vasopressor (epinephrine every 3 5 min)

continue CPR & identify reversible causes
Reversible causes of asystole/PEA
5 Hs
5 Ts
tension pneumoTx
H+ ions (acidosis)
toxins (narcotics,benzos)
hypo- or hyperK+
no role for synch. cardioversion or defibrillation
--------------------------------------------------------------- synchronized cardioversion: Rx symptomatic
or sustained monomorphic VT & hemodynamic
unstable a-fib with rapid ventricular response
--------------------------------------------------------------- DDx of asthma vs COPD: spirometry before/after
inhaled bronchodilator challenge (albuterol)
low FEV1/FVC obstructive disease
o after bronchodilator challenge
FEV1 > 12% = asthma
no change = COPD
normal/high FEV1/FVC, low VC restrictive
normal DLCO = chest wall weakness, OSA
DLCO = interstitial lung disease

long-term Rx asthma: inhaled corticosteroids

long-term Rx COPD: inhaled long-acting
--------------------------------------------------------------- Ebsteins anomaly causes atrialization of the RV
risk factor: lithium exposure in 1st trimester
--------------------------------------------------------------- child with fever, preceding acute diarrheal illness,
pallor, purpura, acute renal failure: HUS
microangiopathic hemolytic anemia
o LDH, reticulocytosis, thrombocytopenia
schistocytes & giant platelets
U/A: hemosiderin, albumin, RBC & WBC casts
--------------------------------------------------------------- elderly patients with iron deficiency anemia
require colonoscopy & endoscopy despite a
single negative FOBT; MCC is GI blood loss
--------------------------------------------------------------- PSA screening: case-by-case basis by physician
& patient discussion
--------------------------------------------------------------- severe aortic stenosis is a/w GI angiodysplasia
resulting in occult GI bleed
--------------------------------------------------------------- acute mediastinitis: complication of cardiac surgery
2/2 intraoperative wound contamination
chest pain, fever, tachycardia, leukocytosis, &
sternal wound drainage or purulent discharge
within 14 days post-op
CXR: widened mediastinum
Rx: surgical debridement & prolonged ABX
Dx: surgical evidence of pus in mediastinum
--------------------------------------------------------------- a-fib is common within days after CABG &
resolution within 24 hrs; self-limited
Rx: rate control with -blocker or amiodarone
hemodynamic unstable a-fib with rapid ventricular
response Rx: synchronized cardioversion
Rx a-fib > 24 hr after CABG: anticoagulation or
--------------------------------------------------------------- MCC of bloody diarrhea without fever: E. coli
EHEC produces Shiga toxin, causing
inflammatory diarrhea with bloody stools
Dx: stool assay for Shiga toxin

Rx: supportive; ABX may risk of HUS

--------------------------------------------------------------- abdominal pain, N/V, Hx recent travel, myositis,
periorbital edema, eosinophilia: Trichinellosis
fever, diarrhea, splinter hemorrhages
ingestion of undercooked meat; up to 4 wks
MC in Mexico, China, Thailand
---------------------------------------------------------------Evaluation of chest pain in the ER
if unstable: stabilized, & assess underlying causes
(PE, pericarditis, aortic dissection)
if stable: O2, IV access, EKG, CXR
o possible ACS & low risk of aortic dissection
--------------------------------------------------------------- premature newborn with poor feeding, abdominal
distension, bloody stools: necrotizing enterocolitis
CXR: pneumatosis intestinalis (extravasation of
bowel gas into damaged bowel wall)
Necrotizing enterocolitis
risk factors
prematurity, very low birth weight,
mesenteric perfusion (hypotension,
congenital heart disease),
enteral feeding (formula > breast)
poor feeding, vomiting, blood stools,
abdominal distension
pneumatosis intestinalis,
portal venous gas, pneumoperitoneum
supportive, bowel rest,
empiric IV ABX, parenteral nutrition,
+/- surgery
complications septic shock, intestinal strictures,
short bowel syndrome, death
DDx: intussusception, milk-protein enterocolitis
--------------------------------------------------------------- child with mild/moderate dehydration: oral fluids
child with moderate/severe dehydration: IV bolus
o IV isotonic crystalloids only
---------------------------------------------------------------Rx for ischemic stroke
symptom onset within 3 4.5 hrs, IV alteplase
no C/I
within 24 hr of stroke onset,
no prior anti-platelet Rx
recurrent stroke, already on ASA

stroke, with a-fib (CHADS2)


ASA reduces risk of early recurrence of ischemic

stroke; continue indefinitely to prevent future strokes
clopidogrel: not for ASA-nave patients with stroke
unfractionated heparin/LMWH: should be avoided
in acute stroke; risk of bleeding
---------------------------------------------------------------Evaluation of suspected gastrinoma
initial test: endoscopy shows thickened gastric folds
& stomach/duodenal ulcers
next: fasting serum gastrin (off PPI for 1 wk)
if gastrin < 100 pg/mL = no gastrinoma
if gastrin > 1000 check gastric pH
o pH < 4 requires testing to localize gastrinoma
o pH > 4 = no gastrinoma
if gastrin is 110 1000 secretin stimulation test
o secretin stimulates gastrin release by gastrinoma
normal G-cells are inhibited by secretin
--------------------------------------------------------------- Turners is prone to osteoporosis 2/2 low estrogen
due to gonadal dysgenesis
--------------------------------------------------------------- Hx of nocturnal teeth grinding, pain with chewing,
referred ear pain: TMJ dysfunction
Rx: nighttime bite guard or surgery
--------------------------------------------------------------- non-glomerular hematuria: gross hematuria
with normal-appearing RBCs, no proteinuria
glomerular hematuria: microscopic hematuria,
MC due to glomerulonephritis or BM disease;
proteinuria, dysmorphic RBCs or RBC casts
--------------------------------------------------------------- proteinuria, transient gross hematuria following
acute pharyngitis: IgA nephropathy
hematuria within 5 days of URI (synpharyngitic)
--------------------------------------------------------------- MCC of papillary necrosis: NSAID
o NSAIDs, Sickle cell disease, Analgesic abuse,
Infection (pyelonephritis), Diabetes
--------------------------------------------------------------- bronchoalveolar lavage: samples lung cells

Dx: suspected malignancy & opportunistic infection

Dx: suspected PCP pneumonia
o non-productive cough, progressive dyspnea,
weight loss, tachypnea
o CXR: B/L interstitial alveolar infiltrates
o Dx sputum induction with hypertonic saline
o Dx: bronchoalveolar lavage if sputum is
not diagnostic
--------------------------------------------------------------- proximal deep veins (iliac femoral, popliteal) of
LE are the MC sources of symptomatic PE
--------------------------------------------------------------- adolescent female with hirsutism, irregular menses,
acne, 17-hydroxyprogesterone: CAH 2/2 partial
deficiency of 21-hydroxylase
precocious puberty in boys
concomitant aldosterone deficiency results in
salt wasting
androgen excess impairs hypothalamic sensitivity
to progesterone, resulting in GnRH secretion,
LH/FSH gonadal steroids
DDx: classic CAH 2/2 21-hydroxylase deficiency
(infant virilization & salt wasting), Cushings
(hypercortisolism), PCOS (amenorrhea)
--------------------------------------------------------------- diastolic rumble at the apex may be heard in a
large VSD due to flow across mitral valve
Dx: echo to determine location & size of defect
complications: pulmonary HTN & Eisenmengers
--------------------------------------------------------------- infant with meningitis, nuchal rigidity, lethargy,
large purpuric lesions, hypotensive: adrenal
hemorrhage 2/2 meningococcemia
(Waterhouse-Frederickson syndrome)
sudden vasomotor collapse & purpuric skin rash
MCC of death: adrenal gland failure
---------------------------------------------------------------Features of hypopituitarism
central hypothyroidism
amenorrhea, infertility, loss of libido, small testes
ACTH/cortisol deficiency (20 adrenal insufficiency):
pale skin, fatigue, hyponatremia, hypoglycemia,
normal aldosterone, normal serum K+

fever, progress to abdominal pain & salmon-colored

rash, then hepatosplenomegaly with intestinal bleed:
typhoid fever
--------------------------------------------------------------- gout begins with asymptomatic hyperuricemia &
progression to monoarticular arthritis
o swelling & pain in great toe due to
deposition of monosodium urate = podagra
uric acid in renal tubules = nephrolithiasis
chronic urate deposits in soft tissues = tophi
risk factors: HCTZ enhance uric acid reabsorption
---------------------------------------------------------------Dx panic disorder
1 unexpected full-symptom panic attack
Dx: clinical; drug screen, monitor vital signs,
EKG, & cardiac enzymes
Rx panic disorder
immediate: benzo, then tapered
long-term: SSRI/SNRI &/or CBT
---------------------------------------------------------------Water-soluble vitamin deficiencies
B1 (thiamine)
peripheral neuropathy (dry),
dilated cardiomyopathy (wet)
angular cheilosis, stomatitis,
B2 (riboflavin)
glossitis, seborrheic dermatitis,
normocytic anemia
pellagra (dermatitis, diarrhea,
B3 (niacin)
dementia, death) glossitis
cheilosis, stomatitis, glossitis,
B6 (pyridoxine)
irritability, confusion, depression
megaloblastic anemia, NTDs
B9 (folate)
megaloblastic anemia,
B12 (cobalamin)
confusion, paresthesia, ataxia
scurvy (punctate hemorrhage,
C (ascorbic acid)
gingivitis, corkscrew hair),
ecchymosis, petechiae

angular cheilosis: fissures at corners of lips

glossitis: hyperemic tongue
stomatitis: hyperemic/edematous oropharyngeal
mucous membranes, sore throat

hard, unilateral, non-tender solitary submandibular

or cervical lymph nodes in an older patient with
smoking Hx: SCC head & neck cancer
Dx: panendoscopy & biopsy
--------------------------------------------------------------- painful, fluctuant cervical lymphadenopathy:
bacterial infection
---------------------------------------------------------------DDx of hyperandrogenism in females
non-classic CAH
ovarian/adrenal tumors
Cushings syndrome
--------------------------------------------------------------- H1-antihistamines (diphenhydramine,
chlorpheniramine, hydroxyzine) have significant
anticholinergic effects 2/2 inhibition on
muscarinic receptors
urinary retention results from detrusor inactivity
controlled by pelvic splanchnic nerves
--------------------------------------------------------------- midazolam: induce conscious sedation during
medical procedure
--------------------------------------------------------------- young boy with headache, vomiting, bitemporal
hemianopsia, & calcified lesion above sella:
located suprasellar & inferior to optic chiasm
a/w diabetes insipidus; growth failure 2/2
hypothyriodism or GH deficiency
Dx: MRI; cystic calcified parasellar lesion
Rx: surgical removal
--------------------------------------------------------------- Brown-Sequard: damage to lateral spinothalamic
C/L loss of pain & temp, 2 levels below lesion
I/L motor weakness, spasticity, loss of vibration
& proprioception 1 2 levels below the lesion
I/L loss of all sensation at the lesion level
--------------------------------------------------------------- B/L lower extremity edema, stasis dermatitis, &
venous ulcerations 2/2 venous insufficiency

pressures in post-capillary venules damages

capillaries causing loss of fluids, plasma proteins,
& RBCs into tissues
RBC extravasation cause hemosiderin deposition
& discoloration; MC @ above medial malleolus
Rx: leg elevation, exercise, compression stocking
o if refractory venous duplex USS
o Rx: endovenous ablation
--------------------------------------------------------------- Ludwigs angina: infection of submandibular &
sublingual glands 2/2 tooth infection
rapidly progressive B/L cellulitis, firm induration
of submandibular space
dysphagia, drooling, fever, palpable crepitus
MCC of death: asphyxiation 2/2 airway constriction
Rx: ABX & tooth removal
--------------------------------------------------------------- fever, acute monoarthritis, hot, swollen joint with
ROM, ESR & CRP: septic arthritis
risk factors: underlying joint abnormality (RA,
OA, gout, prosthetic joint), intra-articular
glucocorticoid joint injections
Dx: synovial fluid analysis show leukocytosis
>50,000, +Gram stain, culture
Rx G+ cocci: IV vancomycin
Rx G- rod: IV 3rd gen cephalosporin
Rx negative microscopy: vancomycin
--------------------------------------------------------------- most significant risk factor for stroke = HTN
4x increased risk for all stroke types

standard deviation of normal distribution


Hx of blunt trauma or MVA, CXR with left

lower lung opacity, elevated hemidiaphragm, &
mediastinal deviation: diaphragmatic rupture
confirm Dx: abdominal & chest CT
--------------------------------------------------------------- hemineglect: right (non-dominant) parietal lobe
--------------------------------------------------------------- provoked seizure 2/2 severe hyponatremia
Rx: 3% saline, corrected @ 0.5 mEq/L/hr to avoid
osmotic demyelination or central pontine
myelinosis 2/2 rapid correction of hyponatremia
with excess water moving intra- extracellularly
DDx: rapid correction of hypernatremia results
in cerebral edema
--------------------------------------------------------------- MCC of death from acromegaly: cardiovascular
o excess IGF-1 risk of coronary heart disease,
cardiomyopathy, arrhythmias, LVH, &
diastolic dysfunction
--------------------------------------------------------------- brain death is a clinical Dx
o absent cortical & brain stem functions
HR does not accelerate after atropine injection
due to absence of vagal control
spinal cord may be intact: DTRs present
--------------------------------------------------------------- newborn with tachycardia, warm/flushed skin,
poor feeding, irritability, low birth weight,
maternal Hx of Graves: neonatal thyrotoxicosis
transplacental passage of maternal anti-TSH Rc
antibodies that bind to infants TSH receptors
can occur despite maternal Rx for Graves
Dx: maternal anti-TSH Rc antibodies
self-limited in 3 months
o Rx: methimazole + -blocker to prevent
A/E on developing nervous system
--------------------------------------------------------------- long-term tobacco use, chronic cough, JVD,
barrel-shaped chest, & hepatomegaly: COPD
with cor pulmonale
cor pulmonale: RV dysfunction caused by
pulmonary HTN due to underlying lung disease
(COPD), OSA, or pulmonary arterial HTN
dyspnea, angina, syncope, peripheral edema, RV S3
Dx: clinically & echo

definitive Dx: right heart catheterization showing

pulmonary artery systolic pressure (> 25)
--------------------------------------------------------------- portal HTN: portal venous resistance
2/2 cirrhosis or extrahepatic portal vein thrombosis
palmar erythema, spider angiomata, caput medusae,
complications: ascites, SBP, variceal bleeding
--------------------------------------------------------------- Rx acute psychosis: 2nd gen antipsychotic
o lorazepam as adjunct only for agitation
--------------------------------------------------------------- recent cardiac catheterization, anticoagulation with
heparin, sudden onset hypotension, tachycardia,
flat neck veins, & back pain: retroperitoneal
hematoma 2/2 bleeding from arterial access site
arterial puncture sites above the inguinal ligament
can extend into retroperitoneal space
Dx: non-contrast CT
Rx: supportive, bed rest, IV fluids, transfusion
avoid strenuous activity for one week
--------------------------------------------------------------- preterm fetus with severe congenital anomalies
incompatible with life (B/L renal agenesis)
Rx: spontaneous vaginal delivery
--------------------------------------------------------------- unilateral breast pain with isolated, firm, tender,
erythematous area, & fever: mastitis
Rx: frequent breastfeeding or pumping, analgesia,
anti-Staph ABX
DDx: breast abscess, plugged ducts, engorgement
---------------------------------------------------------------Iron poisoning
elemental iron is corrosive to GI mucosa
free radical production & lipid peroxidation
feature 30 min 4 days: abdominal pain,
hematemesis, melena, hypotensive shock
within 2 days: hepatic necrosis
within 2 8 wks: pyloric stenosis 2/2
gastric scarring
anion gap metabolic acidosis, serum iron,
XR: radiopaque tablets
whole bowel irrigation, IV deferoxamine
(binds ferric iron urinary excretion)
pre-natal vitamins appear as radiopaque on XR

--------------------------------------------------------------- progressively worsening dyspnea, bibasal crepitus.

S3, cardiomegaly, macrocytosis, AST > ALT:
dilated cardiomyopathy 2/2 alcoholism, resulting
in CHF
Rx: abstinence from alcohol reverses disease process
Rx: ACE-I slows progression
Rx: digoxin for systolic dysFx & rapid ventricular
rates due to a-fib or a-flutter
--------------------------------------------------------------- young healthy female with recent upper URI with
sudden onset CHF: dilated cardiomyopathy 2/2
acute viral myocarditis
MCC Coxackie B virus
Dx: echo shows dilated ventricles & diffuse
hypokinesia, resulting in low EF
Rx: supportive, manage CHF symptoms
--------------------------------------------------------------- concentric hypertrophy: 2/2 chronic pressure
overload (valvular stenosis)
eccentric hypertrophy: 2/2 chronic volume
overload (valvular regurgitation)
--------------------------------------------------------------- chronic mitral stenosis can cause RV hypertrophy
& RV heave 2/2 pulmonary HTN
--------------------------------------------------------------- young female with chronic anterior knee pain,
worse with climbing stairs on knee extension:
patellofemoral syndrome
a/w chronic overuse
Dx: patellofemoral compression test
Rx: exercises to stretch & strengthen thigh muscles
--------------------------------------------------------------- MC renal stones: calcium
high protein diet is a/w calcium stones
increased Na+ intake enhances Ca++ excretion
Dx: CT without contrast detects radiopaque &
radiolucent (uric acid) stones
Rx: dietary protein, oxalate, & Na+
o fluids & dietary Ca++
hypercalciuria & recurrent stones Rx: HCTZ
--------------------------------------------------------------- acute acetaminophen overdose: N/V or
asymptomatic for 24 hr

acute ASA poisoning: tinnitus, fever, hyperpnea

(respiratory alkalosis), & metabolic acidosis
--------------------------------------------------------------- acute Vit A overdose: N/V, blurry vision, dry skin
chronic Vit A toxicity: pseudomotor cerebri
--------------------------------------------------------------- abrupt onset B/L flaccid paralysis, loss of pain &
temp sensation below the lesion
anterior cord syndrome 2/2 spinal cord infarct
MC due to thoracic aortic aneurysm repair
anterior spinal artery is dependent on blood supply
from radicular arteries of thoracic aorta
UMN signs develop over days to weeks
vibration & proprioception are intact
--------------------------------------------------------------- sudden, painless loss of vision in one eye, with
pallor of optic disc, cherry red fovea, & boxcar
segmentation of blood in retinal veins: central
retinal artery occlusion
--------------------------------------------------------------- premature atrial contractions (PACs)
Rx if symptoms cause stress or SVT: -blocker
avoid precipitating factors: alcohol, tobacco, stress
--------------------------------------------------------------- post-MI secondary prevention; mortality benefits
o ASA, -blocker, ACE-I, statin
add clopidogrel for unstable angina/NSTEMI,
& post-PCI
clopidogrel is an ASA alternative
clopidogrel + ASA for post-PCI is more effective
than ASA alone; prevents subacute stent thrombosis
clopidogrel for STEMI with primary PCI
--------------------------------------------------------------- LMWH: only Rx post-MI for 48 hrs or until
angiography is performed
o not necessary after hospital discharge
---------------------------------------------------------------Lung cancer types
(squ-Ca++mous) necrosis &

small cell
large cell


Cushings, SIADH,

large, peripheral, irregular pulmonary nodule a/w

hemoptysis & weight loss: adenocarcinoma
--------------------------------------------------------------- painless, monocular vision loss, photopsia (light
flashes), floaters, & curtain coming down over
my eyes: retinal detachment
grey, elevated retina
Rx: laser therapy & cryotherapy
--------------------------------------------------------------- sudden loss of vision & onset of floaters:
vitreous hemorrhage
MCC: proliferative diabetic retinopathy
fundoscopy: loss of fundus detail, floating debris,
dark red glow
--------------------------------------------------------------- mask-like, immobile facial expression, bradykinesia,
resting tremor, & fenestrating, hypokinetic gait:
substantia nigra degeneration & DA activity
with anticholinergic activity
--------------------------------------------------------------- waddling gait: muscular dystrophy
spastic gait: UMN lesions (cerebral palsy)
wide-based, high-stepping gait: sensory ataxia,
loss of proprioception
staggering gait: vestibular ataxia, a/w vertigo &
broad-based gait: multiple system atrophy
--------------------------------------------------------------- non-tender ulcer on penis shaft with raised border
& smooth base, B/L inguinal lymphadenopathy:
primary syphilis (chancre)
Dx: dark field microscopy
o also HIV screening with ELISA
--------------------------------------------------------------- first-degree heart block: no further evaluation
a/w risk of heart failure, a-fib, & mortality
first-degree heart block with prolonged QRS
likely have conduction delays below AV node
o Dx: electrophysiology testing

--------------------------------------------------------------- lactose intolerance Dx: hydrogen breath test

indicates bacterial CHO metabolism
--------------------------------------------------------------- resting pill-rolling tremor in Parkinsons
starts in one hand, progress to other extremities
more pronounced with distractibility (mental tasks)
--------------------------------------------------------------- physiologic tremor: benign postural tremor
(holding arms ourstretched); usually not visible;
low amplitude, high frequency
o worsens with emotions, stress, caffeine
--------------------------------------------------------------- anterior urethra injury: distal to urogenital
MCC: straddle injuries, urethra instrumentation
perineal tenderness or hematoma, bleeding urethra,
normal prostate
--------------------------------------------------------------- posterior urethra injury: contains prostatic &
membranous urethra
MC a/w pelvic fractures
high-riding prostate, suprapubic pain, blood at
urethral meatus, scrotal hematoma, inability to
void, distended bladder
--------------------------------------------------------------- long-term prognosis of STEMI: duration of time
before restoration of coronary blood flow
o PTCA door-to-balloon time: < 90 min
o fibrinolysis door-to-needle time: < 30 min
--------------------------------------------------------------- androgens are produced in adrenals
estrogens are formed through conversion of
androgens by aromatase in granulosa cells of
the ovary in child-bearing women
o aromatase activity in ovaries ceases after
peripheral fat tissue also contains aromatase
conversion of adrenal androgens to estrogen by
adipose tissue alleviates menopausal symptoms
& mild hot flashes
estrogen is not produced in peripheral fat

initial menstrual cycles in pubertal females are

usually irregular & anovulatory 2/2 immaturity
of the hypothalamic-pituitary-gonadal axis
endometrium builds up under estrogen influence
in absence of progesterone
o progesterone is produced by corpus luteum
following ovulation; withdrawal of
progesterone as corpus luteum degenerates
results in menses
menstrual-like bleeding occurs due to estrogen
break-through bleeding
--------------------------------------------------------------- acute severe anemia with low/absent reticulocytes
in patient with sickle cell disease: aplastic crisis
o transient arrest of erythropoiesis results in a
severe drop in Hb
MCC: parvovirus B19
Rx: blood transfusion
DDx: aplastic anemia (pancytopenia),
hyperhemolytic crisis (appropriate reticulocytosis),
splenic sequestration (persistent reticulocytosis &
rapidly enlarging spleen)
--------------------------------------------------------------- neonatal tetanus: MC in infants of unimmunized
mothers, following umbilical stump infection
within 1st 2 wks of birth
poor suckling, fatigue, rigidity, spasm, opisthotonus
MCC of death: apnea or septicemia
--------------------------------------------------------------- pulmonary contusion is not clinically evident
immediately after injury; hypoxia & respiratory
distress develops hours later as pulmonary edema
sets in
IV fluids may exacerbate hypoxia
CXR: patchy, irregular alveolar infiltrates
DDx: myocardial contusion ( PCWP)
---------------------------------------------------------------Screen for developmental dysplasia of hips (DDH)
age 0 12 months serial hip exam at each visit
until walking
+Barlow or +Ortolani refer to orthopedics
asymmetric inguinal folds extending beyond
the anal aperture, & negative Barlow/Ortolani
hip laxity at birth resolves by age 2 wks
age 2 wks 6 months hip USS

age 4 6 months hip XR

Rx: Pavlik hip harness for infants < 6 months
complications of delayed Dx: Trendelenburg gait,
scoliosis, arthritis, avascular necrosis
--------------------------------------------------------------- Barlow method identifies a loose hip that can be
pushed out of the socket with gentle pressure
Ortolani method identifies a dislocated hip that
can be reduced into the socket; audible clunk;
confirms Barlow
B comes before O
o Barlow: we are going out tonight; hip can
be popped out
o Ortolani: Oh, its time to gO home; femoral
head is reduced
--------------------------------------------------------------- screening occult spina bifida: lumbosacral USS
abnormal USS spinal MRI
--------------------------------------------------------------- early pregnancy: N/V, bloating, constipation
serum quantitative pregnancy test can be
positive within 4 days of implantation
urine pregnancy test may take one week
Dx: pelvic USS for intrauterine vs. ectopic
--------------------------------------------------------------- sensitivity determines how well a test identifies
people with disease (to rule it out; SNOUT)
specificity determines how well a test identifies
people without disease (to rule it in; SPIN)
--------------------------------------------------------------- tick-borne paralysis: absence of prodrome fever,
rapidly ascending paralysis, normal CSF
Rx: meticulous search for tick results in
spontaneous improvement
DDx: Guillain-Barre (ascending symmetrical
paralysis, albuminocytologic dissociation)
---------------------------------------------------------------2nd degree AV block
Mobitz I
Mobitz II
AV node
below AV node
progressive PR PR & R-R
remain constant
leads to a

narrow or wide
exercise or
AV block
AV block
vagal maneuvers worsens
risk of complete low risk,
high risk;
heart block
AV node blockers: digoxin, -blockers, CCB
--------------------------------------------------------------- unexplained syncope evaluation: EKG
prolonged PR & QRS suggests intermittent
bradyarrhythmia or high-grade AV block
isolated PVCs with normal EF is not a/w syncope
---------------------------------------------------------------Rx symptomatic ureteral stone < 1 cm
pain control
-blocker (tamsulosin) facilitate stone passage
--------------------------------------------------------------- bethanechol: cholinergic agonist; Rx urinary
retention, atonic bladder
oxybutynin: anticholinergic; Rx overactive bladder
(detrusor instability)
imipramine: TCA with anticholinergic activity;
Rx childhood enuresis
--------------------------------------------------------------- Mg++-sulfate toxicity: depression of DTRs &
respiratory depression
o Mg++ blocks neuromuscular transmission &
cause CNS depression
Rx: Ca++ gluconate, stop Mg++-sulfate,
monitor DTRs
---------------------------------------------------------------Neonatal respiratory distress syndrome
tachypnea (RR > 60/min), grunting, nasal flaring,
intercostal retractions, cyanosis
surfactant deficiency results in alveolar
collapse & diffuse atelectasis
risk factors: prematurity, very low birth weight
CXR: diffuse, reticulogranular (ground-glass)
opacities, bronchograms
Rx: continuous PAP ventilation
--------------------------------------------------------------- MCC of respiratory distress in full-term infants:
transient tachypnea of the newborn

inadequate alveolar clearance at birth results in

mild pulmonary edema
CXR: B/L perihilar linear streaking
resolves by day 2; no long-term sequelae
--------------------------------------------------------------- persistent pulmonary HTN of the newborn
should be suspected in all term & post-term
neonates with cyanosis
high pulmonary vascular resistance result in
right-to-left shunting of deoxygenated blood
through foramen ovale & ductus arteriosus
tachypnea & severe cyanosis
CXR: clear lungs, vascularity
--------------------------------------------------------------- dry cough, weight loss, right arm pain, smoking Hx:
superior sulcus tumor
compressive symptoms: Horners, hoarse voice,
SVC syndrome, Pancoast syndrome (brachial
plexus invasion @ C8, T1)
shoulder pain radiating in ulnar distribution
--------------------------------------------------------------- swelling of head, neck, & arms upon waking;
plethoric face, engorged chest veins, smoking Hx:
superior vena cava syndrome
MCC: small cell lung cancer, non-Hodgkins
Dx: CXR with F/U CT & histology
--------------------------------------------------------------- painful, red corneal opacification & ulceration
a/w contact lens use: contact lens keratitis
o medical emergency!!
MCC: Pseudomonas
Rx: topical ABX
DDx: anterior uveitis, viral conjunctivitis, episcleritis
--------------------------------------------------------------- MC benign primary intracardiac tumor in LA:
cardiac myxoma
fever, weight loss, Raynauds
mimics mitral valve disease; obstruction of blood
flow across mitral valve, early diastolic rumble
complication: systemic embolization (stroke, TIA)
Rx: surgical resection

chest pain, fever, chills, cough, purulent sputum,

bronchial breath sounds, dullness to percussion,
TVF, & egophony: lobar pneumonia
--------------------------------------------------------------- unregulated spontaneous bladder contractions
that are unresponsive to cortical inhibition: urge
incontinence (detrusor instability) overactive
--------------------------------------------------------------- cirrhosis & portal HTN is a/w ascites &
peripheral edema 2/2 low albumin
hepatic hydrothorax can cause transudative
pleural effusion 2/2 cirrhosis without underlying
cardiac or pulmonary disease
#1 Rx: salt restriction & diuretics
#2 Rx: TIPS for refractory cases
definitive Rx: liver transplant
--------------------------------------------------------------- pleurodesis: prevents recurrent pleural effusion
or pneumothorax
o pleural space is artificially obliterated by
adhesion of the two pleurae
--------------------------------------------------------------- sickle cell trait patients are generally asymptomatic
MC complication: painless hematuria
isosthenuria: impaired concentrating ability
presents as nocturia & polyuria
--------------------------------------------------------------- halo around lights
gradual onset blurred vision, difficulty with
nighttime driving & fine print, glare: cataract
oxidative damage with aging causes progressive
lens thickening & loss of transparency
risk factors: advancing age, diabetes, smoking,
chronic sun exposure, glucocorticoid use
--------------------------------------------------------------- iron deficiency anemia is common in elderly
taking NSAIDs & ASA, resulting in chronic GIT
blood loss
elderly have low-grade chronic anemia at baseline;
idiopathic anemia of aging
evaluation: CBC, iron studies, FOBT
definitive Dx: upper GI endoscopy
Rx: withhold NSAIDS & ASA, initiate PPI

non-traumatic subarachnoid hemorrhage is

MC due to ruptured saccular or berry aneurysm
#1 Dx: non-contrast CT shows hyperdense regions
suspected SAH with negative CT requires
lumbar puncture
o opening pressure & xanthochromia
Rx: cerebral angiography & surgical clipping
--------------------------------------------------------------- night terrors occur during non-REM sleep
episodes of fear, screaming, crying, child cannot
be fully awakened; no recollection of the incident
triggered by acute stress, sleep deprivation,
illness, medications affecting CNS
DDx: nightmares (during REM, does not cry,
scream, or tachycardic; can recall incident)
--------------------------------------------------------------- hypokalemia, hypochloremia, metabolic alkalosis,
& normotensive: surreptitious vomiting
DDx: diuretic abuse (high urine chloride)
--------------------------------------------------------------- meningococcal meningitis: highly contagious
Rx: isolation, IV ABX, ICU setting
--------------------------------------------------------------- hCG is secreted by syncytiotrophoblast
doubles every 48 hr, peaks @ 6 8 wks gestation
maintains corpus luteum, which maintains
progesterone secretion until placenta takes over
also promotes male sexual differentiation
also stimulates maternal thyroid
--------------------------------------------------------------- progesterone inhibits uterine contractions during
estrogen induces prolactin during pregnancy
--------------------------------------------------------------- S4 can be heard during acute phase of MI due
to ischemia induced myocardial dysfunction
can be normal in healthy older adults
--------------------------------------------------------------- paradoxical splitting of S2 seen with myocardial
ischemia/infarction due to delayed myocardial
relaxation & delayed aortic valve closure
--------------------------------------------------------------- pulsus paradoxus seen with cardiac tamponade,
severe asthma, COPD, hypovolemic shock

Crohns or fat malabsorption are predisposed to

hyperoxaluria 2/2 oxalate gut absorption,
leads to oxalate stone formation
fatty acid absorption & bile salt recycling are
reduced in Crohns
normally, Ca++ binds oxalate in the gut, thus
preventing its absorption
in fat malabsorption, Ca++ preferentially binds fat,
leaving oxalate unbound & absorbed in the gut
also, failure to absorb bile salts damages colonic
mucosa, contributing to oxalate absorption
--------------------------------------------------------------- first unprovoked VTE: age-appropriate screening
(colonoscopy, mammogram) & CXR can identify
occult malignancy
unprovoked & recurrent VTE (thrombophlebitis,
DVT), smoking Hx, back pain, & weight loss
requires further workup: CT chest/abdomen/pelvis
--------------------------------------------------------------- osteonecrosis is a common complication of
sickle cell anemia 2/2 vaso-occlusion
MC sites: humeral & femoral heads
--------------------------------------------------------------- Charcot arthritis: joint destruction 2/2
deterioration of proprioception, pain & temp
MC a/w diabetic neuropathy, syringomyelia,
spinal cord injury, Vit B12 def, tabes dorsalis
--------------------------------------------------------------- infection can precipitate DKA due to systemic
release of insulin counterregulatory hormones:
catecholamines & cortisol
o resultant excess glucagon causes
hyperglycemia, ketnonemia, & osmotic diuresis
depletion of total body K+ stores
osmotic diuresis activates the R-A-A system,
thus accelerates K+ loss
osmotic diuresis urinary excretion of glucose,
ketones, Na+, Mg++, & phosphate
--------------------------------------------------------------- tumor lysis syndrome MC a/w Burkitts, ALL
Ca++, phosphate, K+, uric acid
o K+ & phosphate are intracellular ions
o released phosphate binds Ca++
Rx: allopurinol reduces acute urate nephropathy

dry beri beri: symmetric peripheral neuropathy

with sensory & motor impairments
wet beri beri: neuropathy + cardiac involvement
(cardiomegaly, cardiomyopathy, CHF)
--------------------------------------------------------------- denial: behaving as if an aspect of reality does not
exist; block acceptance of external sensory data
repression: blocking upsetting feelings from
entering consciousness; blocking inner states
dissociation: disrupting memory, identity, &
consciousness to cope with an event
isolation of affect: separating a though from its
emotional component
--------------------------------------------------------------- sublimation: channeling impulses into socially
acceptable behaviors
suppression: putting unwanted feelings aside to
cope with reality
--------------------------------------------------------------- transabdominal USS cannot visualize
gestational sacs when -hCG < 6,500
transvaginal USS can visualize an intrauterine
gestational sac when -hCG @ 1500+
o #1 Dx: r/o ectopic pregnancy
o failure to detect intrauterine or adnexal sac,
serial -hCG is required in 48 hrs
normal pregos, -hCG doubles every 48-72 hrs
until 10,000 - 20,000 IU/mL
ectopic pregnancies, -hCG levels increase less
--------------------------------------------------------------- respiratory alkalosis causes H+ dissociation from
albumin albumin-Ca++ ionized Ca++
total Ca++ is unchanged
crampy pain, paresthesia, carpopedal spasm
DDx: acidosis ionized Ca++
--------------------------------------------------------------- stool sample with oocysts on modified acid-fast
staining: Cryptosporidium parvum
severe diarrhea with malaise, nausea, anorexia
MC seen in HIV CD4 < 180
---------------------------------------------------------------Management options of ectopic pregnancy
Expectant: asymptomatic & no evidence of
rupture or hemodynamic instability
o demonstrates declining -HCG levels

tension (closed) pneumoTx: air within pleural

space pushes mediastinum to the opposite side,
obstructing venous return
Rx: needle thoracostomy (2nd IC, mid-clavicular)
before CXR or IV access for fluid resuscitation
--------------------------------------------------------------- dry eyes, photophobia, difficulty adapting to
darkness, dry scaly skin, follicular hyperkeratosis
on extensors: Vit A deficiency
MC @ age 2 3 yrs
keratomalacia (wrinkled, cloudy cornea)
Bitot spots (dry, silver-gray plaques on bulbar
--------------------------------------------------------------- sore throat, cheilitis, hyperemic & edematous
oropharyngeal mucous membranes, stomatitis,
glossitis, photophobia, normocytic anemia,
seborrheic dermatitis: riboflavin (B2) deficiency
--------------------------------------------------------------- ecchymosis, petechiae, hyperkeratosis, Sjogrens,
arthralgias, depression, neuropathy, coiled hair:
Vit C deficiency

Methotrexate: single-dose IM injection

o Rx unruptured ectopic pregnancy
o hemodynamic stability, normal baseline
liver & renal function
Laparoscopy: last resort Dx of ectopic
---------------------------------------------------------------Sodium bicarbonate therapy
Rx TCA overdose by alleviating depressant action
on myocardial sodium channels when QRS > 100
Rx salicylate/ASA overdose by alkalinizing urine
Rx severe hyperK+ by driving extracellular K+
into cells
--------------------------------------------------------------- child with acute, U/L cervical lymphadenitis,
tender, rapidly enlarging & fluctuant
MCC: Strep pyogenes, S. aureus
Rx: I&D + clindamycin (covers Strep & Staph)
--------------------------------------------------------------- child with U/L cervical lymphadenitis & Hx of
periodontal disease or dental caries
MCC: anaerobes
Rx: clindamycin or amoxicillin/clavulanate
--------------------------------------------------------------- amoxicillin covers streptococcal infections, but
not S. aureus, which produce -lactamase
--------------------------------------------------------------- dyspnea on exertion, weakness, fatigue, chest pain,
hemoptysis, clear lungs: pulmonary HTN
mean pulmonary artery pressure > 25 at rest
CXR: prominent pulmonary arteries with rapid
tapering of distal vessels (pruning) & enlarged
right heart border
untreated complication: cor pulmonale
--------------------------------------------------------------- severe persistent bronchial asthma requiring
multiple medications, recent weight gain, HTN,
bruising, acne, proximal muscle weakness:
Cushings 2/2 excess systemic corticosteroids
hypokalemia due to corticosteroids which have
mineralocorticoid activity that bind aldosterone Rc
Rx: spironolactone
--------------------------------------------------------------- morning stiffness, deformities, enthesitis,
dactylitis sausage digits @ DIP joints,
onycholysis, & nail pitting: psoriatic arthritis

Rx: NSAIDs, methotrexate, anti-TNF agents

DDx: tophi (gout), enterohepatic arthritis (UC,
Crohns), Gottrons papules (dermatomyositis),
Charcot joint (diabetes), osteoarthritis, RA
--------------------------------------------------------------- urethritis, asymmetric oligoarthritis, conjunctivitis,
mouth ulcers, & enthesitis (Achilles pain):
reactive arthritis
seronegative spondyloarthropathy
synovial fluid analysis is sterile
DDx: gonococcal septic arthritis
--------------------------------------------------------------- enthesitis: pain @ tendon & ligament insertion sites
MC a/w ankylosing spondylitis, psoriatic arthritis,
& reactive arthritis
--------------------------------------------------------------- pain with eye movement, proptosis, diplopia,
ophthalmoplegia: orbital cellulitis
MC predisposing factor: bacterial sinusitis
complications: cavernous sinus thrombosis,
subperiosteal abscesses
--------------------------------------------------------------- heel pain & tenderness, recent UTI on cipro:
Achilles tendinopathy 2/2 fluoroquinolone use
complication: tendon rupture
Rx: stop medication, avoid exercise
--------------------------------------------------------------- child with tachycardia, tachypnea, muffled heart
sounds 1 wk after cardiac surgery, with new
cardiomegaly on CXR: pericardial effusion
with progression to cardiac tamponade 2/2
post-pericardiotomy syndrome
inflammation from surgical intervention leads to
reactive pericarditis, pericardial effusion, &/or
tamponade (Becks triad: distant heart sounds,
JVD, hypotension)
Rx: pericardiocentesis or pericardiectomy
--------------------------------------------------------------- classic CAH: ambiguous genitalia (clitoromegaly)
& salt-wasting
nonclassic CAH: premature pubarche, hirsutism,
severe acne
---------------------------------------------------------------Management of RA


o MTX not for pregos, severe renal insufficiency,
liver disease, or excess alcohol intake
NSAIDs, COX-2 inhibitors, & glucocorticoids are
adjuncts for symptomatic relief, but do not reduce
disease progression or joint destruction
persistent symptoms > 6 months
o Step-up therapy with biological DMARDs
(etanercept, infliximab, adalimumab) + MTX
if inadequate response switch to an alternate
TNF- inhibitor & continue MTX
--------------------------------------------------------------- chronic abdominal pain, diarrhea, weight loss,
Hx of daily alcohol intake
Chronic pancreatitis
etiology alcohol, CF, duct obstruction, autoimmune
features chronic epigastric pain, malabsorption, DM
amylase/lipase can be normal,
dilated ducts, enlarged pancreas
CT scan show calcifications
pain management,
alcohol & smoking cessation,
pancreatic enzyme supplements
--------------------------------------------------------------- glycosylated Hb (HbA1c) is dependent on plasma
glucose concentration, reflective of blood glucose
over the average RBC lifespan (3 months)
hemolytic anemia causes a falsely low HbA1c
--------------------------------------------------------------- confusion, lethargy, psychosis, seizures
Evaluation of hyponatremia
test #1: serum osmolality > 290
o marked hyperglycemia
o advanced renal failure
if serum osmolality < 290
test #2: urine osmolality < 100
o primary polydipsia
if urine osmolality > 100
test #3: urine sodium < 25
o volume depletion, CHF, cirrhosis
if urine sodium > 25
o SIADH (concentrated urine), hypothyroid,
adrenal insufficiency
--------------------------------------------------------------- adrenal insufficiency lack of aldosterone

presents with hypovolemia, leading to ADH &

hyponatremia, thus concentrated urine
--------------------------------------------------------------- central & nephrogenic DI decreases ADH action,
thus renal water reabsorption, hypernatremia,
thus dilute urine
--------------------------------------------------------------- primary polydipsia is common with psychiatric
conditions (schizophrenia) 2/2 central defect in
thirst regulation
--------------------------------------------------------------- fever, productive cough, foul-smelling sputum
after upper GI endoscopy: anaerobic infection
Rx: clindamycin
--------------------------------------------------------------- ventricular remodeling occurs weeks months
post-MI, causing LV dilatation with thinning of
ventricular walls, resulting in CHF
Rx: ACE-I within 24 hr post-MI to limit
ventricular remodeling
---------------------------------------------------------------Late-term & post-term complications
cesarean delivery
meconium aspiration infection
perineal trauma

aging placenta has decreased fetal perfusion

oligohydramnios is an indication for delivery
risk factors: nulliparity, Hx of postterm pregnancy,
obesity, fetal anomalies
--------------------------------------------------------------- fever, diaphoresis, malaise, jaundice, dark urine
following a tick bite: Babesiosis
MC in NE U.S.; MC in post-splenectomy
parasite enters RBCs hemolytic anemia
no rash
Dx: Giemsa stain thick & thin
Rx: quinine-clindamycin or atovaquone-azithromycin
--------------------------------------------------------------- shoulder pain with passive internal rotation &
flexion @ shoulder: subacromial bursitis 2/2
microtrauma to supraspinatus tendon

--------------------------------------------------------------- gaze abnormalities, limb ataxia, sensory loss,

vertigo, Horners: Wallenberg syndrome
(lateral medullary infarct)
--------------------------------------------------------------- dizziness, inability to walk, stabbing facial pain,
topples over when sitting, reduced corneal reflex,
ptosis, horizontal nystagmus: Wallenberg syndrome
MC site: lateral medulla 2/2 vertebral artery or
PICA occlusion
Rx: IV thrombolytics (tPA)
Wallenberg syndrome
(lateral medullary syndrome)
vestibulo- vertigo, falling TOWARD the lesion,
difficulty sitting upright,
nystagmus (horizontal & vertical),
abnormal facial sensation/pain,
pain/temp loss on I/L face & C/L body
dysphagia, aspiration, dysarthria,
hoarseness, diminished gag reflex
autonomic I/L Horners (ptosis, miosis, anhidrosis)
motor function of face & body are spared
--------------------------------------------------------------- medial medullary syndrome: C/L hemiparalysis,
tongue deviates toward lesion, C/L loss of tactile,
vibration & position sense
--------------------------------------------------------------- lateral mid-pontine lesion: affect motor & sensory
nuclei of I/L trigeminal nerve
weak muscles of mastication, jaw jerk reflex,
impaired tactile & position sense in the face
--------------------------------------------------------------- medial mid-pontine lesion: C/L ataxia &
hemiparesis of face, trunk, & limbs
--------------------------------------------------------------- infant develops weakness, lethargy, poor appetite,
constipation, macroglossia, umbilical hernia:
congenital hypothyroidism
MCC: thyroid dysgenesis
infants appear normal at birth due to maternal
hormones in circulation
screening: T4 & TSH

varicocele: worsens with standing & Valsalva,

decreases when supine
spermatocele: painless, fluid-filled cyst @ head of
epididymis; mass outside the testes that contains
non-viable sperm; no change with position
--------------------------------------------------------------- flank pain, hematuria, left-sided varicocele that
fails to empty when recumbent: renal cell ca
also anemia or polycythemia, thrombocytosis,
fever, hypercalcemia, cachexia
obstruction of gonadal vein results in varicocele
Dx: abdominal CT
---------------------------------------------------------------Effect of intensive glycemic control in DM Type II
macrovascular complications (acute MI, stroke):
no change
microvascular (nephropathy, retinopathy)
complications: reduces risk
target HbA1c: 6 7%; no change in mortality
--------------------------------------------------------------- non-productive cough a/w ACE-I is due to
accumulation of kinins, which are normally
degraded by ACE
--------------------------------------------------------------- Hx of wheezing with ASA or NSAIDs, rhinitis,
post-nasal drainage: ASA-exacerbated
respiratory disease (AERD)
asthma, chronic rhinosinusitis with nasal polyps,
& bronchospasm or nasal congestion following
ingestion of ASA or NSAIDs
B/L glistening mucoid masses in nasal cavities
nasal polyps tend to recur
---------------------------------------------------------------MI infarction location
lead V1 V6
RCA or ST elevation in II, III, aVF
posterior LCX or ST depression in V1 V3
ST elevation in I & aVL (LCX)
ST depression in I & aVL (RCA)
ST elevation in I, aVL, V5 & V6
ST depression in II, III, aVF
ST elevation in V4R V6R

RCA occlusion a/w inferior wall MI can lead to

hypotension, AV block, & sinus bradycardia
--------------------------------------------------------------- Rx pheochromocytoma: always -blocker first,
then -blocker
-blockers first lead to unopposed stimulation of
vascular -receptors by catecholamines, results
in rapid, catastrophic BP
o -blockers decrease BP
o -blockers Rx tachycardia & tremors
labetalol can be used as initial Rx
--------------------------------------------------------------- SSRI A/E: anorexia & sexual dysfunction
--------------------------------------------------------------- personal Hx or family Hx of febrile seizures is
NOT a C/I to immunization (DTaP)
o febrile seizure are benign; no sequelae
immediate anaphylaxis following DTaP is the
only C/I for avoiding all vaccine components
unstable neurologic disorders or encephalopathy
within a week of DTaP are C/I to pertussis
component of the vaccine
--------------------------------------------------------------- fever, lower abdo pain, adnexal tenderness,
purulent discharge, cervical motion tenderness,
leukocytosis, ESR: PID
MCC of infertility in age < 30
N/V is an indication for hospitalization
Rx: IV ABX before cultures
o cefoxitin, or cefotetan/doxycycline, &
untreated complications: tubo-ovarian abscess,
pelvic peritonitis, sepsis
--------------------------------------------------------------- MS neurologic deficits can be exacerbated by
exercise or hot weather
internuclear ophthalmoplegia is caused by
demyelination of the MLF
--------------------------------------------------------------- fever, acute RUQ pain, jaundice, confusion,
hypotension: acute ascending cholangitis
infection of common bile duct 2/2 obstruction by
gallstones or stricture or bacterial contamination

#1 Rx: supportive & IV ABX

refractory cases: ERCP biliary decompression
---------------------------------------------------------------Medications a/w pancreatitis
o valproic acid
o diuretics
o sulfasalazine, 5-ASA (Rx IBD)
o azathioprine
o metronidazole
CT scan: swelling of pancreas with
peripancreatic fluid & fat-stranding
Rx: resolves with supportive care
--------------------------------------------------------------- cirrhosis, heart failure, diabetes, hypogonadism,
libido, pseudogout: hemochromatosis
AR inheritance
intestinal iron absorption & deposition in tissues
leads to oxidative damage
initial evaluation: serum iron studies
o serum iron, ferritin, & transferrin, TIBC
Dx: genetic testing for mutated HFE gene
o liver biopsy for staging
Rx: phlebotomy relieves iron overload
complications: hepatic fibrosis, cirrhosis, HCC
--------------------------------------------------------------- hemochromatosis is a/w Ca++ pyrophosphate
dihyrate (CPPD) deposition in joints, leading to
chondrocalcinosis (calcified articular cartilage),
which is a/w pseudogout
---------------------------------------------------------------MCC of male infertility
anabolic steroid use (testicular atrophy)
Klinefelters (testicular fibrosis)
mumps (orchitis)
myotonic dystrophy (testicular atrophy)
CF (B/L absence of vas deferens)
5--reductase deficiency
Prolactinoma (hypogonadism)
--------------------------------------------------------------- urine dipstick
o leukocyte esterase indicates pyuria
o nitrites indicate Enterobacteraceae (E. coli)
negative dipstick & +UTI symptoms require a
urine culture

---------------------------------------------------------------Prosthetic joint infection

MCC early onset: S. aureus, Pseudomonas
MCC delayed onset (> 3 months): S. epidermidis
---------------------------------------------------------------Unprovoked first seizure
Dx: brain CT without contrast if unstable
o identify intracranial/subarachnoid hemorrhage
Dx: MRI if stable/non-emergency situations
o identify structural causes of epilepsy, TBI,
cerebral infarct, CNS tumors, infections
---------------------------------------------------------------Hemorrhagic stroke sub-categories
1. subarachnoid hemorrhage: sudden onset severe
headache, N/V, meningismus
2. intracerebral hemorrhage: acute focal neurologic
deficits that worsen over minutes hrs
o headache, vomiting, altered mental status
Dx: head CT without contrast to r/o hemorrhage
--------------------------------------------------------------- child with lethargy, altered mental status, N/V;
Hx of fever, malaise, headache, cough, coryza, &
sore throat treated with ASA: Reye syndrome
pediatric ASA Rx: juvenile idiopathic arthritis
& Kawasaki s
Reye syndrome
microvesicular fatty infiltration &
y on liver Bx
hepatic mitochondrial dysfunction
pediatric ASA use for influenza or
VZV infection
o hepatomegaly
o acute liver failure
o encephalopathy
o transaminitis
o hyperammonemia
--------------------------------------------------------------- macrovascular fatty infiltration: alcoholic hepatitis
& nonalcoholic fatty liver disease (NAFLD)
--------------------------------------------------------------- NAFLD is MC due to peripheral insulin resistance
with peripheral lipolysis & hepatic FA uptake
o a/w metabolic syndrome, obesity, DM
Rx: diet/exercise, bariatric surgery for BMI 35

--------------------------------------------------------------- vague abdominal pain, fatigue, microcytic anemia,

positive FOBT, hepatomegaly with a firm edge:
colon cancer with mets to liver
liver is MC site of mets for colon cancer
Dx: abdominal CT with contrast
--------------------------------------------------------------- Werdnig-Hoffman (spinal muscular atrophy):
autosomal recessive degeneration of anterior horn
& motor nuclei
symmetric proximal weakness & hyporeflexia
does not affect pupils (vs. botulism)
floppy baby syndrome (also infant botulism)
---------------------------------------------------------------Hyperandrogenism in pregnancy
Luteoma of pregnancy
o B/L, solid ovarian masses of large lutein cells
o benign, MC in A-A
o new onset hirsutism & acne
o Rx: spontaneous regression after pregnancy
o high risk of female fetus virilization
Theca luteum cyst
o B/L multi-septated ovarian cysts on USS
o arise from high -hCG levels a/w molar
pregnancy or multiple gestation
o Rx: spontaneous regression after pregnancy;
suction curettage for complete moles
o low risk of female fetus virilization
Krukenberg tumor
o B/L solid ovarian masses on USS
o new onset hirsutism
o mets from primary GIT cancer
o high risk of female fetus virilization
DDx: PCOS (hyperandrogenism in non-pregos)
6 inattentive &/or 6 hyperactive/impulsive
symptoms, 6 months in at least 2 setting
functional impairment, before age 12 yrs
subtypes: inattentive, hyperactive/impulsive, or
combined type

impaired social interaction & communication,

restricted interests, insistence on routine,
delayed language: autism spectrum disorder
can occur without language impairment
--------------------------------------------------------------- risk factors for cholesterol gallstones: Caucasian,
obesity, female, rapid weight loss, OCPs, GB
hypomobility (fasting, prolonged TPN, pregnancy)
protective factors: low-CHO diet, exercise,
caffeinated coffee, ASA or NSAID use
--------------------------------------------------------------- female with joint pain, fatigue, ankle edema,
facial rash, proteinuria, & decreased C3: SLE
2/2 immune complex-mediated kidney damage,
resulting in complement activation ( C3)
DDx: cytotoxic antibodies (Goodpastures)
--------------------------------------------------------------- thalamic stroke involving VPL nucleus, which
transmits sensory info from C/L body
C/L hemianesthesia with transient hemiparesis,
athetosis, or ballistic movements
dysesthesia in areas affected by sensory loss:
thalamic pain phenomenon
DDx: internal capsule strokes (motor symptoms)
---------------------------------------------------------------Causes of urinary incontinence in elderly
detrusor contractility,
detrusor overactivity,
bladder/urethra obstruction (tumor, BPH)
urogenital fistula
neurologic dementia (Alzheimers, Parkinson, NPH),
MS, SCI, disk herniation
potentially DIAPPERS
reversible Delirium
Infection (UTI)
Atrophic urethritis/vaginitis
Pharma (-blockers, anticholinergics)
Psych (depression)
Excess urine output (diuretics, DM, CHF)
Restricted mobility (post-op)
Stool impaction
Dx: U/A with culture

Hx of painful, itchy, red streaks on chest, then

arms; Hx smoking: superficial migratory
thrombophlebitis 2/2 Trousseaus syndrome
Trousseaus: hypercoagulable disorder with
recurrent, migratory superficial venous thrombosis
at unusual sites (arms, chest); Dx prior to or during
occult visceral malignancy; MC pancreas
evaluate: abdominal CT r/o pancreatic carcinoma
--------------------------------------------------------------- oliguria s/p renal transplant, HTN, BUN & Cr,
renal Bx: lymphocytic infiltration & vascular
involvement with intima swelling: acute rejection
Rx: IV steroids
---------------------------------------------------------------Late presentation of aortic coarctation
asymptomatic HTN, chest pain,
claudication, headache, epistaxis,
heart failure
brachial-femoral delay,
continuous cardiac murmur from large
CXR: rib-notching, 3 sign
confirm Dx: echo
balloon angioplasty +/- stent
bicuspid aortic valve, VSD, Turners
mild: tachycardia, tachypnea, ataxia, dysarthria,
moderate: bradycardia, lethargy, hypoventilation,
severe: coma, CV collapse, v-fib, acidosis
--------------------------------------------------------------- bradycardia a/w hypothermia is refractory to Rx
with atropine & cardiac pacing, but improves
with correction of hypothermia
Rx hypothermia
warmed crystalloid IV fluids for hypotension
intubation if comatose
rewarming techniques to improve
hemodynamic status
o mild cases: passive external rewarming
(cover with blankets)

moderate: active external rewarming (warm

blankets, heating pads, warm bath)
o severe: active internal rewarming (warmed
pleural or peritoneal irrigation, warmed
humidified oxygen)
--------------------------------------------------------------- TBI of any severity can lead to post-concussive
headache, confusion, amnesia, mood alteration,
difficulty concentrating, vertigo, sleep disturbance
resolves with symptomatic treatment within
weeks to months following TBI
DDx: delayed subdural hematoma (neuro deficits)
--------------------------------------------------------------- hypochromic, microcytic anemia unresponsive to
iron supplementation: thalassemia
2/2 reduced Hb synthesis
--------------------------------------------------------------- acute bleeding with liver failure Rx: FFP to
replace clotting factors
o liver failure hepatocytes cannot utilize Vit K
---------------------------------------------------------------Aspiration syndromes
pathophy lung parenchyma
lung parenchyma
aspiration of oral
aspiration of
cavity anaerobes
gastric contents
with acid injury
days after aspiration
hours after
fever, cough, sputum
range from
asymptomatic to
non-prod cough,
resp distress
infiltrate in dependent infiltrates in one
lung (RLL)
or both lower
lobes; resolves
without ABX
ABX: clindamycin,
or -lactams &
no ABX
-lactams inhibitors

aspiration pneumonitis: acute lung injury 2/2

chemical burn from gastric contents

aspiration pneumonia: infection by

oropharyngeal secretions 2/2 impaired
consciousness (overdose, seizure, anesthetics)