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UWORLD Internal Medicine

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Epi:
For a cross-sectional study: null means that there is simply no relationship
o For a cohort: null means for both groups there is no diff btwn their outcomes
Musc/Derm:
Cellulitis: obesity, tinea pedis (barrier disruption), regional LAD, strep & staph
Erysipeloid: occupational dz, affects fingers & hands
Felty syndrome: form of RA w/splenomegaly & granulocytopenia
Sarcoid Tx thats Symptomatic: glucocorticoids
SLE w/renal involvement tx: cyclophosphamide
Anti-phospholipid syndrome: hypercoag, manage w/heparin when preg, longer PTT paradox
Anserine bursitis: just below knee joint medially, valgus stress doesnt reproduce pain, norm
XRAY, worse at night when knees touch
RA: periarticular osteopenia and joint margin erosions
MC site for ulnar nerve compression is at elbow: presents as hand weakness (interosseus
muscles) and decreased sensation in 4th and 5th digits
Erysipelas: MC from GAS; Sudden onset sharply-demarcated, erythematous, edematous, tender
skin w/raised border, febrile
Hi-dose steroids myopathy: diffuse muscle weakness and rhabdomyolysis
Reactive arthritis: asymmetric oligoarthritis a/w urethritis, conjunctivitis, mouth ulcers
Disc herniation tx: NSAIDs & early mobilization (exercise not shown to be beneficial), and if still
bad 4-6wks, get MRI or CT.
HIV drug SE:
o Didanosine: induced pancreatitis
o Abacavir: Hypersensitivity
o Lactic acidosis from NRTIs
o S-J syndrome from NNRTs
o Nevirapine: liver failure
Impingement is present in all rotator cuff tendonitis and improved ROM after lidocaine injection
distinguishes it from rotator cuff tear. MRI
Non-inflmm comedones: topical retinoids
Inflmm acne: topical benzyl or topical AB
Mod-severe inflmm acne: oral AB
Recalcitrant acne, nodulocystic, scars present: isotretinoin
Wegeners: since its a vasculitity, goes w/subQ nodules (painful), palpable purpura, and
pyoderma gangrenosum-like non-healing ulcerative lesions ; c-anca against proteinase-#
Warning signs for back pain: weight loss, >50yo, nighttimepain, greater than 1mo first step is
plain XRAY to see lytic lesions or spinal infection
Gout xray: punched out erosion w/rim of cortical bone
OA: narrow space w/osteophytes, subchondral sclerosis/cysts
RA: periarticular osteopenia & joint margin erosions
Hearing loss in pagets: from bone mineral density loss in the cochlea capsule
Hypervitaminosis A: abundant mineralization of the periosteum
Asymmetric polyarthritis in teen: gonococcal arthritis (sometimes comes with tenosynovitis and
skin rash); Dx: gram statin of synovial fluid, bl cultures and urethral cultures
Hydroxychloroquine: for pts w/SLE w/arthritis and skin manifests chk eyes (retina) every
6mos.

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Heat stroke: >105; seizures, ARDS, DIC, hepatic/renal failue can occur PE: scattered rales +
low plates and PT/PTT prolonged
Malignant melanoma: excisional biopsy with narrow margina and depth thru subQ fat if bad
after this biop, then take wider margins of 1cm if <1mm deep if deeper than 1mm, sentinel LN
study
Lupus arthritis MC affects MCP and PIP like RA!
Acrochordon: a skin tag
Micro:
HIV TB positive PPD Tx: requires prophylaxis in form of ISN + pyridoxine for 9mos (CXR
unremarkable)
Disseminated fungal infection test: urine antigen test
Histo tx: itraconazole preferred tx
Actinomycosis: GP branching bacilli; Tx is hi-dose penicillin for 6-12 wks
G-B is opposite in presentation of botulism in that one ascends the other descends
Inactive vaccines for HIV pts: Tdap, pneumo, flu, Hep A, Hep B, meningococcal, HPV, Hib, and live
if CD4>200: MMR, Varicella, Zoster (>60yo)
o No BCG vac (live), anthrax, typhoid, oral polio
o Recommendation for meningitis is the same as for non-HIV pts: college age, asplenia,
travel exposures
Legionnaires dz tx: erythromycin (Z-pak)
Clindamycin: covers GP, anaerobes but not GN
First line tx for human bite: amox-CA to cover GP, GN, anaerobes
EBV: lymphs are convoluted nuclei with vacuolated cytoplasm, maculopapular rash (mebe),
palatal petechial
Rubella: erythematous maculopapular starts on face and progresses down; occipital & posterior
cervical LAD, arthritis also in adults, mild coryza & conjunctivitis
pneumovax <65yo: lung, CVD, DM, chronic liver disease, alcoholism, cochlear implants
Vaccines that have peptides (not polysacharrides) can illicit T cell response b/c can be presented
to T cells (not polysacharrides). Pneumovax is only a poly so it creates a B cell response that
doesnt use T cells; things are conjugated to tetanus toxoid protein to illicit T and B cell response
for longer memory
Disseminated gonorrhea: polyarthritis, tenosynovitis, painless vesculopustular skin lesions on
shins, ankles and wrists.
IV ceftriaxone for Lyme: for early diss dz or late dz oral doxy is good for EM
Allergic to penicillin for syphilis tx: doxycycline for 14d
Cocci: arthralgias & erythema multiforme
Trichinosis: from pig, starts as diarrhea/vomit infection; then splinter hemorrhages,
conjunctival and retinal hemorrhages, periorbital edema, chemosis, jaw and neck pain; then
muscle pain, tenderness, swelling & weak
Treatment of malignant otitis externa (pseudomonal infection in DM2 pts): ciprofloxacin
Trimethoprim SEs: hyperK and increased Cr b/c inhibits ENAC channels like amiloride in CDs
and competes with Cr secretion in the PTs
Serous otitis media (non-infectious) in HIV: the MC middle ear pathology in AIDS
All chronic liver dz pts: vaccine w/hep A and B
HIV vaccines: pneumococcus recommended for pts w CD4 >200 (also MMR); hepA only if pt
suffering from hepB or IVDU, homosexuals; no meningitis
CMV and EBV both have atypical lymphs but EBV only heterophile +
o CMV lacks pharyngitis and cervical LAD of EBV
CSF analysis in meningitis

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o

WBC
Glucose
Protein
Normal
0-5
45-80
18-58
Bacterial
>1000
<40
>400
meningitis
TB
5-1000
<40
>400
Viral
100-1000
45-80 (N)
<100
G/B
0-5
45-80
45-1000
Herpes enceph High + RBCs
norm
norm
Syph tx if allergic to penicillin: doxycycline oral or z-pack but resistance w/Z
o Secondary syph Sx: rash inc. palms and soles, generalized LAD, fever, sore throat, malaise
(constitutional Sx)
Rash starts on trunk and moves to extremities (whereas rickettsia rash starts on
extremities and moves inwards these pts also have severe headache and
myalgias)
Crypto meningitis tx: amp + flucytosine an w/clinical improvement, d/c and start fluconazole PO
HIV pt w/esophagitis: most likely candida so give fluconazole, but if doesnt respond in 3-5d,
esophagoscopy w/cytology, biopsy and culture cld be HSV (give acyclovir) or CMV (give
ganciclovir)
Ocular toxo: necrotizing retinochoroiditis looks white, fluffy lessions surr by retinal edema
and vitritis
HIV retinopathy: benign, cotton wool spots on retina that remit spontaneous
CMV retinitis: yellow-white patches of retina opacification + retinal hemorrhages; tx: ganciclovis
or foscarnet
Can get reactive arthritis after chlamydia but also: shigella, salmonella, yersinia, campylobacter
and c-dif
MAC vs. whippeli: acid-fast vs. non-acid fast (both PAS-positive macrophages
Osteomyelitis a/w nail puncture wound: PSEUDOMONAS
o Tx: quinolones and surgical debridement aggressively
Ehrlichiosis: spotless rocky mtn lone star tick fever, malaise, h/a, n/v, leukopenia &
thrombocytopenia
Babesia tx: atovaquone-azithromycin or quinine-clindamycin
Cardio
CHF: respiratory alkalosis w/hypoxia - highly suggestive of CHF vs COPD
OD beta-blockers: brady, AV block, hypotension, diffuse wheezing; TX: glucagon
PVCs aSx: observation; Sx: Amiodarone
Cold leg without pulses means a arterial occlusion most likely from thrombus from large MI
creating ventricular aneurysm
Enterococci endocarditis: in pts with genitourinary manipulation
Hypokalemia Sx: hyporeflexia, decreased muscle strength, imbalance, broad/flat T waves, U
waves, ST depression, premature ventricular beats (a-fib, torsades de pointes, v-fib can occur)
Diastolic HF: S4, exertional dyspnea, prolonged HTN
Lidocaine: given to prevent ventricular tachy and v-fib in post-MI pts (or ACS); SE: asystole
Pulseless electrical activity (w/ a-fib): CPR & epinephrine (Tx)
o Pulseless vent tachy/v-fib: non-perfusing rhythm therefor defib (Tx)
o Less severe: v-tachy, a-fib w/rapid ventricular response not yet pulseless: synchronized
electrical cardioversion (Tx)
Septic shock: low bl flow back to heart dec RA, pulm artery and PCW pressures; CO increases to
maintain tissue perfusion; early on, warm/flushed extremities

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Hypovolemic shock: dec RA, RV, pulm A, and PCW pressures; SVR inc to maintain perfusion
LAD occlusion: cardiogenic shock due to LV damage, inc PCWP, dec CO, inc SVR
Hemochromatosis-induced cardiomyopathy: reversible (sarcoid and amyloid are not but sarcoid
can be controlled w/glucocorticoids)
1st line for stable angina tx: beta blocker, then Ca-C blocker, nitrates for acute setting
Electrical alterans (or beat-to-beat variation in QRS axis): pericardial effusion (or low-voltage
QRS); diffuse ST segment elevation: pericarditis
Ventricular aneurysm: persistent ST-segment elevation after recent MI or Q waves in same
leads; can cause mitral regurg, embolism
o Dx of ventricular aneurysm: echo showing dykinetic wall motion of portion of LV
Pulsus bisferiens (biphasic): AR w/ or w/o AS and in HCM
hyperK = bradycardia, sine wave pattern; immediate tx is Ca gluconate
aortic coarctation: ECG shows inc voltate of QRS (due to LVH) and ST and T wave changes in left
precordial leads (like depression and inversion, respectively)
Beta blocker OD: bradycaria & hypotension, AV block wheezing
Dig toxicity: bradycardia & normotensive, blurred vision, disturbed color perception, headache
& ab pain; tx w/ anti-dig ABF
o Arrhythmia: atrial tachy w/AV block
MI can cause S4: ischemic damage from MI diastolic dysfunction & stiff LV
Angiodysplasia: a/w end-stage renal dz and AS AS causes turbulent blood flow to break von
wilibrand multimers (acquired vWD) = inc risk of bleeding.
o Diverticulosis MCC painless lower GI bleeding
PACs risk factors: smoking, alcohol, caffeine, stress only tx if SVT w/Beta-blockers
MVP: disappears w/squatting b/c increases preload; can cause atypical cardiac pain lasting 5-
10s that is unrelated to anything.
Differ NSTEMI from unstable angina: NSTEMI has changes in troponin and angina has no
changes
Thrombolytics contraindications: cardiogenic shock (use PCI), prior intracerebral hemorrhage,
ischemic stroke <3 mos, suspected aortic dissection, active bleed
o PCI good within 12 hrs of onset
Tx for right ventricular infarction that presents w/hypotension: normal saline to increase BP,
then if still low, dobutamine
Heart block (3rd is a/w Lyme dz)
o 1st: PR greater than 0.2 s
o 2nd I: longer and longer; II: dropped beat w/no elongation
o 3rd: MCC bradycardia w/rates 30-50; no atrial conduction to ventricles; very symptomatic
w/weakness, syncope and ventricular arrhythmia; uncoordinated p and QRS complexes
descending thoracic AA a/w: splenic ischemia, renal insufficiency, lower extremity ischemia,
focal neuro deficit due to spinal cord ischemia
PE: presents w/increased JVD, edema, tachycardia
Tx increasing angina with increased beta-blocker & increased nitrates
o If still bad: coronary angiography
First step in chest pain evaluation (even if atypical): stress test > pharma stress test; adenosine
nuclear perfusion stress test is contraindicated in ppl w/asthma
V-tachy: QRS >0.12; a/w previous MI causing structural heart changes, canon waves in JVD b/c
of disorganization btwn ventricles and atria
WPW: a type of AV reentrant tachycardia syncope shortened PR delta wave
ACD NSTEMI tx: beta blockers IV improve filling and perfusion, also use aspirin, IV nitrates,
LMWH, clopidogrel, statin; dont use warfarin
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Sick-sinus syndrome (aka SA node dysfunction): a-fib or flutter alternates with bradycardia
A-fib tx: warfarin & metoprolol
Digoxin tx for HF: no improvement on survival but good for Sx and decreases hospitalizations
so good to add to regimen in someone w/class IV
Prolonged QT Sx: syncope and cardiac arrest due to torsade de pointes
AR valve replacement: LV enlargement signs, adverse hemodynamic effects on LV, EF <50-55%
Cardiogenic vs hypovolemic shock: PCWP is low in hypovolemic shock (with inc SVR, dec BP, dec
CO, inc HR) and HIGH in cardiogenic shock (b/c of the back-up of blood)
Ventricular fibrillation as cause of death during MI: ischemia creates re-entrant pathways, and
reentrant arrhythmia is ultimate cause of death in pts with v-fib.
Theophylline toxicity: headache, insomnia, seizures, nausea/vomit, arrhythmias
Pt w/acute HF due to diastolic dys (i.e. HTN): give nitrates even better than morphine and
loops b/c work FASTER (and faster than hydralazine) dont give thou if pt hypotensive
Beta-blocker OD: brady, AV block, hypotension, diffuse wheezing
o Antidote: glucagon
Septic shock: low PCWP and higher than normal mixed venous O2 amount due to hyperdynamic
circulation; preload pressure is also down, SVR is down, cardiac index (pump function) is up
while in hypovolemic and cardiogenic shock the index is DOWN (also in these two, O2 extraction
is high and return of venous blood shows LOW O2 conc.)
Aortic dissection: if involved spinal arteries can result in SC ischemia which presents as LE
weakness; also pleural cavity can cause hemothorax seen as pleural effusion XRAY; Dx: TEE, or
contrast CT too see blood flowing
PE can cause: RV dilation, RBBB, RV strain, RV hypokinesis, decreased CO, decreased coronary
perfusion and RV myocardial O2 supply, elevated JVD, accentuation of 2nd heart sound
Lidocaine and ACS: can stop v-tachy or v-fib in pts w/ACS (MI), but shouldnt be given as
prophylaxis in even someone with ventricular premature beats b/c also it decreases the risk,
and increases the risk for ASYSTOLE
Cholesterol emboli after angio and catheter placement: blue toe syndrome, livedo reticularis
with reddish to cyanotic reticular discoloration of skin, acute renal failure, GI pain and nausea,
pancreatitis, increased eosinophils in blood, + low complement levels
Dig toxicity Sx: nausea, vomit, diarrhea, vision changes, arrhythmias felt as palpitations = has
narrow TI
Acut hemolytic transfusion rxtn: sx of fever, chills and flank pain and can lead to DIC and renal
failure and shock; due to preformed ABs to donor RBCs as a result of ABO mismatching
A-flutter mech: reentrant circuit that rotates around tricuspid annulus
Ddx for hypoxemia and bilateral infiltrates on CXR inc cardiogenic pulm edema and ARDS diff
based on PCWP w/<18 means ARDS and > is heart
o Tx ARDS w/PEEP b/c of dec lung compliance
AAA: strongest prediction of growth and rupture is large diameter and cig smoking; surg is
>5.5cm, >1cm/yr or Sx i.e. ab, back, flank pain, limb ischmia regardless of an size
Becks triad: hypoT, distended neck veins, muffled heart sounds
Constrictive pericarditis: signs of venous overload b/c of impaired filling like elevated JVD,
ascietes, pedel edema; kussmauls signs, pericardial knock (early heart sound after S2), sharp X
and Y descents b/c pericardium collapses
Giant cell arteritis (temporal arteritis): can involve large vessels of aorta and aortic aneurysm is
a common complication.
hypoCa: hyperactive DTRs, muscle cramps, convulsions (i.e. blood transfusions with citrate as
preservative)
During stress test hold meds: BBs, CCBs, and nitrates; continue ACE, diuretic

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Marfans suffer from MVP & AR (which can be result of aortic dissection!)
Rate-control Rx for A-fib: diltiazem, verapamil, metoprolol, digoxin
CHADS2 is for anti-coagulation score: 1 point for age >=75, HTN, DM, CHF, prior stroke (2pts);
>2 is warfarin/dabigatran
Differentiate restrictive from hypertrophic (b/c both cause diastolic dysfunction) via symmetric
or aSym thickening of ventricles
Beta-blockers improve mortality in STEMI: dec O2 demand and inc diastole thereby increases
coronary perfusion
o Also in STEMIs always give heparin, ACE-I (shown to improve mortality in STEMI), and
aspirin (also improves survival)
o Never use CCBs in STEMI b/c cause reflex tachy and inc O2demand
PVC;s: can occur after MI with more frequency, just observe then suppressing them w/anti-
arry meds worsens survival; look like wide QRS, bizarre morphology and compensatory pause
o 1st line tx for Sx pts: beta-blockers to delay conduction to ventricles
o 2nd line: amiodarone
Digoxin tx: for a-flutter and a-fib (any atrial arry to delay conduction down to ventricles)
o Digitalis toxicity: atrial tachycardia (due to increased ectopy) and AV block occurring at
the SAME TIME
Adenosine: 1st line pharma (after vagal maneuver) for PSVT. If fail, try dig
DC cardioversion: [P]SVT w/unstable vitals (low BP), refractory chest pain
Endocrine:
The single MCC aSx isolated elevated alk phos in elderly is Pagets (osteitis deformans)
o Bone pain due to prostate mets: elevated alk phos, higher >4 PSA and hyperCa
Glucagonoma: DM, necrolytic migratory erythema (like eczema), weight loss, diarrhea, anemia of
chronic disease; dx: hyperglycemia w/elevated glucagon>500, CT/MRI to localize.
Hyperthyroidism: proximal musc myopathy that can look like polyomyositis
Pancreatitis due to GS: even if stone passes, and itis resolves, must take GB OUT
MC side effect of radioactive Iodine tx for graves: hypoT
hyperT tx: before giving radioactive therapy, give methimazole to deplete thyroid hormone
Acute panc management: conservative w/analgesics (meperidine, fentanyl), IV fluids, NPO
o ERCP: only if a stone is causing the panc, not if its alcohol causing it
hypoCa: prolonged QT
autoimmune hypoparathyroidism: APECED = autoimmune epolyglandular endocrinopathy
candidiasis & ectodermal dysplasia; in pts w/mucocutaneous candidiasis
Intensive BP control is the only thing shown to slow renal decline in diabetics once AZOTEMIA
develops why they are put on ACE and goal is <130/80
Cushing: hypertension due to vasoconstriction from cortisol, insulin resistance and increased
mineralocorticoid activity (low K)
SIADH cause: NSAIDs!!!!
o Suspect w/low plasma osmolality (<280) and high urine osmolality (>100) & hypoNa
Steroid-induced myopathy: sounds like polyomyositis w/prox musc weakness, but with normal
CK levels & ESR
Addisons: eosinophilia present
o Dx: early morning cortisol (should be high >15, 5-15 is intermediate), ACTH (if high is
diagnostic) and cosyntropin test
Cosyntropic is like ACTH, and an inc in cortisol >20 in 30-60m rules out AI
If adrenal gland atrophy, could be ACTH deficiency (central AI)
Cushings Dx: 24 hour free cortisol and low-dose dexamethasone suppression test

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Hearing loss in pagets: correlates w/loss of bone mineral density in cocholear capsule; also inc
headaches, inc hat size
Acromegaly: #1 cause of death is congestive heart failure; inc risk for LVH; also inc risk for
hypertension & hyperglycemia
3 causes of reduced iodine uptake in thyroid test w/thyrotoxicosis: subacute granulomatous
thyroiditis (painful), subacute lymphocytic thyroiditis (painless), levothyroxine OD
(exogenous), iodine-induced thyrotoxicosis
hyperCa due to metastatic dz tx: bisphosphonates for long-term tx
Resistance to thyroid hormones causing hypoT: elevated T3/4 and normal TSH
Organophosphate poisoning: remove clothes to prevent abs from skin if vomited on self
Acute panc: complications inc pleural effusion, atelectasis, elevated hemidiaphragm, pulm
infiltrates, ARDS; Sx relieved by leaning forward
Viralzing tumor: test testosterone (meanin ovary origin) and DHEAS (meaning adrenal origin);
DHEA is secreted from both the adreneal and ovaries
Follicular thyroid CA: early hematogenous spread to lung, brain, bone must show invasion of
capsule and blood vessels to differentiate from follicular adenoma
o Papillary: unencapsulated and spread via lymphatics
Diabetic head infections: rhizor is in the nasal and goes up to orbit thru brain; pseudomonas is
in ear with granulations and can go into jaw and skull base and cause cranial nerve lesions
Metabolic syndrome is 3 of 5:
o Waist in men >40in and women >35in
o Fasting glucose >100
o BP>130/80
o TG>150
o HDL <40 in men and <50 in women
Insulin resistance causes: dyslipidemia, endothelial dysfunction prevents endothelial-
dependent vasodilation, procoag state, inc sympathetic activity, inc inflmm markers, dec uric
acid excretion, inc Na absorption, inc testosterone from ovaries (hairy fat ladies)
Cortisol def: eosinophilia!
Most GS are radiolucent b/c most are of cholesterol!
Acromegaly Dx: IGF-1 level if elevated oral glucose suppression test if GH not
suppressed MRI of brain if mass in pituitary then surgically resect or manage medically
Decreased Iodine uptake test: painless thyroiditis, subacute granulomatous thyroiditis (De.
Quervains, which is painful), too much thyroid meds, iodine-induced thyrotoxicosis.
Lipid screening: 45 for women and 35 for men 20 for DM, family Hx of premature CAD, familial
hyperlipidemia, several risk factors
Bechets: also get erythema nodosum
Sick euthyroid syndrome: in pts w/chronic illness from inc in IL1, IL6 and decrease in calories
low T3, normal T4 (decreased conversion to T3), normal TSH if prolonged, TSH and T4 can
increase
Graves dz best tx: radioactive iodine contraindicated in pregnancy and severe
ophthalmopathy
o Surgery: for large goiter or nodule susp of CA; also risk of laryngeal nerve palsy,
hypoparathyroidism, hypoT
Cushing Sx: central obesity, wasting of limbs w/proximal musc weakness, purple striae, easy
brusing, HTN, skin pigmentation (due to ACTH increase) on sun-exposed area, if ectopic, can
act like mineralcorticoid and cause HTN and low K+
hypoT is a/w hyperlipidemia esp increased LDL

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IF there is an enlarged, palpable GB! And its NOT PAINFUL, then its PANCREATIC CA until
proven otherwise
o Or PAINLESS JAUNDICE
Glucocorticoids for vit-D caused hyperCa of sarcoid and lymphoma
hyperT on PE: goiter, HTN, tremors in fingers/hands, hyperreflexia, prox. Musc. Weakness, lid
lag, a-fib
GI/Liver:
Infectious endocarditis: can cause septic emboli to spleen (IVDA can get right or left sided
endocarditis) left also carries a worse prognosis
Hepatitis C a/w: cryoglobulinemia, B-cell lymphomas, plasmacytomas, sjogrens syndrome,
thyroiditis, lichen planus, porphyria cutanea tarda, ITP
Corrected Ca++ = 0.8(normal albumin (4) measured albumin) + measured Ca++
SAAG: serum ascites albumin gradient = serum albumin ascites albumin; if >1.1 its prb
transudate process consistent w/portal HTN, if <1.1, its exudative
Mallory-weiss: submucosal arteries of distal eso and prox stomach; versus varices is submucosal
vein at G-E junction
hepB acute: most recover, few go crhonic and fewer go FHF
o FHF: hepatic encephalopathy w/in 8-wks onset acute liver failure, also w/ALT high, inc
PT, coagulopathy (active bleeding); high mortality so transplant ASAP
o Contraindications to Transplant; cardio-pulm dz, incurable/recent (<5yrs) malignant
external to liver, active alc or drug abuse
Evolution of appendicitis pain: first visceral pain (dull, peri-umbilial), then as inflmm increases,
parietal peritoneum and skeletal musc gets inflmm causing localized, more severe pain
Tx for dermatitis herpatiformis: dapsone
MC complication of peptic ulcer: hemorrhage aka bleeding ulcer
SBO: colicky pain, vomit, no bowel mvmt or gas (obstipation), ab distention, diffuse tenderness,
positive BS, air-fluid levels on imaging; labs: mild leukocytosis and modest inc in amylase
o if metabolic acidosis, tachy, fever = urgent surgical exploration
tx of toxic megacolon: IV fluids, Antibiotics, bowel rest; for IBD-induced dz = IV corticosteroids
zinc def: presents as alopecia, abnormal taste, bullous/pustulous lesions around orificies inc
mouth; common in TPN b/c lacks Zinc
SBO: fever and leukocytosis can occur; no bowel mvmt, vomit, relieve by NG tube and if not
better, surgery; also hyperactive bowel sounds (vs. ileus which is absent bowel sounds), pain in
all 4Qs w/no guarding or rebound tenderness
Malabsorption in alcoholics: due to chronic pancreatitis, cant absorb fat-soluble vitamins i.e. D,
A, E, K low Ca b/c D is down; also when albumin drops it doesnt make iononized Ca++ drop,
which remains the same
SAAG: >1.1 means transudate
o Exudate is <1.1; from inc capillary permeability
pANCA is positive in UC; also UC arthritis similar to AS arthritis
ursodeoxycholic acid tx: for cholestasis of pregnancy and PBC
lye toxicity: epi pain, hypersalivation, odynophagia; tx: hydration, serial ab and chest XRAYS,
endoscopy to see extent of esophageal damage; strongly alkaline and can lead to perforation or
mediastinitis
thumbprinting and ischemic colitis
wilsons: can get liver changes that look like they are from alcohol w/Mallory bodies &
macrovesicular steatosis
Z-E syndrome test (gastrinoma): measure serum gastrin
ischemic hepatic injury: can inc Liver enzymes into thousands!

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UC and colonoscopy: peak incidence is 15-25 and 8-10 years post dx = yearly colonoscopies to
look for CA (1% if incidence)
Severe panc: panc + end organ damage to at least 1 organ; can lead to vessel dilation, capillary
leak and shock; indicated for CT/MCRP to look for panc necrosis and extrapancreatic
inflammation; tx: several liters of lost fluid
Someone who gets panc from no other risk factors must have gallstones, an indication for taking
GB out once stable
Severe B12 def: vitiligo, glossitis, thyroid ab, neuro dz, thrombocytopenia, leukopenia
Active GI bleed (varices) in cirrhotic pt: administer FFP b/c has all clotting factors and cirrhotic
pts have coagulopathies (spontaneous bleeds only occur when plates <10,000)
hepC a/w: cryo, b-cell lymphoma, sjogrens, lichen planus, porphyria cutanea tarda, ITP
Gastric outlet obstruction (i.e. from an ulcer) tx: NG tube to decompress stomach, NaCl for
hydration, KCl b/c low K from vomiting
Heme/Onc:
Lead poisoning: interstitial nephritis, extensor weakness (peripheral neuropathy), abdominal
pain, constipation, difficulty concentrating, fatigue, myalgias, anemia
RA pt on Methotrexate: joint stiffness symmetrically, then gets mouth ulcers (stomatitis), anemia
(megaloblastic), hepatotoxicity, nausea, fever, enlarged spleen, myelosuppression
Prostate CA w/lumbar spine involvement: MRI but first dexamethasone if evidence of
neurological involvement
Tx for autoimmune hemolysis due to NHL/CLL: pt has large liver, axillary LAD, tx w/prednisone
Corrected retic count = % reticXHCT / normal HCTXretic maturation time
Waldenstroms: aneimia, IgM, hyper viscosity = visual defects, pain & numbness in extremities
due to demyelinating sensorimotor neuropathy
CT scan: for staging disease after a biopsy is perform & a malignancy discovered good for
revealing mets esp to liver (gastric CA question)
o H-pylori is only w/MALT, not adenocarcinoma
Autoimmune conditions a/w vitiligo: pernicious anemia, graves, thyroiditis, DM1, primary
adrenal insufficiency, hypopituitarism, alopecia areata
MM: elevated ESR >100, can have normal leukocyte count or be leukopenic, kidney failure,
elevated Ca++
Sickle cell pts often suffer from folate def b/c their BM is trying to compensate for the chronic
hemolysis
Desired INR range for someone with prosthetic heart valve: 2.5-3.5
Breast cancer HER2 detection: FISH or immunohistochemical staining
hyperCa: hyperactive DTRs, muscle cramps, convulsions
o hypoMg can mimic b/c causes dec PTH secretion
hyperMg: decreased DTRs, musc paralysis, apnea & cardiac arrest
G6PD activity is often normal during hemolytic episode
Cachexia in CA tx: megestrol acetate (progesterone analog) for inc appetite and weight gain
tx of hodgkins w/chemo+rad: MC secondary malignancies from the tx are breast and lung CA
3.2% w/in 20y get CA
autoimmune hemolytic anemia tx (like from NHL): prednisone first line and then splenectomy if
not working
Spherocytes: in both AIHA and hereditary spherocytosis (strong family Hx b/c AD)
PNH: complement-mediated (not Ig) hemolysis so Coombs negative test. Due to lack of cell
membrane anchor. Causes venous thrombosis and episodic intravascular hemolysis
Anti-phospholipid syndrome tx: sx inc thrombocytopenia and prolonged PTT; tx during
pregnancy: LMWH (not prednisone)

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CLL: presence of thrombocytopenia indicates poorer Px


Polycythemia: inc gout (cell turnover) inc peptic ulcers (inc histamine from basophils)
Hx of smoking w/neck mass: have high suspicion fro head/neck sq cell CA
Febrile neutropenia is a medical ER: blood cultlures + IV empiric broad-spec antibiotics i.e.
cefepime, meropenem, zosin for pseudo coverage
Sickle cell: hyposthenuria (cant concentrate urine) found in pts w/sickle cell and w/sickle cell
trait due to sickle in vasa rectae of inner medulla = impaired countercurrent exchange and
free H20 absorption
Lead toxicity: ab pain, constipation, fatigue, irritable, insominia, neuropathies, neuropsych
issues, nephropathy, joint pain basophilic stippling and microcytic anemia due to siderblasts
Waldenstroms: hyperviscosity!! IgM! Tx: spleen, liver, LNs bigger, anemia, bruise easily, night
sweats, headache, dizzy, sensory deficits in extremities due to demyelinating sensorimotor
neuropathy, visual issues: dilated, segmented tortuous vessels (hyperviscous!)
Bernard-Soulier syndrome: AR, missing platelet glycoprotein Ib-IX-V which is vWF receptor =
mild thrombocytopenis, giant plates, bleeding
Neuro:
NF type II Dx: best w/MRI w/gadolinium enhancement
Glioblastoma multiforme: butterfly, central necrosis, heterogenous, serpiginous contast
enhancement typical of high-grade astrocytoma
MS presentation: paraplegia, urinary incont, urgency, spasticity & hyperreflexia, impaired
vibration & proprioception (b/c where white matter is and upper motor neurons)
Carb: best tx for trigem neuralgia but can cause aplastic anemia
Opiod withdrawal: for musc aches & pains use methadone
o Sx: mydriasis, piloerection, hyperactive BS, also nausea/vomit, cramps/diarrhea,
dysphoria, restlessness, rhinorrhea, lacrimation, myalgias & arthralgias
Pronator drift: UMN lesion
Ischemic stroke tx: fibrinolytics like tPA, then if thats not there, aspirin; only anticoag after
stroke to prevent recurrence.
HIV lymphoma: periventricular; HIV toxo: basal ganglia
Cauda equine syndrome: an emergency, sx: perineal anesthesia, poor rectal tone, lower
extremity musc weakness, reflex abnormalities, elevated post-void residual volume, back pain,
frequent falls; must obtain MRI of spine (spinal nerve root compression)
amyloid angiopathy: can cause intracerebral hemorrhage that is lobar, >75yo, more fragile blood
vessels
HTN strokes: more common with intraparenchymal or intracerebral hemorrhages (basal
ganglia, thalamus) than extra-axial hem (like subarachnoid, which on CT can look intra-
parenchymal, but is rly just filling the cisterna)
Subarachnoid: MC is berry aneurysm rupture, then AV malformation
MS Dx choice: MRI brain
Cerebellar hemorrhage: occipital headache, repeated vomit, gait ataxia; if large: 6th nerve
paralysis, conjugate deviation, blepharospasm
HSV encephalitis: lymphocytosis in CSF with lots of RBC b/c of hemorrhagic destruction of
temporal lobes, normal glucose, higher opening pressure
o Tx: IV acyclovir
o Dx gold std: HSV PCR of spinal fluid
Cerebellar hemorrhage: ataxia, vomit, occipital h/a, facial weakness one side, and gaze palsy to
opposite side no hemiparesis
Primidone: converts to phenobarbital which can cause AIP with ab pain, neuro Sx and psych
abnormalities: ab pain, confusion, headaches, hallucinations, dizziness

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Fluphenazine (typical anti-psych): can inhibit bodys thermoregulation and cause hypothermia
especially in the cold setting.
Withdrawl from opiods in hospital tx: methadone
o Sx: vomit, ab pain, diarrhea, restlessness, muscle and joint pain, mydriasis, piloerection,
hyperactive bowel sounds
Shy-Drager syndrome (mult system atrophy): parkinsonism, autonomic dysfunction (postural
hypotension, abnormal sweating, disturbed bowel/bladder control, salivation/lacrimation,
impotence, gastroparesis), other neuro signs (cerebellar, pyramidal or LMN)
o Tx: intravascular volume expansion, salt, alpha-adrenergic ag
Riley-Day (familial dysautonomia): AR, autonomic nervous system w/severe orthostatic
hypotension
Pseudotumor cerebri dx: must get LP to show opening pressure >20 (must be done to remove
CSF, show hi pressure and r/o meningitis, encephalitis, and subarachnoid hemorrhage)
o Also dx criteria inc: ICP hi in alert pt, no neruo deficits except for 6th nerve palsy, no
ventricle abnormality except for slit-like ventricles due to ICP
Types of stroke
o Subarachnoid hem: sudden, thunderclap h/a
o Ischemic: a/w previous TIAs, no impaired conscious
o Hem stroke: focal neuro that gradually worsen until h/a + vomit + altered mental status
develops

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Renal
Rhabdo: first hypoCa then HyperCa weeks after during recovery
Tubulointerstitial nephritis: seen with white casts, WBCs and sterile pyuria (so chlamydia and
nephritis are 2 causes of sterile pyuria)
Membranous glomerulonephritis: the MC nephrotic syndrome cause of renal vein thrombosis
due to antithrombin III lost in urine
o Renal vein thrombosis Sx: sudden onset ab pain, fever, hematuria
Anion gap: Na-Ca + HCO3
Hypokalemia: from alcoholism and vomiting
Methanol damages eyes, ethylene glycol damages the kidneys
Vomit causes alkalosis so replace w/KCl: due to contraction alkalosis (hyperaldoism), and renal
K wasting in an effort to reabsorb H+ instead
RCC triad: hematuria, flank pain and palpable abdominal mass
IgA versus PSGN: complement levels normal in IgA, IgA usu 5d or less after infection, adults
Hypernatremic: means free water deficit, so first replace w/isotonic saline (0.9%) b/c this is
hypotonic to the person, and is replacing vol. Then add normal saline for more free H20
o 5% dextrose: for euvolemic, hypervolemic hyperNa (above was hypovol, hyperNa)
chloride-resistant metabolic alkalosis: urinary Cl >20 with ECF volume expanision; not corrected
by giving normal saline primary hyperaldoism, bartters, gitelmans, excessive black licorice
ingestion
Pathophys of membranoproliferative nephrotic syndrome: antibodies against C3 convertase
lease to perssiten complement activation and deposition within kidney causing damage
Renovascular HTN tx: angioplasty w/stent placement
Below the umbilicus = SUPRAPUBIC
nephrogenic DI: if lithium give amiloride b/c blocks Li accumulation in kids; if low BP and
hypernatremic correct volume status first with normal saline than water loss with 0.45% saline;
if normotensive, correct only water loss w/0.45% saline
If chloride is low, prb an anion gap meta acidosis (aka hypochloremic met acidosis); if chloride is
high its a non-gap i.e. with RTAs

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o Chronic renal failure is a type of hypochloremic (gap) meta acidosis


Ca-phosphate stones common in primary hyperPTH and RTAs
Insolubl crystal deposition resulting in acute renal failure: hyperuricemia, indinavir, acyclovir,
sulfas
Chloride responsive met alk: low chloride output (<20) due to hypovolemia and hypochloremia
(kidneys are conserving NaCl)
o Chloride unresponsive: high Cl output i.e. excess mineralcorticoid causing output H & K
and inc Na/volume retension, kids respond w/inc NaCl excretion.
On urinalysis, blood can be blood or myoglobin since globin is what is measured
Hyponatremia:
o aSx or unstable gait/forgetful: fluid restriction, loop diuretic if urine osmolality >2 times
serum osmolality
o confusion/lethargy: hypertonic saline for 3-4 hrs to >120 then above
o seizure, coma, inability to communicate: bolus of hypertonic saline until Sx resolve +/-
conivaptan
side effects of EPO: worsening of HTN, headaches, flu-like, red cell aplasia
HypoK: flaccid paralysis, hyporeflexia, tetany, rhabdo, arrhythmias, broad flat T waves, U waves,
ST depression and PVCs
o Causes diarrhea (wastes K), vomiting (contraction alk.), anorexia, hyperAldosteronism
Simple cysts: just need reassurance
IV crystalloid vs colloid: cystalloid is sodium containing and used for re-hydration due to
dehydration; colloid is albumin in ppl w/burns (loss of fluid and protein) and hypoproteinemia
Amyloidosis: nephrotic syndrome, common in RA pts, enlarged kids and liver
Respiratory:
PEEP: peak airway pressure = airway resistance + plateau pressure; plat pressure = elastic
pressure and PEEP (positive end-expiratory pressure), calculated by performing end-inspiratory
hold maneuver
COPD + clubbing? Not due to hypoxemia but suggests an underlying malignancy
COPD exacerbation: if not crashing, but no meds are working: noninvasive positive pressure
ventilation rec for pH<7.35, PaCO2>45, RR>25 (versus intubation)
PE: low O2 sat and a-fib a/w poorer Px; Sx: sudden, sweating, RR fast, low O2, high WBC, fever
o ECG: S1Q3T3; CXR: hamptons hump, Westermarks sign
FiO2 on ventilator: normal air is 21%; starts at 80% and would like to go down to 50-60%; so if
over-oxygenated, then best to bring FiO2 down
Good pastures: can present as pulmonary infiltrates on CXR due to thickening
O2 criteria for COPD pts:
o pO2 < 55 or SaO2<88%
o cor pulmonale or Hct>55%
o pO2>60 or SaO2>90 but becomes hypoxic during exercise or sleep
Haldane effect: deoxyHb has higher CO2 affinity which increases CO2 excretion back to lungs,
while oxyH has a lower CO2 affinity to deliver O2 but if O2 given to COPD pt, there will be less
removal of CO2 and increase in CO2 retention
Steroids for asthma often cause left shift and increased WBCs
Pleural fluid pH <7.2 means infection whereas 7.35 is okay for transudate
New clubbing in pts w/COPD is not a feature of COPD but a sign of malignancy
Epi indicated: no proven benefit over aerosol in asthma, but use for anaphylaxis with
bronchospasm.
Restrictive lung dz w/increased FRC: ankylosing spondylitis

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Hypertrophic osteoarthropathy: digital clubbing and sudden-onset arthropathy of wrists and


hand joints bilaterally (in COPD pts) and can be due to underlying dz like lung CA, TB, emphy,
bronchiectasis get CXR
Exudate pleural effusion needs just 1 of the following:
o Protein to serum: >0.5
o LDH: >0.6
o LDH greater than 2/3 upper limit of normal for serum LDH
o Exudates: PE, malignancy, infection, connective tissue dz, iatrogenic cause
Ophtho:
Optic neuritis in MS: unilat eye pain, visual loss, afferent pupillary defect
Amaurosis fugax: transiet monocular blindness w/risk from atherosclerosis
HIV pt w/HSV retinitis: bilateral necrotizing retinitis, eye pain, visual loss rapidly, pal, peripheral
lesions w/central necrosis of retina
o HIV pt w/CMV retinitis: painless, fluffy/granular retinal lesions near retinal vessel a/w
hemorrhages (no conjunctivitis or keratinitis like in HSV)
Central retinal artery occlusion: painless loss of monocular vision; a/w amaurosis fugax before
full occlusion; fundo shows retinal whitening (& cherry spot)
o Tx: ocular massage to dislodge clot and O2 flow
Optic neuritis: color perception malfunctions (washed out), afferent pupil defect, central
scotoma, pain on eye mvmt
Repro Chalazion: granulomatous inflmm of meibomian gland that is hard, painless lid nodule
o Persistent ones (on and off for 2yrs): meibomian gland carcinoma!
Orbital cellulitis: post to septum, fever, proptosis, extraoc restriction, swollen red eyes
Episcleritis: infection btwn conjun and s acute onset photophobia, discomfort and watery
discharge
Hordeolum (stye): abscess over the lower or upper lid red, tender swelling over eyelid
Dacrycystits: inflmm of lacrimal gland medial eye with pus comes out
Repro:
seminomatous germ cell tumor: beta-HCG can be elevated but AFP is always normal
non-seminomatous germ cell tumors: inc yolk sac tumor, choriocarcinoma, embryonal
carcinoma (can also be a mixture of these = mixed); most have AFP elevated and sometimes b-
HCG
Screening:
Mammo: 50-74, every 2 years
Lipids: men at 35, women at 45, every 5 yrs about
Colon: start at 50-74, every 10 yrs; 10 yrs earlier than a 1st degree relative had it
Pap smear in someone w/CIN II/III: pap w/ or w/o colposcopy every 6 mos until 3 negative
samples are obtained then resume annual screening
Wells criteria: pre-test prob for DVT:
o 1 pt each
previous DVT
active CA
recent immobilization
recent bed rest >3 d
localized tenderness along vein distribution
calf swelling >3cm
pitting edema
collateral superficial non varicose veins
alternate dx more likely (-2pts)

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0 OR 1 DVT unlikely, if 2 or + DVT likely


if unlikely: get D-dimer
if likely: get US, (or in case of PE, get CTA)

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Emergency CPR
In pulseless electrical activity: there is organized rhythm on cardiac monitoring w/o
measureable or palpable pulse in a cardiac arrest pt do CPR or vasopressor therapy to achieve
cerebral and coronary perfusion
V-fib or pulseless VT: early d-fib
Use cardioversion in:
o Symptomatic or sustained (VT) v-tachy
o Hemodynamically unstable a-fib w/RVR (rapid ventricular response)


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